COVID-19 no longer an emergency, but still dangerous

On 5 May, the director general of the World Health Organization (WHO), Dr Tedros Ghebreyesus, formally terminated the Public Health Emergency of International Concern (PHEIC) for COVID-19.

“It’s therefore with great hope that I declare COVID-19 over as a global health emergency,” Ghebreyesus said. On 11 May, the Centers for Disease Control (CDC) similarly ended the emergency in the United States.

Undoubtedly these were watershed moments in the history of the worst public health disaster the world has seen in the past 100 years. But does this now mean that the COVID-19 pandemic is over? Has the virus, SARS-CoV-2, disappeared as did its predecessor, SARS-CoV-1, in 2003?

The International Health Regulations (IHR), instituted in June 2007, is the legal instrument of WHO to promote global health security by reducing the risk of international spread of diseases, infectious and non-infectious, (including chemical or radiation threats). These regulations are legally binding on the 194 member countries of WHO.

The IHR committee of experts constantly reviews outbreaks of diseases throughout the world and decides to declare a PHEIC should a serious public health threat arise with a significant risk of international spread and which requires a co-ordinated international response. What the PHEIC achieves is the streamlining of international public health funding and the acceleration of the development of vaccines, therapeutics, and diagnostics under emergency use authorisation. Various internationally binding regulations are drawn up to minimise cross-border spread of infection, including travel and trade restrictions and vaccination requirements.

Since 2007, six events have been declared PHEIC. The first, in March 2009, followed an outbreak of human cases of a novel strain of H1N1 influenza virus, dubbed “swine flu”, as the pig was the intermediate host of the virus. (Unfortunately the name “swine flu” has often been tagged onto any influenza to raise its importance. Influenza is influenza, and calling it “swine flu” doesn’t enhance its significance.)

Five years later in 2014, polio was designated a PHEIC to promote the global eradication initiative. (Interestingly there were only 68 recorded cases of polio in two countries in the world at the time.) In 2014 and 2018, PHEIC was declared for Ebola outbreaks in West Africa and the Democratic Republic of the Congo, respectively. These were the two largest outbreaks of this dreaded disease in history.

The South American outbreak of Zika virus, responsible for congenital malformations of the developing foetus, became the fifth PHEIC in 2016. Finally, on 30 January 2020, WHO designated COVID-19 to be a PHEIC.

The pandemic has clearly been in decline over the past year, with hospital admissions and fatalities dropping markedly. There has been no new variant of concern since the advent of Omicron in November 2021, well over a year ago. Fortunately, while there have been many subvariants of Omicron, these have all proven to be significantly less virulent. The WHO emergency committee thus felt that COVID-19 is now an established endemic human virus, and no longer an unexpected novel virus. The virus is also widespread throughout the world and, of course, there’s now no need for regulations to prevent cross-border spread.

Unfortunately, the termination of the international emergency doesn’t signify that the virus has miraculously disappeared and is no longer a threat. Indeed, in the United States, a few thousand deaths are still being reported weekly to the CDC. (The current toll of COVID-19 in South Africa is difficult to determine because of the marked decline in surveillance.) The virus is still circulating in the global population, usually causing a relatively milder illness with occasional clusters of cases or mini-outbreaks following super-spreading indoor crowding events.

COVID-19 won’t disappear, it’s now an established viral disease of humans. Unlike influenza, which it resembles clinically, COVID-19 hasn’t yet become a seasonal disease, although this may change in the future and winter outbreaks may become a characteristic of COVID-19. Continuing into the future we will likely come to recognise COVID-19 as an ongoing endemic disease with periodic upswings, but these are unlikely to develop into the major waves which we experienced with the previous variants of the virus in the earlier days of the pandemic.

The present-day scenario of COVID-19 could be maintained if the prevailing population immunity remains high and as long as we’re not confronted by a new viral variant of concern. We’re likely to retain existing high levels of population immunity because the ongoing circulation of the virus in the community constantly re-stimulates the immune systems of individuals who are infected, whether or not they have any illness as a result.

What’s uncertain, however, is whether a new variant of concern will arise, which could significantly circumvent population immunity and also cause serious disease. Monitoring programmes throughout the world constantly take samples for genomic surveillance from clinical specimens and from wastewater to look out for a new variant. When, where, and if a new variant is born, is anybody’s guess. Nevertheless, in anticipation, the future possible new variant has already been given a name, Pi, the next letter in the Greek alphabet.

COVID-19 is today a far less threatening public health problem. Nevertheless, the virus is still lurking in the population and is still infecting individuals and causing illness. COVID-19 still poses a danger to vulnerable individuals, and the recommendations still stand for older individuals and persons at risk of serious illness to maintain their vaccination status. Individuals with severe underlying medical conditions should try to avoid insecure environments such as crowded, poorly-ventilated indoor settings which are likely to be on the rise as our winter weather sets in. If this is unavoidable, there really should be no embarrassment in wearing a mask.

• Barry Schoub is professor emeritus of virology at the University of the Witwatersrand, and was the founding director of the National Institute for Communicable Diseases. He chaired the Ministerial Advisory Committee on COVID-19 Vaccines. This article is written in his private capacity. He reports no conflicts of interest.