COVID-19 Explained: What Is The Endemic Stage Of COVID-19 That India May Be Entering Into?

New Delhi: “We may be entering some kind of stage of endemicity where there is low-level transmission or moderate level transmission (of COVID-19) going on, but we are not seeing the kinds of exponential growth and peaks that we saw a few months ago. As far as India is concerned that seems to be what is happening”, said WHO Chief Scientist Dr Soumya Swaminathan, in an interview with The Wire. Ms Swaminathan believes that the situation in India may continue like this with ups and downs in different parts of the country, particularly where there is a more susceptible population.

Also Read: Explained: What Is A Breakthrough Infection And How To Prevent Catching COVID-19 After Getting Fully Vaccinated

But what does entering into an endemic stage mean? Does it mean an end of the COVID-19 pandemic? The United States’ Centers for Disease Control and Prevention (CDC) defines endemic as “the constant presence and/or usual prevalence of a disease or infectious agent in a population within a geographic area.”

Explaining the endemic stage of a disease in simple terms, Dr TS Anish, Associate Professor of Community Medicine, Government Medical College, Thiruvananthapuram and Member, Kerala’s State Expert Panel of COVID-19, said,

Endemic means the disease is there along with the population, nobody is very much concerned about the disease, but it is there. The disease is affecting a very small proportion of the society, neither growing nor shrinking at a faster rate. It is just there with you. At any point in time, you may or may not get the disease. For example, every year we get some amount of diarrhoeal disease in Kerala. This happens with every pandemic, before it ceases to exist, there will be a sustained period of endemicity that means your system might not be concentrating on the disease and your health system may not be stretched by the disease.

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However, the CDC believes that under such a situation, in the absence of intervention and assuming that the level of the disease is not high enough to deplete the pool of susceptible persons, the disease may continue to occur at this level indefinitely.

Tuberculosis, dengue, malaria to name a few are endemic infectious diseases which we have learnt to deal with. If we dial the clock back because back then we did not have much information, dissemination of information, social media, media interest, we did not even look at these diseases with so much worry, said Dr Ravindra Mehta, Chief of Pulmonary and Critical Care Medicine at Apollo hospitals, Jayanagar, Bangalore.

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How Is An Endemic Different From Epidemic And Pandemic?

The CDC defines an epidemic as an increase, often sudden, in the number of cases of a disease above what is normally expected in that population in that area. Outbreak carries the same definition of epidemic but is often used for a more limited geographic area.

On the other hand, the term pandemic relates to the geographic spread of the disease. It refers to an epidemic that has spread over several countries or continents, usually affecting a large number of people. Pandemic is an epidemic on a global level. WHO explains that an epidemic becomes a pandemic when it spreads over significant geographical areas and affects a large percent of the population.

Pan means entire, demos means population; this means the entire population is affected. When the disease is spreading, cutting across the regional boundaries to maybe boundaries of continents and it is spreading all over the world then we call it a pandemic, said Dr Anish.

Also Read: Coronavirus Outbreak Explained: What Is The Difference Between Pandemic And Epidemic?

What Will Happen If COVID-19 Becomes Endemic?

COVID-19’s exit from the pandemic to endemic stage means it is there in some part or the other. It becomes like influenza; people are not worried about it. Endemic is desirable and better than a pandemic. It allows us to co-exist with the virus. Co-existence is another manifestation of endemicity, said Dr Mehta.

Further explaining the consequences of COVID-19 reaching the endemic stage, Dr Anish said,

If you look at the endemic diseases all over the world, especially airborne diseases, you will see that a significant proportion of endemic diseases are contributed by two families of viruses – influenza viruses and coronavirus. Both are originally animal viruses. Seasonal flu will affect the human population and may cause some kind of complications like a portion of our population may be affected. Most of them will be affected by a very mild disease but if the vulnerable group that means people with comorbidities and elderly age group are affected, it can complicate the situation in them. So, we will try to protect them by giving vaccines against seasonal flu. And wherever new flu viruses are introduced to the human population, we will modify our vaccines by incorporating the new flu viruses. This may happen for COVID-19 also. Even now, among the viruses which are causing flu like symptoms among human beings, almost 30 per cent of the viruses are in the group of coronaviruses.

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Dr Anish added that COVID-19 is going to lose its teeth due to natural infection and vaccination. For example, during the Spanish flu, the virus affected the human population more than once and then died and sustained for a long time during the endemic stage. However, back then, there was no vaccine for Spanish flu. Whereas in the fight against COVID-19, we have vaccines that have the property to reduce the clinical severity of the disease, he said.

Talking about the steps needed to contain the pandemic, Dr Giridhara R Babu, Professor of Epidemiology at Indian Institute of Public Health, PHFI, Bengaluru, said,

With COVID-19 becoming endemic, the world has to evolve a control strategy to prevent flare up’s resulting in higher numbers than the background prevalence. In this stage, the goal is to prevent deaths and not to prevent infection. This is why the ‘zero COVID’ strategy failed. They fail to recognise that it is impossible to eliminate this virus, at least at this stage.

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Endemic Stage Of COVID-19: Can One Stop Wearing Masks?

Double masking, hand hygiene and physical distance are the basic COVID appropriate behaviour put in place by health authorities to break the chain of transmission of the virus. But will we have to continue with these protocols, especially masking even when COVID reaches the endemic stage? Answering the same, Dr Giridhara said,

As long as there is a high circulation of the virus, we need to continue with COVID-19 appropriate behaviour. The trouble is that we are viewing this as a negative thing to follow these behaviours. We need to alter that state of mind at the population level. Whether you are vaccinated to not, you are at the risk of getting an infection and transmitting it.

As the new variants of Novel Coronavirus, emerge, there are reports that some of the variants may be more infectious and evade vaccines. This essentially means, we might need a booster dose or a second generation vaccine, which would be better in terms of the immunity it provides. With the possibility of COVID entering the endemic stage, a question pops up, will we have to take booster shots annually like in the US people take influenza (flu) shots?

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Dr Giridhara said, a booster dose is no magic; it cannot change anything in minimising the need for COVID-19 appropriate behaviour. Adding to this, Dr Anish said, it will be an individual’s choice to take a booster dose but there will be a risk involved in not taking – you might get infected with the new variant. However, in India, adult vaccination is not as popular as immunisation of children against numerous diseases, he said.

Similar to our youngsters or children, our elderly population is also vulnerable to viral diseases. But the routine vaccination happens only for children because, in India, the proportion of people aged 60 and above is around 10 per cent. In the future, this figure will rise, and we have to take care of the elderly and protect them from common infections. It’s a good idea to inject them with new coronavirus and influenza strains just like it’s being done in the US and Europe annually. Also, we might want to give a booster dose to everyone, that’s not known currently, said Dr Anish.

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When Will We Reach Endemic Stage?

In an interview with The Wire, Dr Swaminathan said that in a year and a half to two years, we will be in that position; hopefully by the end of 2022, we would be in a situation where we have achieved adequate vaccine coverage.

The WHO is calling for 70 per cent coverage in all countries by the middle of next year and if we can do that then I think, countries should start getting back to normal, she added.

In an interview with NDTV, Dr Randeep Guleria, Director, AIIMS said the Novel Coronavirus will not go away. However, it will become an endemic illness like flu which is happening to some extent in certain states and we will have to live with it.

This will happen in the coming months but I think it is too early to say that COVID-19 is entering the endemic stage in our country. We still have a large number of cases and a significant number of people who are susceptible. Unless we get a large number of people vaccinated and our cases come down, we can’t say that for the whole of India it has become an endemic disease, said Dr Guleria.

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