Chandrakant Lahariya | A new worry: How we need to ‘live with Covid’ in India

Two years since Covid-19 was declared a pandemic -on March 11, 2020 - finally, for India, there seems to be some light at the end of the pandemic tunnel. The daily new Covid-19 cases in the country have come down to around 4,000 to 5,000, the lowest in 22 months since May 2020. This has revived some of the discourses -- (a) whether the third wave of Covid-19 pandemic is over in India? (b) Has Covid-19 become endemic in the country? (c) Will there be another wave? and (d) Does everyone need a Covid-19 vaccine booster dose? These are some of the many questions that people have in the mind.

To start with -- in a pandemic or epidemic -- when the number of daily new cases comes down and stabilises at low levels, for at least two weeks, it is considered an end of the wave in that specific setting. If on a graph, these new cases are plotted on y-axis and the time on x-axis, a curve with a flattened pattern would appear towards the end. Moreover, at present, the daily new Covid-19 cases in India are lower than the cases before the third wave in the country. In this backdrop, it is logical to conclude that the Covid-19 third wave is over. However, a wave getting over does not mean that SARS CoV2 has gone. In fact, the newer pathogens including viruses, once detected, stays with humanity for long, possibly forever. This seems to be the most probable scenario with SARS CoV2 as well. It clearly is time for us to prepare to live with SARS CoV2.

That brings another question: Has Covid-19 become endemic in India? To start with, we need to understand that Covid-19 becoming endemic is not a binary that today it is a pandemic and tomorrow it is endemic. Also, “endemic” does not mean the “end” of the virus transmission. So, when do we call a disease “endemic”? An epidemic or pandemic starts with a pathogen (in this case a virus) but ends with a “socio-political consensus”. Therefore, when Covid-19 would be considered endemic in any setting or country is going to be determined by every country at different points of time. There is going to be some risk associated with SARS CoV2, which would be greater than pre-Covid period. Therefore, a decision on endemicity would be influenced by societal consensus and political leadership based upon how much risk any society or community is willing to accept, in the return to normalcy, in other spheres of life? Sweden, Denmark and Britain, without explicitly declaring Covid-19 as endemic, removed nearly all Covid-19 related restrictions. When these countries removed restrictions, the number of daily new Covid-19 cases were far higher than even the peak of the earlier waves in those settings.

The third wave of the Covid-19 pandemic in India can be considered over. But in the last week of February 2022, a pre-print mathematical modelling study by a group of researchers at a reputed educational institution in India claimed that the fourth wave in India would start in June 2022. Since then, the study has been criticised for lack of rigour and methodological flaws, including by not taking relevant epidemiological aspects in the consideration, the findings are on a weak scientific footing and as good as “an intelligent guess”. Considering high population level immunity after either natural infection in the second and third wave and nearly 95 per cent of the adult population receiving at least one shot of Covid-19 vaccines, there is a situation of hybrid immunity in the country. Though immunity and protection decline over a period, two shots of the vaccines continue to provide protection from severe disease and hospitalisation for long. In this backdrop, the possibility of a fresh large-scale wave in India is very low.  This is also to argue that there is no urgency to get a booster for a healthy adult population.

What would endemicity or “living with SARS CoV2” mean? It would mean that for most people adherence to Covid appropriate behaviour of face masks and physical distancing - in public places - would become a voluntary decision. However, it would be pragmatic to remove the restrictions in a graded manner. First, the restrictions may be removed for the outdoor public spaces, then for closed spaces and before finally being removed for everyone. However, even when Covid-19 becomes endemic, it would be advisable for high-risk individuals - adults with co-morbidities or the 60-plus population, to voluntarily adhere to masks and distancing as deemed appropriate. It is very likely that for many months to come, some people will voluntarily wear masks in public places. The Covid-19 pandemic has underscored the relevance of staying healthy. Therefore, living with SARS CoV2 essentially would mean every individual needs to do their bit of adopting a healthier lifestyle, which would minimise their risk.

Living with Covid-19 would not mean no policy intervention would be needed. In fact, some areas would require sustained and priority policy attention. As an example, among all age groups, school-age children are at lowest risk of severe disease. Therefore, proactive interventions will be needed to bring everything for them to normalcy, urgently. The policy interventions needed to reopen schools with 100 per cent attendance in physical classes. The end of a wave or entering into the endemic stage also means that the face mask mandates for school-age children should be done away. Every effort by all state governments would have to be made to ensure continuity of school, which should not be disrupted by a temporary rise in cases. It is also the time to focus upon the physical and mental health of children through strengthened school health services.

At a broader level, even now, tackling misinformation (about various aspects of virus and disease) should remain a priority. Science communication with the public should be strengthened and sustained to counter misinformation.  The general health services, both government and private facilities, for post and long Covid conditions need to be expanded and strengthened. The strengthened mental health services should get renewed attention. For both, post Covid and mental health services, tele consultation services should be strengthened.

One thing is certain -- the Covid-19 pandemic will be over. However, SARS CoV2 is likely to stay with humanity for long. All epidemiological and immunological evidence suggests that India is inching towards a Covid-19 endemic stage. It is time we as a society start preparing to live with Covid-19. This requires actions at individual, societal and policy level.