This article first appeared in Forum, The Edge Malaysia Weekly on January 24, 2022 - January 30, 2022

World Health Organization director-general Tedros Adhanom Ghebreyesus has said that “2022 must be the end of the Covid-19 pandemic”. He believes the pandemic will end this year because two years into the situation, “we know the virus very well, and we have all the tools [to fight it]”. The Economist, in a recent article, wrote: “Covid is not done yet. But by 2023, it will no longer be a life-threatening disease. It will still pose a deadly danger to billions in the poor world. Covid will be well on the way to becoming just another disease.”

With more than 281 million infections and 5.41 million deaths recorded worldwide, the Covid-19 pandemic has emerged as one of the most devastating human pandemics in recent times. With the infection rate of the Omicron variant soaring, you may find yourself asking in despair — is Covid-19 here to stay, or can we eradicate it?

Whatever the answer is, 2022 will be the year we finally have all the means, measures and tools to control the pandemic to a non-lethal state. Although the total eradication of Covid-19 is still uncertain, the good news is that eventually, it will become endemic. With at least half the world’s population having some level of immunity either through vaccines or natural infections, the transmission will ultimately remain steady and follow seasonal patterns, with fewer spikes in infection.

In the ideal situation of endemicity, the harm caused may end up somewhere between influenza, which kills an estimated 300,000 to 650,000 people annually, and other coronaviruses, such as the common cold. But endemicity is still a long way off for most countries. The virus will continue to affect our lives and livelihoods unless the global community collectively addresses inequitable access to vaccines, therapeutic agents and diagnostics.

As it stands, we are giving the virus the room it needs to thrive through uneven and inconsistent national policies undermined by division and politicisation. Of the more than eight billion doses administered globally so far, less than 3% were to countries on the African continent. The failure to provide sufficient vaccine doses to low- and middle-income countries is unethical and economically unwise. And the longer inequity continues, the greater the chance of this virus mutating into new variants that we can neither prevent nor predict.

The ultimate way to stop variants is global vaccination. Vaccine equity is a global problem. If we don’t address this quickly enough, our exit from the pandemic will be set back, possibly for months or years on end. As the longer the pandemic rages on, the more chances the virus will evolve, especially in unvaccinated individuals.

Over the last two years, SARS-CoV-2 has shown its ability to better adapt to the human host, with variants Alpha and Delta demonstrating enhanced transmissibility throughout the pandemic. One of the biggest unknowns in 2022 will be how this evolution continues. We are certainly not out of the woods yet as Delta continues to evolve and the Omicron variant has shown that the virus will continue to adapt.

Viruses mutate because they are constantly making copies of themselves in enormous numbers. Each time it is transmitted from one person to another, the chances of making errors (mutations) increase. Think of it this way. Suppose you are typing exceptionally fast multiple times. You would probably make some errors. This is precisely how the virus mutates. Moreover, concerns about coronavirus variants that may be partially resistant to antibody defences have spurred renewed interest in other immune responses that protect against viruses.

While initial data show that protection from booster doses may wane after 10 weeks, this is merely looking at the efficacy of neutralising antibodies. However, neutralising antibodies is not the only defence that the immune system can muster. Immune responses are layered and redundant. Meaning that when one layer falters, another can swoop in to help. Killer T-cells — a group of immune cells that can target and destroy virus-infected cells — represent one such layer.

T-cells could also be more resistant than antibodies to threats posed by emerging variants as they home in on different aspects of the virus than antibodies do. Data from the labs of Alessandro Sette, an immunologist at the La Jolla Institute for Immunology, and Andrew Redd of the National Institutes of Health showed that despite Omicron’s many mutations, most protein fragments recognised by T-cells are identical to those of other variants.

These findings suggest that T-cells trained by vaccines or previous infections will respond aggressively to Omicron rather than standing by. In addition, all vaccines generate memory B-cells, which produce high levels of neutralising antibodies if they “see” the virus or its variants again. Memory B-cells, once generated, are long-lasting and this is observed in all vaccinated individuals despite the threat from Omicron, which bodes well for potential longer-term immunity.

Globally, the path to endemicity will be a bumpy one as current vaccines by themselves are insufficient to stem transmission. Therefore, increases in cases should be expected whenever public health and social measures are lifted, irrespective of vaccination coverage. Furthermore, with newer variants having immune evading capabilities, we will continue to see a slight increase in the number of cases. As we continue the path toward an endemic Covid, what we should be focusing on instead is the number of severe cases as well as hospitalisation and mortality rates.

Nonetheless, in any scenario for the future of the Covid-19 pandemic, much depends on the ways in which societies respond. Three levers are likely to be especially important, starting with the extent to which countries can effectively scale and make available new oral therapeutics with the potential to reduce the chance of progression to severe disease, and which are unlikely to be blunted by Omicron. Second, evidence is accumulating that booster doses are especially important for protecting against the Omicron variant; accelerating their rollout will help protect populations. And third, given public fatigue and the lessons of the past two years, finding the right combination of public health measures will be critical.

It is worth noting that current Malaysian data show that most vaccinated individuals who were reinfected only showed mild symptoms or were asymptomatic. This clearly shows the importance of vaccination in building an immunity wall against serious symptoms. As for now, we know that the third booster dose protects us from severe disease, symptoms and hospitalisations, and can neutralise the Omicron variant. But how frequent these booster doses are needed will depend on real-time data.

Looking towards 2022 and beyond, Malaysia and much of the world will need to continue with effective measures to bring transmission under control. To that end, it is essential for governments to continue improving national and sub-national public health infrastructure to better target and tailor local responses.

Strengthening healthcare systems will not only help to control Covid-19 but also ensure that we are in a better position to confront the next outbreak. Whether we enhance or reduce Covid-related restrictions truly depends on the adherence to the standard operating procedures, and the usage of ventilators and intensive care unit beds as well as hospitalisation and mortality rates from the current variant.

At the end of the day, the transition from pandemic to endemic will likely play out differently in various locations around the world. The most important thing we can do to help reach a safe level of endemic Covid is to get the booster doses and continue to adhere to Covid-safe practices. By doing this, we protect ourselves and those around us, and move together towards a future without the fear of both Covid and lockdowns that have haunted us for the past two years.

Dr Vinod Balasubramaniam is a molecular virologist and senior lecturer at the Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia

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