Has COVID-19 become endemic or not, that is the question. While the world over, the debate rages on whether COVID-19 has reached an endemic phase, in India there seems to be broad consensus that it has, in India, though epidemiologists might have taken various paths to get there. Interestingly, another question, whether endemicity is significant at all in the current context, is also cresting this wave of discussion among professionals, and might even take over the debate in the not so near future.
Jacob John, retired professor of virology, Christian Medical College, Vellore, says the terms endemic and epidemic are based on patterns, and no one has attempted yet to post numbers that could establish the stage the SARS-CoV-2 virus is at currently. However, he uses a comparison with the numbers of the past, more a rule of thumb criteria to argue that the infection has entered the endemic stage in India.
Considering the seven-day average of cases during the peak of the epidemic, the daily numbers have not crossed the 10% of that figure since the decline in numbers began, he points out. Despite the rise in cases in the last few days, the number has remained below 10 % of the seven-day average of cases during the peak of Omicron, Dr. John says. There has been a similar trend in South Korea, he adds.
“If you look at Bharat COVID-19 or World-o-meter, the disturbances in the flat line since the drop have been very minor,” he says, adding that similar to what happens in an epidemic, the numbers have been going up only in certain cities in Maharashtra, Kerala, Delhi and Tamil Nadu. “It is still virtually a flat line.” Even when a disease is in the endemic stage, there can be seasonal outbreaks, and the spike in cases that a few cities in India are seeing now, could be equated to that, he reasons.
Chandrakant Lahariya, epidemiologist and public policy and health systems specialist, treads another path to arrive at his conclusion. Endemic and pandemic are all academic terms, not dependent solely on scientific parameters, he says. He draws attention away from the endemic-pandemic binary to a more experiential angle. “We know the extent of social and economic impact that COVID-19 had on the world. So, I believe that the idea is for societies to agree that the infection is an acceptable risk, as some countries are already doing so, despite the numbers going up. None of these countries are saying the disease is endemic, but they are saying ‘life is returning to normal.’ Of course, this will differ from country to country.
Dr. Lahariya also says it is his firm belief that it is irrelevant to India to debate endemicity or not of the virus in the country. “We should approach it from the practical position of ‘acceptable risk’ - of whether or not it is disrupting social and ecomomic life in the country.” India has reached a stage wherein the virus is not creating great havoc in terms of death or morbidity. “Three years down the line, a nation could look back and mark the point of time in which it turned endemic, but it is not logical or practical to look for these signs now,” he explains.
While he advances the view that the disease is no longer a population-level public health challenge, but rather an individual one, and recommends that our responses change appropriately, once again professionals are split in their opinion on this too. While Dr. Lahariya recommends protection of the vulnerable, continued economic surveillance, tracking the parameters (but don’t worry) and COVID-19 appropriate behaviour, he believes that the onus has moved on to the individual, from the health system.
“I agree with the view that endemic or not, our action right now must be linked to where we are in terms of vaccination coverage (public health coverage), and continuing surveillance,” says Prabhdeep Kaur, deputy director, ICMR- National Institute of Epidemiology, Chennai. “This virus is fascinating in terms of its evolution, it keeps springing surprises on us. It is not like anything we have read in our text books.”
At present, she says, COVID-19 does not conform to the text book definition – by being present all over the world, though it waxes and wanes, and not being confined to a few areas. That is probably why, she reasons, why epidemiologists find themselves ranged on different points of the endemicity spectrum.
“The point is if we know that a disease in a community is present at a certain level, we do not have to react to it. There are different thresholds for different diseases and they also may be seasonal thresholds, but we have not been able to establish the threshold for COVID-19, because of several reasons – including changing practices for testing and surveillance. At the moment we have to calibrate when we have to launch an outbreak-like response,” she adds.
COVID will continue to remain a disease of importance that has the ability to cause outbreaks, Dr. Kaur explains, listing why she believes vaccination should continue to be a public health activity. If we fail to do this, there is potential to cause great damage in terms of mortality and morbidity.
Dr. John says: “Somehow vaccination in India seems to have lost steam along the way. People are now asking why vaccinate when the peak is over. And as far as the government goes, the outreach and public education activity on why a booster dose is required, has not been sufficient. There is a difference between individual vaccine for averting risk, and a population-based vaccine. We still have to focus on the latter.”
Along with the vaccine, the other tool in the armoury is mask wearing, Dr. John says. He recommends that governments make mask wearing mandatory in public gatherings and public places, whenever an upswing in the number of cases is noticed. If left to the individual’s choice, compliance will be very low, and leave a number of people without the protection that masking affords, he adds.
