THE WANING HOPE OF ENDGAMEOctober 13, 2021
Even as the prospect of COVID-19 turning endemic seems the likely long-term scenario for many countries, experts feel that even that will remain a distant dream for India
Kerala, the only major state which continues to report a high number of Covid-19 cases in India, is getting ready to open up schools, theaters and hotels in an effort to relegate pandemic lockdowns to the past. Maharashtra, the state that remained the largest breeding ground of SARS CoV-2 throughout the first and second waves, got rid of most of its lockdown protocols when case numbers started declining. Other former hotspots, including Tamil Nadu, Delhi and Gujarat, have also lifted most of the restrictions, despite the threat of a third wave.
In short, India, where the delta variant of the Covid pandemic wreaked havoc for several months, is coming to terms with Covid-19 in a hurry. The reason for the hurry is the flagging economy, but it is also fueled by the belief that the virus is here to stay and likely to become endemic.
This means that the virus will continue to circulate in pockets across the globe for years to come and will join the list of many viral diseases, mainly flus, that have become endemic over the past decades.
Yet,the decline of cases has been far from smooth. This raises an important question — how long before Covid-19 can at least be curbed to the endemic stage, if not got rid of entirely?
Epidemiologists, medical experts and virologists are unanimous in their assessment that a total eradication of the virus now looks improbable, if not downright impossible, and a downgrade
to endemic status seems far more achievable.
At the same time, no one is ready to predict how long it may take to downgrade Covid from the pandemic to the endemic stage in India.
Instead, they point to how earlier coronaviruses, including NL63, OC43, HKU1 and 229E, joined the endemic list and existed in the world for at least a century. At least three of them circulated in human populations for more than a century, while a couple are responsible for approximately 15% of the flus and respiratory infections across the world.
After starting off with high hopes, policymakers and the scientific community are increasingly coming round to the view that the initial optimism around eliminating this virus from the earth is misplaced.
Michael Osterholm, a well known epidemiologist at University of Minnesota in Minneapolis, recently compared efforts to eradicate the virus from the world right now to trying to build a stepping-stone pathway to the Moon.
“Eradication of the virus is difficult due to several reasons,” says Dr Sahadulla, an eminent internist with wide global exposure, and chairman of KIMSHealth hospital chain.
According to him, the reasons include (a) the quick escalation of the disease into a pandemic (b) unpredictable efficacy and longevity of the vaccines (c) lack of universal adoption of vaccines; and (d) the absence of a medicine or therapy to cure the disease and control its spread.
Among these, the inability of the vaccines to prevent viral transmission is considered a key contributor to our helplessness against this disease.
“Unlike Polio or Measles vaccines,” says Dr MV Pillai, Professor at Thomas Jefferson University, USA, and Senior Advisor to Global Virus Network (GVN), “covid vaccines now do not eliminate transmission, especially the delta variant with extreme transmissibility.”.
Dr Padmanbha Shenoy, a Kochi-based Senior Immunologist and an active medical researcher, pointed out that the concept of herd immunity makes little sense when the vaccines do not prevent viral transmission.
“Eradication will be impossible,” agrees Dr Alok Roy, Chair of FICCI Health Services Committee, and chairman, Medica Hospitals, Kolkata. “But, with regular vaccinations this will get into a much milder form.”
In the minority is Dr Mohan, an eminent Indian Diabetologist who has been working in the field of diabetes treatment and research for over 30 years in Chennai, who still believes that eradication may be possible by checking the rapid evolution of the virus.
“If one takes the case of Spanish flu, which is the only one that can be compared with Covid 19, after a few waves in a period of 2 to 3 years, it actually disappeared,” he points out. “In fact, with all the earlier pandemics, it was the same story. Hence, I think we will eventually be able to eradicate the virus. But for that, either herd immunity would have to be developed after the majority of the people contract the infection, or vaccination of almost the whole population would have to be been completed.”
Going by the history of pandemics, viruses eventually lose their potency due to the development of herd immunity in the population, which in turn leads them to become endemic. Such viruses keep circulating in the world, but only cause an outbreak when they contract a virus-naive population.
Besides the inability of vaccines to check viral transmission, another complicating factor when trying to predict the future course of the pandemic is the varying immunization rates across the world, say experts.
“This (problem of not developing immunity) is compounded by the widening disparity in vaccination of people among developed and developing countries. Large populations of unvaccinated people in low and middle income countries can become breeding grounds for new variants with high transmissibility. More infected people and rapid transmissibility set the ground for faster replication of viruses. The faster they replicate, higher the chances of more mutations, the significance of which is unpredictable now,” says Dr Pillai.
Until we succeed in vaccinating at least 70-80 % of the population in all countries this disease will stay with us and we may have to accept a policy of “peaceful coexistence’’, he added.
Another factor crippling our efforts to control, or even model, viral transmission is our poor understanding of the evolution of this virus.
“Covid-19 has been one of the most enigmatic diseases that humanity has confronted in recent years,” says Dr Mohan, who was involved in several studies on diabetes as a risky comorbidity to Covid-19.
According to Dr Mohan, when a new disease appears it is very difficult to predict the course of the same. “Time and again, even expert epidemiologists, infectious diseases specialists and virologists have been proved to be wrong as far as their predictions of Covid 19 were concerned,” he says.
“Since the novel SARS CoV-2 is related to the influenza virus, it is possible that Covid-19 too will eventually become endemic. Then we will start treating it like a common flu to which we are all accustomed to and it will no longer be a panic situation. If and when that occurs, it will be the old, frail and sick people and those who are immunocompromised will be susceptible to more serious Covid-19 infections and not the general population,” Dr Mohan added.
According to Dr Alok Roy, Covid-19 will mostly become a recurrent feature, but the intensity will be much lower, from pneumonia it will move to fever to myalgia to weakness etc.
“This virus will be in circulation as long as human beings exist, but not necessarily be disease producing,” he says.
Complex Affair For India
For India, exiting from the pandemic is going to be a more complex affair, as the situation in the country is different from that in most other places. Few experts are willing to predict when India will exit the pandemic stage.
Dr Shivkumar Shankar Utture, president of the Maharashtra Medical Council, calls the exit more of a dream at this moment. “I hope it happens, but it is going to be difficult. The way people are moving around in the crowded cities like Mumbai without enough caution after the relaxation in lockdown is worrisome,” he says.
He points out that despite antibodies being present in almost 80 percent of the population in a city like Mumbai, herd immunity looks uncertain due to the virus’ tendency to mutate frequently.
“In addition, a large population, especially the young, are still not inoculated and there is a high risk of
new infections when the schools and market places are reopened,” he points out.
Dr Mohan, who thinks India has done “extremely well” on the vaccination front, too is unwilling to predict when herd immunity is likely to set in.
“One can expect that by the end of 2021 or first quarter of 2022, most of India would have been vaccinated. It is to be hoped that we don’t get a third wave or, if it occurs, that we will be able to tackle it. Eventually, like the earlier pandemics, it has to settle down on its own. I am confident that in India also, we will overcome the Covid 19 eventually,” he said.
Most experts agree that the virus will remain active for long and will be difficult to eradicate completely.
“India is going to fight it for many years [because of the presence of a] huge vulnerable population as new hosts and strained resources,” says Dr Sahadulla.
This leaves nations with only one option — focus on building immunity in the population and try to restrict the spread as much as possible.
“Our strongest weapon against Covid-19 now is vaccination,” says Dr Shenoy, who led a study among autoimmune rheumatic disease (AIRD) patients that pointed to the benefits of hybrid immunity borne out of a combination of vaccination and natural infection.
Dr Roy, meanwhile, is more optimistic. “It looks like year 22 is the year of getting rid of the severe form of COVID-19 in India,” he says.
But, In the end, says Dr Pillai, the motto for India should be — Hope for the best, and prepare for the worst.