Whither COVID-19 in 2022?

With 2022 well underway, many expected to see the end of the COVID-19 pandemic. Instead, we find ourselves rather bewildered by the information at hand.

On the one hand, Hong Kong is reeling from its worst onslaught of the disease, with hospital facilities overwhelmed without precedent with severe COVID-19 cases. By contrast, Boris Johnson of the United Kingdom is scheduled to announce “COVID-19 Freedom Day” on Thursday, 24 February.

The premier of Denmark, one of the most highly vaccinated countries in the world, has welcomed a “completely open Denmark”. This is in spite of experiencing one of the highest daily COVID-19 death rates in the world.

Myriad questions have arisen.

Let’s tackle the most frequent. Does the relatively milder but more contagious Omicron variant herald the end of the pandemic and the commencement of a tolerable endemic phase of the disease?

Much has been made of the relative mildness of the erstwhile fourth wave caused by the Omicron variant of COVID-19. Combining this with the much greater infectiousness of the virus and its ability to escape pretty effectively from the body’s immunity, it has been suggested by some that the virus may now be evolving into a more manageable endemic agent.

We can but hope that this is the case, and that the virus will soon join its relatively benign four endemic human coronavirus relatives. However, there is as yet no scientific evidence to support this. Virus evolution to milder endemicity has been demonstrated with some animal viruses, but not for any human virus.

With so many people suffering “breakthrough” infections – being infected in spite of being vaccinated – does this mean that the vaccine is ineffective?

What has been strikingly apparent in the fourth, Omicron-driven wave has been the great number of people who became infected in spite of being fully vaccinated. Yes, COVID-19 vaccines are undoubtedly effective and, indeed, very effective in protecting against severe disease and death.

The great majority – more than 80% – of severe cases have been in unvaccinated individuals or in persons already compromised with underlying illnesses and comorbidities.

Do we still need to keep our masks on and minimise social functions?

With the current lull in the COVID-19 pandemic, there has been a widespread creeping tendency to discard COVID-19 regulations and restrictions. Nevertheless, the national epidemic curve has still stubbornly refused to descend to a baseline inter-wave level.

There are a number of reasons for this. First, the aftermath of the opening of schools and the further evolution of the Omicron variant to an even more infectious subvariant (from the original Omicron subvariant BA.1 to Omicron BA.2).

Second, the epidemic has been prolonged to a significant extent by the growing carefree abandonment of preventive precautions. Data for the Jewish community, reflected by the Hatzolah home monitoring programme, have revealed an almost fourfold increase in new cases over the past month.

With monotonous regularity, one hears of superspreading outbreaks of COVID-19 following celebratory functions. Also, in a number of shuls, caution has been thrown to the proverbial aerosol wind, not to mention the flouting of government regulations and general public-health advice, with the abandonment of wearing masks indoors.

Can we expect more waves and, if so, when and how severe will they be?

Given the unpredictability of COVID-19, no serious scientist would rush to predict the future. Historically, the first four waves have followed a fairly regular cyclical pattern of a 75-day duration and a 100-day inter-wave interval, albeit that the fourth wave broke somewhat with tradition by appearing significantly earlier and lasting for a significantly shorter time.

Epidemic waves reflect the balance between the fitness of the virus, in other words its contagiousness and immunity evasiveness on the one hand, and the resistance of the population on the other. South Africa was quite fortunate in the relative mildness of its fourth wave, largely the result of the extensive immunity in the population, both vaccine induced as well as, to a large extent, derived from the silent spread of the virus through a younger, less clinically affected population.

Though the resistance of the population is extensive in our country and will be even more so following the fourth Omicron wave, what remains unpredictable is the fitness of the next new variant and how mild or severe the disease it causes. Unfortunately, we remain vulnerable to new variants as long as the virus is able to multiply in under-vaccinated human populations or in individuals whose immune system is suppressed by infection, such as HIV, or drugs – for example chemotherapy for cancer. As immunosuppressed individuals are unable to eliminate replicating the virus fully, selective pressure in the remnant virus could well foster new variants.

Ultimately, control of the pandemic may need to wait for a new generation of vaccines better at combating new variants and perhaps even protecting against the remote risk of the introduction of a completely new coronavirus from an animal reservoir, as indeed was the case with SARS-CoV-1 and 2.

Was it really necessary for South Africa to retain COVID-19 restrictions, as announced by the minister – probably for the remainder of 2022?

It’s clear that as much as we are anxious to return to our pre-COVID-19 lifestyles, and as much as we are fed up with two years of COVID-19 restrictions and disturbed by their economic implications, and as much as there’s political pressure to abolish restrictions immediately, the reality is that COVID-19 hasn’t disappeared. In South Africa, mask requirements and social gathering warnings will remain for 2022 if not under the Disaster Management Act then under the National Health Act. However, regulations can really achieve only a limited amount. Controlling this pandemic will ultimately be determined by common goodwill, common sensitivity, common humanity, and common sense.

• 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 chairs the Ministerial Advisory Committee on COVID-19 vaccines. This article is written in his private capacity. He reports no conflicts of interest.