As a virus-weary world limps through the third year of the COVID-19 pandemic, experts are sending out a warning signal: Do not expect the Omicron variant of SARS-CoV-2 to be the last variant we contend with — and do not let your guard down yet.
In the midst of a vast wave of milder infections, countries around the world are dialing back restrictions and softening their messaging. Many people are starting to assume they have had their run-in with COVID-19 and that the pandemic is tailing off.
That is not necessarily the case.
Illustration: Mountain People
The crisis is not over until it is over everywhere. The effects could likely continue reverberating through wealthier nations — disrupting supply chains, travel plans and healthcare — as the virus largely dogs undervaccinated developing countries over the coming months.
Before any of that, the world must get past the current wave. Omicron might appear to cause a less severe disease than previous strains, but it is wildly infectious, pushing new case counts to once unimaginable records. Meanwhile, evidence is emerging that the variant might not be as innocuous as early data suggested.
There is also no guarantee that the next mutations — and there are more coming — would not be offshoots of a more dangerous variant such as the Delta variant of SARS-CoV-2, and your risk of catching COVID-19 more than once is real.
“The virus keeps raising that bar for us every few months,” Yale School of Medicine professor of epidemiology Akiko Iwasaki said. “When we were celebrating the amazing effectiveness of booster shots against the Delta variant, the bar was already being raised by Omicron.”
“It seems like we are constantly trying to catch up with the virus,” she said.
It is sobering for a world that has been trying to move on from the virus with a new intensity in the past few months.
However, the outlook is not all gloom. Anti-viral medicines are being introduced to the market, vaccines are more readily available, and tests that can be self-administered in minutes are easy and cheap to obtain in many places.
Nevertheless, scientists agree that it is too soon to assume the situation is under control.
Many richer countries in six months should be transitioning from pandemic to endemic. However, that does not mean masks are becoming a thing of the past. We might need to grapple with our approach to booster shots, as well as the pandemic’s economic and political scars. There is also the shadow of long COVID-19.
IS IT HERE TO STAY?
“There is a lot of happy talk that goes along the lines that Omicron is a mild virus and it’s effectively functioning as an attenuated live vaccine that’s going to create massive herd immunity across the globe,” said Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine in Houston. “That’s flawed for a number of reasons.”
Experts believe that the virus can never disappear entirely, and instead is to continue evolving and creating new waves of infection. Mutations are possible every time the pathogen replicates, so surging caseloads put everyone in danger.
The sheer size of the current outbreak means more hospitalizations, deaths and virus mutations are inevitable. Many people who are infected are not making it into the official statistics, either because a home test result is not formally recorded or the infected person never gets tested at all.
Trevor Bedford, an epidemiologist at Fred Hutchinson Cancer Research Center in Seattle, known for detecting early COVID-19 cases and tracking the outbreak globally, estimates that only about 20 percent to 25 percent of Omicron infections in the US get reported.
With daily cases peaking at an average of more than 800,000 last month, the number of underlying infections could have exceeded 3 million per day — or nearly 1 percent of the US population, Bedford said.
Since it takes five to 10 days to recover, as much as 10 percent of people in the country might have been infected at any one time.
He is not alone in projecting astronomical numbers. At the current infection rate, computer modeling indicates that more than half of Europe could contract Omicron by the middle of next month, WHO regional director Hans Kluge said.
Meanwhile, a sub-variant known as BA.2 is spreading rapidly in South Africa. It appears to be even more transmissible than the original strain and could cause a second surge in the current wave, one of the country’s top scientists said.
Just because you have already had the virus does not mean you cannot get reinfected, as COVID-19 does not confer lasting immunity.
New evidence suggests that Delta infections did not help avert Omicron, even in vaccinated people. That would explain why places like the UK and South Africa experienced such significant outbreaks even after being decimated by Delta.
Reinfection is also substantially more common with Omicron than previous variants.
“With Omicron, because it has more of an upper respiratory component, it’s even less likely to result in durable immunity” than previous variants, Hotez said. “On that basis, it’s incorrect thinking to believe that this is somehow going to be the end of the pandemic.”
BEING PREPARED
Preparing for the next COVID-19 strains is therefore vital.
“As long as there are areas of the world where the virus could be evolving, and new mutants arriving, we all will be susceptible to these new variants,” South African Medical Research Council CEO Glenda Gray said.
Lockdowns and travel curbs are not going away, even if they are becoming less restrictive on the whole.
“The things that will matter there are whether we are able to respond when there is a local surge,” said Mark McClellan, former director of the US Food and Drug Administration and director of the Duke-Margolis Center for Health Policy. “Maybe going back to putting on more masks or being a little bit more cautious about distancing.”
Inoculation is still the world’s primary line of defense against the virus. More than 62 percent of people around the world have received at least one dose of a COVID-19 vaccine, with overall rates in wealthy countries vastly higher than in developing ones. At the current pace, it would take another five months until 75 percent of the world’s population has received their first shot.
However, studies show that one or two injections do not ward off the pathogen. The best bet at this point is a booster shot, which triggers the production of neutralizing antibodies and a deeper immune response.
People inoculated with more traditional inactivated vaccines, such as the widely used shots from China’s Sinovac Biotech Ltd, could need at least two boosters — preferably with different vaccines — to control the virus, Iwasaki said.
In the next six months, more countries are expected to be contending with whether to roll out a fourth shot. Israel has started and the US backs them for vulnerable people, but India is pushing back and refusing to “blindly follow” other countries.
While the virus is not expected to overwhelm hospitals and trigger restrictions forever, it is still unclear when — or how — it can be left on the back burner.
Experts Bloomberg News spoke to agree that in developed countries, including the US and much of Europe, the virus could be well in hand by this summer. There should be better access to pills such as Pfizer Inc’s Paxlovid, rapid antigen tests should be more readily available and people are likely to accept that COVID-19 is here to stay.
Robert Wachter, chair of medicine at the University of California, San Francisco, puts the odds at 10-to-one that most parts of the US and the developed world by the end of this month would no longer be struggling with severe outbreaks.
Vaccinations, new treatments, widespread testing and immunity as a result of previous infections are helping. Countries such as Denmark are getting rid of all pandemic restrictions despite ongoing outbreaks.
“That is a world that feels fundamentally different from the world of the last two years,” he said. “We get to come back to something resembling normal.”
“I don’t think it’s irrational for politicians to embrace that, for policies to reflect that,” he added.
NEW WAVES
Elsewhere in the world, the pandemic is far from over.
The threat of new variants is highest in less wealthy countries, particularly those where immune conditions are more common. The Delta variant was first identified in India, and Omicron emerged in southern Africa, apparently during a chronic COVID-19 infection in an immunocompromised HIV patient.
“As long as we refuse to vaccinate the world, we will continue to see new waves,” Hotez said. “We are going to continue to have pretty dangerous variants coming out of low and middle-income countries. That’s where the battleground is.”
Amesh Adalja of the Johns Hopkins University Center for Health Security in Baltimore sees the pandemic continuing into next year for parts of the developing world.
“The transition from pandemic to endemic is when you’re not worried about hospitals getting crushed,” he said. “That will happen in most Western countries in 2022, and it will take a little bit longer for the rest of the world.”
In parts of Asia, public health officials are not even willing to consider calling the end of the pandemic.
While most of the world seeks to live alongside COVID-19, China and Hong Kong are still trying to eliminate it. After spending much of last year virtually virus-free, both places are dealing with outbreaks.
“We do not possess the prerequisites for living with the virus because the vaccination rate is not good, especially amongst the elderly,” Hong Kong Chief Executive Carrie Lam (林鄭月娥) said. “I could not stand seeing a lot of old people dying in my hospitals.”
Harsh virus restrictions, including border closures and quarantines, could be in place until the end of this year, although the higher contagiousness of new variants is making that harder to maintain, as Hong Kong’s challenges show. Walling out the virus completely, as a swath of countries did early in the pandemic, might no longer be possible.
With so much of the world mired in the pandemic, virus-related dislocations could continue everywhere.
The immense strain on global supply chains is only worsened by workers sickened or forced to quarantine as a result of Omicron. The problem is especially acute in Asia, where much of the world’s manufacturing takes place, and means global concerns about soaring consumer prices are unlikely to disappear any time soon. China’s increasingly vehement moves to keep quashing COVID-19 are also becoming disruptive.
With many countries only partially open to visitors, international travel is still very far from what was considered normal in 2019. Hospitals and healthcare systems around the world face a long, slow recovery after two years of monumental pressure.
For some individuals, the virus could be a life sentence. Long COVID-19 sufferers have been experiencing severe fatigue, muscle aches and even brain, heart and organ damage for months.
How long are we to deal with the long-term ramifications of the virus?
“That’s the million-dollar question,” Gray said. “Hopefully we can control this in the next two years, but the issues of long COVID-19 will persist. We will see a huge burden of people suffering from it.”
LIFE AFTER COVID-19
Over the coming months, a sense of what living permanently with COVID-19 looks like should take shape. Some places might forget about the virus almost entirely, until a flare-up means classes are canceled for a day or companies struggle with workers calling in sick. Other countries might rely on masking up indoors each winter, and an annual COVID-19 vaccine is likely to be offered in conjunction with the flu shot.
To persist, the virus needs to evolve to evade the immunity that is hitting high levels in many parts of the world.
“There could be many scenarios,” Iwasaki said. “One is that the next variant is going to be quite transmissible, but less virulent. It’s getting closer and closer to the common cold kind of virus.”
If that evolution takes a more toxic path, we could end up with a more severe disease.
“I just hope we don’t have to keep making new boosters every so often,” she added. “We can’t just vaccinate everyone around the world four times a year. It’s really hard to predict.”
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