Endemic to endgame: Why COVID-19 remains part of our communities

At a press conference on January 21, 2022, BC Provincial Health Officer Dr. Bonnie Henry addressed changes in how the province is approaching COVID-19, and referenced similarities between the new measures and how other respiratory diseases are dealt with.

She added that the province wasn’t moving into “endemic mode.”  

“We are clearly not in a place where it’s endemic right now,” Henry said. “What we are doing is adjusting to the changes that we’ve seen from the new variant.”

But this statement from Henry is in contrast to another press conference from November 30, 2021. “We know this virus is endemic now,” she said, “which means it is circulating in the community.”

“We can no longer contain it with some of the measures that we had early on.”

In turn, institutions like the BC Centre for Disease Control (BCCDC) have described “the expectation” that COVID-19 will become endemic.

“I think the expectation, the hope perhaps, is that we’re headed to a situation of endemic circulation of the virus, probably some periodic changes to the virus,” said Dr. Monika Naus, medical director of communicable diseases & immunization service at the BCCDC.

An endemic infection is when “overall rates are static — not rising, not falling,” as described in a Nature article published in January 2022.

As of February 2022, hundreds of people are testing positive for COVID-19 each day, with the BCCDC acknowledging that these numbers “likely underestimate the true number of COVID-19 cases in BC” due to changes in testing measures. Hospitalizations finally declined after peaking in January, according to the BCCDC, and masks remain a staple of daily life.

As conversations surrounding the endemicity of the novel coronavirus mount, Oxford Professor Dr. Aris Katzourakis highlighted that endemic diseases can still be deadly. In his Nature article, he emphasized that policymakers should not use endemicity “as an excuse to do little or nothing.”

“Thinking that endemicity is both mild and inevitable is more than wrong, it is dangerous: it sets humanity up for many more years of disease, including unpredictable waves of outbreaks,” according to Katzourakis.

Over the course of the pandemic, herd immunity — which was once the goal of public health experts and the provincial health authority — has slowly been seen as more and more unattainable. From emerging variants to vaccine inequality, an array of factors have contributed to the persistent presence of COVID-19 in our communities.

Cracking the coronavirus

The best place to start is by understanding the basic science of herd immunity.

Herd immunity is achieved by isolating a virus and impeding its ability to spread. It is based on the idea that if an overwhelming proportion of the population is immune, then the ability of the disease to circulate is hindered.

Making communities immune to a disease is necessary for herd immunity, according to a 2020 Journal of the American Medical Association article.

Whether it be through a vaccine or through remaining antibodies from a previous infection, immunity reduces one’s risk of getting a disease. Herd immunity also protects those who cannot get vaccinated by limiting the spread of the disease.

Therefore, if a large enough segment of a population is vaccinated, then the pathogen’s ability to circulate is greatly reduced and new outbreaks cannot be sustained, according to a 2020 Nature news feature.

Naturally, this means that a high level of vaccine uptake is necessary all around the world for any sort of herd immunity situation to occur — which has not happened with COVID-19.

August 2021 predictions in global vaccination campaigns estimated that over 90 per cent of people would need to be vaccinated for herd immunity to be achieved against the Delta variant. As of April 19, 2022, nearly 85 per cent of Canadians have received their first dose of a COVID-19 vaccine and just over 81 per cent are fully vaccinated, according to the federal government. Just 66 per cent of Americans are fully vaccinated, as described by the CDC.

But opposing factors for herd immunity go beyond the vaccination rate in high-income countries. Data scientist Youyang Gu explained in a 2021 Nature news article that herd immunity was “looking unlikely” due to an array of limiting factors like “vaccine hesitancy, the emergence of new variants and the delayed arrival of vaccinations for children.”

Vaccine sharing is caring

While some of the responsibility lies with those choosing not to get immunized, Gu’s interview also pointed to vaccine inequity as a major deterrent to herd immunity.
Vaccine supply to many low-income countries has been limited, preventing citizens from receiving their shots, according to Vaccine Equity Expert and Assistant Professor in the UBC School of Nursing Dr. Katrina Plamondon in a January 2022 interview with The Ubyssey. Instead, predominantly developed countries have hoarded doses from the pandemic’s outset.
“Wealthy countries, Canada included, had the capacity to engage in all these negotiations with pharmaceutical companies and they sort of made guesses about which vaccine was going to work,” said Plamondon. “They [made] lot of pre-purchase agreements with those companies to secure doses for their own populations.”
“The vaccines were incredibly scarce ... It became a race among wealthy countries,” she added.
Not even frontline healthcare workers have had the opportunity to get vaccinated in some places, according to Plamondon, particularly in parts of Africa. The World Health Organization reported in November 2021 that only one in four health care workers in Africa were fully vaccinated. Meanwhile, she said that some countries have even begun offering their citizens fourth doses.
As of April 20, while UBC may have a vaccination rate over 90 per cent, according to Our World in Data, countries such as Burundi and the Democratic Republic of the Congo have rates as low as 0.095 and 0.87 per cent, respectively. Likewise, a Nature news article from September 2021 reported that fewer than one per cent of individuals in low-income countries are fully vaccinated.

This low rate puts the global population short of the threshold for herd immunity, and, as demonstrated by the rapid spread of the Omicron variant, immunity is not a concept limited by lines on a map.
“We don’t live in bubbles where our borders are somehow protected by some sort of shield,” said Plamondon.
There have been multiple global efforts to overcome this inequity.
The World Health Organization (WHO) established the COVAX initiative in April 2020, where wealthy countries donate excess vaccine doses to be distributed to low-income countries. As of January 2022, COVAX had been responsible for the delivery of over a billion doses.
US President Joe Biden has voiced support for waiving intellectual property claims on COVID-19 vaccine development, which would allow producers in developing countries to more easily manufacture a vaccine for their own populations.
Despite these efforts, Plamondon said some countries may not see widespread vaccine access for another eight years at our current pace.
“What we end up doing is failing to recognize just how vulnerable we are to our own policies,” she said. “A pandemic is by nature global, so things that are inherently global in nature require global solutions, not national ones.”
Plamondon said it’s important to recognize the role that Canada has played in furthering systemic inequality during the pandemic. She cited the decision to ban travel from Southern Africa upon the identification of the Omicron variant by South African scientists as “very disappointing.”
“The discovery of that variant by that laboratory in South Africa is actually a signal of science working well, and collaborative intentions working well. And Canada’s reaction was not only ungracious but I would say not at all grounded in science,” said Plamondon.
“We continue to not invest in mechanisms that allow for equitable manufacturing and distribution of vaccines.”

It’s on like Omicron

With continued transmission due to vaccination barriers, the likelihood of COVID-19 mutating to create new variants is high, according to Infectious Disease Expert and Adjunct Professor in the faculty of medicine Dr. Horacio Bach.

“Having so many people around the world that are infected, you produce all the time new mutants,” said Bach. “And since there are so many people infected, then the probability of getting a mutation is increasing.”

New variants can also introduce an additional layer of complexity, as differences in the new version of the virus also impact the conditions needed to achieve herd immunity.

“The problem is herd immunity for one virus does not mean that you have herd immunity for another virus,” said infectious disease modelling expert and UBC Zoology Professor Dr. Sarah Otto. “The level of immunity that we had for the [novel coronavirus] and even for Delta [that] was getting close to the place where we could open up is not enough for Omicron.”

“Really, it’s not that herd immunity isn’t a useful concept but the recognition that evolution is chasing the virus and causing what used to be herd immunity to fail.”

In early 2022, the Omicron variant dominated case loads both provincially and globally.

A December 2021 news article published in The Lancet estimated that Omicron could have an R-nought (R0) as high as 10, meaning that each infected person transmits the virus to an average of 10 others while contagious. The same study estimated the R0s of the Delta variant and COVID-19’s original strain to be just under seven, and between two and five, respectively.

Given the abundance of hospitalizations and case loads — particularly in January 2022 — Bach hesitates to call COVID-19 endemic at this point. He also shared the expectation that new COVID-19 variants will continue to circulate.

“If it’s endemic supposedly, one day we’ll develop a new variant … you get that, you bring that to Canada, and it’s a new variant that the immune system doesn’t recognize properly,” said Bach. “So it’s a circle all the time.”

As variants emerge, vaccination still offers protection against severe illness. One August 2021 study compared the efficacy of the Pfizer-BioNTech vaccine against either the original Alpha variant of the novel coronavirus or the Delta variant. Data revealed “only modest differences in vaccine effectiveness” after two doses of the vaccine, with two shots being associated with 93.7 per cent effectiveness for those with the Alpha variant compared to 88 per cent effectiveness for Delta cases.

In the wake of the newest variant of concern, the BCCDC recommends that residents seek a booster, writing “[a] third vaccine dose helps to provide more protection from [the] Omicron [variant].”

Naus emphasized that “the goal is to achieve as high vaccine uptake as possible” in order to support both individual and population interests.

A new hope

So what can we expect life to look like in the future? No one really knows.

With regards to the provincial pandemic response, the BCCDC said in a January 2022 statement to The Ubyssey that “there will continue to be changes over the coming months and years.” In the meantime, students should stay home when they aren’t feeling well “until they feel well enough to resume regular activities.”

At times, UBC classes may have to go online, if just for a month or two like earlier in the term. The infrastructure necessary for such learning may need to be ready to be used at any time.

For some students, this uncertainty is ever present in both their academic and personal lives.
“We’ve been looking for this light at the end of the tunnel, for the pandemic to be over,” said Emilie Wang, a second-year environmental sciences student and co-founder of UBC’s Vaccine Literacy Club. “Honestly, as of right now I don’t know what is going to happen in the future, what the future is going to look like.”

For Wang, the lack of cohesive international response to COVID-19’s latest developments presents particular challenges.
Not all countries have adopted the same measures to COVID-19 as BC. For example, in 2021 and early 2022, China continued an elimination approach based on hard lockdowns and border restrictions. As a result, Wang and her family  faced major uncertainty for the foreseeable future when visiting with her grandparents, who live in the Chinese city of Xi’an.

Moving forward, Wang said that it is important to encourage vaccination, trust in our health authorities and focus on handling this together.

“Obviously, the pandemic isn’t over yet right now and there’s still very high case counts, a lot of hospitalization,” she said. “I think it’s still important to maintain trust in public health and to move forward in a way that is more unified.”

As students and experts alike consider an endemic novel coronavirus, a future with communities intertwined with COVID-19 may be on the horizon. But for Plamondon, herd immunity was not a lost cause, but rather a monumental challenge requiring systemic change and unity to overcome.

“I really believe that more equitable futures are possible,” she said, “but what would be required is a frank and honest look at what we want as a collective future.”

As of April 20, 2022, the statistics in this article have been updated.