The End of COVID-19? Not for Everybody.

We are now entering our fourth spring of the global COVID pandemic. But this spring looks far different from the last three. April of 2020 saw the world scrambling to get public health measures in place while still maintaining essential health services.

April of 2021 arrived with surges in deaths, even as we started to roll out vaccines to most countries. April of 2022 brought additional surges in deaths, despite effective vaccines, because new variants of the pathogen -- and the world’s pandemic fatigue -- allowed the outbreak to grow.

Now, in April of 2023, the world has largely moved on from the pandemic. Today we rarely see masks worn in public. Hand hygiene stations in stores and airports are rarely replenished. Absent are clear messages about boosters for our COVID-19 vaccines. Gone, it would seem, is the worry about being infected with COVID-19.

But dig a little deeper and you will find signs everywhere that the world has not put COVID entirely behind it, at least not when it comes to those billions of people still at risk of serious outcomes from COVID.

A close friend of mine – I’ll call him Albert - in our community here outside Geneva, Switzerland is older and lives alone, having lost his spouse years ago. He has diabetes and a heart condition, the latter of which he feels has been made worse by the one COVID-19 infection he got earlier in the pandemic. “It was a friend who came by to bring food. I had not seen anyone in so long, I asked him to stay for chatting,” he told me recently. “We wore masks and sat with the windows open, despite the Swiss winter cold. Still, I got infected!”

Albert suffered terribly from that infection. He had high fevers, lost his sense of smell and taste, became very confused and had trouble breathing. He was nearly hospitalized after his oxygen level dropped so low he could barely move in his house. He now lives in fear of any future infection. “I used to be very active in our church, go out and see friends,” he says wistfully. “But now, no one wears masks, no one is worried about COVID anymore. But I am.”

Albert’s story is being played out repeatedly across many countries where the elderly, and those with other health conditions, find themselves at high risk when it comes to a COVID-19 infection.

According to the WHO, the world is officially at one of the lowest points in terms of weekly case and death counts for COVID-19. In total, there have been 761 million cases and nearly 7 million deaths, though most experts agree the real number is probably 10 times this amount.

Recent reports have still seen somewhere between 5,000 to 6000 deaths per week globally, just slightly less than the number dying weekly from homicide. These numbers, however, are only coming from those countries that have continued to case-count, as most have stopped. In fact, countries that are continuing to case-count such as Canada or Australia, are seeing increases in both cases and hospitalizations.

So who is still at risk in this context? Most assume that it is a relatively small population made up of elderly people like Albert. The elderly are an important group but they are certainly not the only communities we need to consider. Anyone who is immunocompromised or has any of a list of nearly 20 underlying health conditions is also in this group. These individuals range from ages five to 65.

In fact, it is estimated that 1.7 billion people (22%) of the global population, has at least one underlying condition that makes them vulnerable to severe COVID-19 [1]. This is roughly five times the population of the entire United States.

But does being at risk now mean those communities will always be at risk? Will there never be a moment when Albert and billions like him can feel relaxed in public again? The short answer is no one can say.

Despite inaccuracies in case numbers, it is clear that transmission of COVID-19 is slowing from its past peaks. It is also seems clearer from recent studies showing the Omicron-derived variants of COVID-19 are less likely to give rise to cases of Long COVID.

At the same time, the world is resetting in ways that do not take vulnerable populations into consideration. Countries like the UK are destroying stocks of personal protective equipment by the millions. Countries across Europe are standing down testing and case reporting. Countries like the U.S. are ending their COVID-19 “task forces” and financial support for COVID-19 related health services.

While the pandemic has surprised experts and policymakers alike across the past three years, it seems clearer that we are now entering the phase of the COVID-19 pandemic that renowned physician and epidemiologist Larry Brilliant calls “the way the coronavirus retires.”

This means that the virus is less able to infect people because of variant evolution and background immunity levels, but the public has discontinued strong public health measures, so there is low-level yet constant transmission. Of the 10 viruses that give us seasonal colds, four are coronaviruses and COVID-19 will likely become the fifth.

Until then, what should be done to help vulnerable populations combat their FOGO (fear of going out)? Well, clearly there are things that individuals can do and things that we must continue as a public health community.

For those at high risk, individuals can and should stay up to date on vaccinations and look for ways to avoid infection.

As a collective, we need to do much more. Local health authorities and governments need to finally come out with clear guidance on boosters, including examining how waning immunity means a “once a year” booster may not be sufficient for those most at risk.

Secondly, we need to continue to monitor the virus. Just last month, one of the core data sources for many websites on COVID-19 numbers, the Johns Hopkins COVID-19 Dashboard, was halted. If we become completely blind to how the pandemic is ebbing and flowing at this stage, we are surely going to be surprised by any surge, however small. If case numbers are no longer viable measures, then weekly mortality tracking is essential.

Finally, some of the services set up for earlier phases of pandemic response need to be continued for at-risk individuals – such as video medical consultations and home health support.

Clearly, the COVID-19 pandemic is in a new phase, one that is more hopeful than at any other time in the emergency. But hope should be something we offer all communities, especially our most vulnerable people.

Ed Kelley is the Chief Global Health Officer of ApiJect and Former Director for Integrated Health Services at the World Health Organization

Charlotte Mackay is a Research Assistant with ApiJect

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[1] (https://www.thelancet.com/article/S2214-109X(20)30264-3/fulltext)