SARS-CoV-2 isn’t going anywhere just yet.

It was once hoped that global eradication of COVID-19 may be a possibility; through vaccines and tough disease mitigation strategies, it was believed we could extinguish this novel virus into obscurity. However, since coronaviruses are so fiendishly skilled at reinfecting people, that bold goal of eradication is now looking improbable. Some countries are still chasing the so-called “zero-COVID” eradication approach, but most are moving away from these elimination strategies and edging towards mitigation strategies.

It appears the world will have to “learn to live” alongside COVID-19, just like how we do with common colds, influenza, chickenpox, and all manner of nasty infectious diseases. But what will this new world look like? And, most pressingly, what will the journey there look like? 

Can We "Learn To Live" With COVID-19?

One common optimistic view among scientists is that SARS-CoV-2 may eventually become a common cold-like bug that causes little more than a sniffle. Along with the three novel coronaviruses that have sparked significant disease outbreaks in recent decades — MERS-CoV, SARS-CoV, and SARS-CoV-2 — there are four types that commonly infect humans: 229E, NL63, OC43, and HKU1. These four coronaviruses are responsible for an estimated 20 to 30 percent of common colds. Chances are you’ve come across some of these in your lifetime, most likely as a child, and they caused little-to-no significant impact on your health. However, they are only relatively harmless now because we, as a global population, have acquired immunity over the past decades and centuries. 

Over 130 years ago, an infection from one of these coronaviruses would have looked very different. There’s some strong evidence that the devastating “Russian flu pandemic” of 1889 to 1891 was not actually influenza, but the coronavirus OC43 having its first foray into the human population. Eventually, much of the global population slowly but steadily gained immunity to the virus and it no longer caused violent surges of deadly infections. 

This is an example of a virus becoming “endemic," when levels of infection are constantly present but are not uncontrollably spreading and are somewhat manageable. Although this term describes bugs like colds and chickenpox, an endemic disease doesn’t necessarily mean it’s harmless. Malaria is technically endemic and it still causes around 600,000 deaths a year, according to World Health Organization (WHO). Likewise, HIV is endemic in significant parts of sub-Saharan Africa and still kills almost 1 million people globally every year. 

It's not yet clear if (or when) SARS-CoV-2 will turn into a common cold-like bug or whether COVID-19, if it becomes technically endemic, will still cause major upset for some years to come.

“There are four other endemic human coronaviruses that came from the animal kingdom into humans and they’re causing the common cold. It’s not known whether this will become the fifth endemic coronavirus that causes a common cold, whether it will be long-term endemic, or just short-term endemic,” Professor David Heymann, an infectious disease epidemiologist from the London School of Hygiene and Tropical Medicine, told IFLScience. 

As the UK, Denmark, and the Netherlands lift almost all their health restrictions, Professor Heymann, who previously served as WHO’s Assistant Director-General for Health Security and Environment, believes they are already well on the way towards treating COVID-19 as an endemic disease. In his view, the UK government is now shifting towards a different tactic: instead of blanket restrictions across the board, they’re going to focus on a finely tuned approach using surveillance, all while pushing more responsibility to the individual. 

“The government is ramping up its ability to investigate outbreaks,” Heymann explained. “The UK has set up a whole series of systems that will make sure they’re dealing with it as an endemic disease. They have influenza-like illness surveillance that will also detect whether there’s coronavirus if they add testing to that, which they will do.” 

The shifting of the responsibility from government action to the individual is a well-recognized sign of treating a disease as endemic. 

“They have also transferred responsibility of risk assessment from the government, which uses tools like blunt lockdowns, to individuals who are using self-testing to determine if they’re a risk to others, as well as wearing masks and other things,” he added. 

He believes some Asian countries, such as Singapore and South Korea, have already nailed this framework, perhaps because they learned lessons during the 2002–2004 SARS outbreak. From the get-go, many Asian countries were providing self-testing, had a good surveillance system in place, and executed precision lockdowns. 

What May Endemic COVID Look Like?

Most experts agree that “living with COVID” doesn’t simply mean we should drop all control measures overnight and instantly go back to the way the world worked in 2019. This approach would result in a huge number of deaths, especially among the vulnerable, elderly, and people with compromised immune systems.

Living with COVID may not mean the total abandonment of "lockdowns" just yet. Sweeping nationwide lockdowns, however, are unlikely to make a comeback. Heymann believes that advanced surveillance and investigation will be used in the UK to closely understand where and when transmission is occurring, so the government can use precision lockdowns if they feel it’s necessary. 

Along with advanced virus surveillance systems, there are certain measures that could help to manage future COVID-19 outbreaks with greater subtlety and intelligence. Dr Elizabeth McNally is a Professor and Director of the Center for Genetic Medicine at Northwestern University who has spent large chunks of the pandemic developing an at-home COVID-19 antibody test. Unlike a typical PCR test or lateral flow, an antibody test doesn't help to show whether a person has an active infection, but it reveals whether their body has previously come into contact with the virus and gained some immunity to the disease. 

McNally told IFLScience that she hopes accessible antibody tests could be useful tools to guide vaccine strategies in the months and years ahead. 

"I have been very struck by how knowing antibody status has really helped people, even as part of a research study," Dr McNally said. 

"With my patients, especially those who are immunocompromised or have serious high-risk health conditions, I frequently wish I had access to quantitative information about their vaccine response. Just yesterday, one of my patients was asking about a fourth shot, and in the ideal world, I would really like to know his antibody status so that I could give him the best advice." 

As for the future of COVID vaccines, it looks like a fourth dose booster will be offered to people in the US and parts of Europe, perhaps as early as this summer or fall 2022, according to Dr McNally. However, it's unclear whether the additional booster will be necessary for everyone. It's also uncertain whether a constant flow of COVID vaccine boosters will be needed in the years to come, although some have floated the idea of annual COVID-19 vaccine boosters, comparable to the annual flu shot that changes each year based on scientists' predictions of the most prevalent strains active that year. 

Are we there yet? Perhaps Not 

When we look towards the new world of endemic COVID, it's crucial to remember there's a huge disparity between parts of the planet where vaccine inequity exists; while most countries in Europe and North America have the majority of their adult population vaccinated, Africa is still struggling to expand rollout, with only 11 percent of the continent being fully vaccinated. Considering this, the risk of new highly virulent variants cropping up in populations that don't have immunity up is still a huge concern and, as we saw with previous variants, a few mutations can have the power to dramatically sway the trajectory of the outbreak. 

At the same time, the world has changed significantly since SARS-CoV-2 burst onto the scene. Much of the world is now armed with vaccines, tests, and antiviral therapies, our understanding of the virus has grown at a remarkable rate, and millions around the world have already developed antibodies to the virus after being infected. 

It's likely the pandemic will end, or be declared over by the WHO, when the virus reaches a final variant that can't better itself or global immunity is achieved, neither of which, however, is likely to happen this year.

For now, it appears that we can see the road ahead, including all of the speedbumps, potholes, and hurdles, even if the time frame is unclear. If COVID-19 has taught us anything, however, it's to always expect the unexpected.