MALAYSIA could see the Covid-19 pandemic begin fading next year into an endemic disease, like the flu or the common cold, unless more dangerous or transmissible variants emerge and gaping vaccine inequalities are left unattended.
The year "2022 must be the end of the Covid-19 pandemic" as countries would by then have all the tools to fight the virus, World Health Organisation (WHO) director-general Tedros Adhanom Ghebreyesus said on Dec 22.
While this appeared optimistic, some scientists are rewriting the recovery timetable as the more transmissible Omicron variant overtakes its predecessor Delta in several countries.
Global citizens are reportedly experiencing fatigue, dread and déjà vu as countries reimpose coronavirus restrictions amid the WHO's warning that both the Omicron and Delta variants of concern are contributing to a "tsunami of cases".
Will the new year spell the end of the pandemic? Three experts — Universiti Malaya epidemiologist Professor Datuk Dr Awang Bulgiba Awang Mahmud, molecular virologist Dr Vinod Balasubramaniam and Universiti Malaya (UM) Medical Centre public health medicine specialist Associate Professor Dr Rafdzah Ahmad Zaki — weigh in on the Covid-19 landscape in 2022.
Looking ahead, Dr Awang Bulgiba, who is Science, Technology and Innovation Ministry's Covid-19 Epidemiological Analysis and Strategies Task Force chairman, expects 2022 to be the "make-or-break year" for Covid-19, when Malaysia would either see the beginning of the end for the pandemic or the beginning of an entirely new normal.
"We have amassed a great deal of knowledge about the virus and effective prevention and treatment options to formulate some interesting hypotheses on how things will work out.
"But in truth, I think things will become clearer only towards the second half of 2022."
Dr Vinod, a senior lecturer (microbiology) at the Jeffrey Cheah School of Medicine and Health Sciences in Monash University Malaysia, dubbed 2022 as "the road towards endemicity" as Malaysia would finally have all the means, measures and tools to control the pandemic to a non-lethal state.
"We have endured two years of missed opportunities, education, connections with family and loved ones. Without action, 2022 could be the same.
"Three levers are likely to be especially important, countries' making new Covid-19 oral therapeutics available, accelerating booster shots and finding the right combination of public health measures."
UM's Centre for Epidemiology and Evidence-Based Practice head Dr Rafdzah said 2022 will be the year of recovery from all health, social and economy aspects, but noted that the challenge of emerging new variants remains.
"Historically, the 1918 influenza pandemic (Spanish flu) lasted about two years. So, we hope to see the end of this Covid-19 pandemic soon," she said.
"But unlike then when there were no flu vaccines, human movement was also not as rapid.
"Today, we have Covid-19 vaccines, but human movements and interactions are high. Also, the Spanish flu virus didn't just go away. A descendent of the virus, which is the modern H1N1, circulates to this day. Thus, we don't expect Covid-19 to disappear completely."
OMICRON AND NEWER VARIANTS
Dr Awang Bulgiba said as the Omicron threat looms large into 2022, the government should ramp up booster administration.
According to the Health Ministry's CovidNow portal, a total of 25,603,645 people have been fully vaccinated up to Wednesday, but only 5,908,852 people have received their booster shots.
If administered quickly, he said Omicron may lead to a short, sharp surge of infections (due to waning antibody levels) followed by a rapid fall in infection numbers as booster doses reestablishes widespread population-level immunity.
"Omicron differs from the original wild coronavirus from Wuhan, which has sparked a debate about the evolutionary path of the virus.
"Omicron is more infectious than Delta, replicates more rapidly and is more likely to infect the upper rather than the lower respiratory passages.
"But it has a lower virulence than the earlier SARS-CoV-2 variants, meaning that it causes a milder illness. A milder illness is not necessarily due to the virus being weaker, but may point to evidence of long-term population immunity prevailing over the variant.
"If the country can weather an Omicron-fuelled infection surge and reestablish sufficient population-level immunity through booster doses, there is a likelihood that an equilibrium will be established between the SARS-CoV-2 virus and its human host.
"Such an equilibrium will mark the start of an endemic state, unless another variant emerges, which upends such an equilibrium."
Consultant paediatrician Datuk Dr Amar-Singh HSS, last month, cautioned that Malaysia could expect an Omicron wave from January to March 2022.
The United States-based Institute for Health Metrics and Evaluation had also predicted a sharp rise of cases in Malaysia due to Omicron, with daily infections projected to hit 300,000 by the end of January.
On the possibility of more dangerous variants emerging, Dr Awang Bulgiba said if the evolutionary path of the virus follows the same path as Omicron, and vaccine inequity is addressed, the chances of such variants developing could be greatly reduced.
Dr Vinod said newer variants are inevitable as the more the virus is allowed to circulate, the more opportunity it has to evolve.
"SARS-CoV-2 has shown its ability to become better adapted to the human host, with variants Alpha and Delta demonstrating enhanced transmissibility.
"One of the biggest unknowns in 2022 will be how this evolution continues.
"Delta continues to evolve, and Omicron has shown that the virus will continue to adapt, and such variants may be more transmissible, cause more or less severe disease, and/or develop properties of immune escape."
GLOBAL VACCINE EQUITY
AND BOOSTERS
Dr Vinod said as the inequity of Covid-19 vaccine distribution comes into sharper focus, 2022 could be the year nations join hands to ensure equal global vaccination, which is key to stopping variants.
"If we don't address vaccine equity quickly enough, our exit from the pandemic will be set back, possibly for months or years on end as seen with the spread of Omicron in South Africa, where just over 35 per cent of people are fully vaccinated."
He said boosters should be prioritised despite the long-term protection of these doses remains to be seen.
"Our immune system is multi-layered and we will have other means of protection, namely from our B cells and T cells, in giving long-term protection should immunity from the booster doses wane, such as reduction in neutralising antibodies over time.
"How frequent these booster doses are needed depends on real-time data over time. Variant-specific boosters are in the pipeline."
Dr Rafdzah said should WHO's target of achieving 70 per cent immunisation coverage at the global level by mid-2022 be achieved, countries can expect the global trend of infections to reduce by the fourth quarter.
"Although young children have not been vaccinated yet, they will have indirect protection if they are living among vaccinated adults," she said.
Dr Awang Bulgiba, however, said it wouldbe difficult to achieve the target in all countries due to supply, logistics and behavioural issues.
The current situation, he said, was made more complicated by global vaccine inequity and the emergence of newer variants, which are related in a chicken-and-egg situation.
"Global vaccine inequity can result in the emergence of newer variants in low-resource countries, which have low vaccine coverage.
"This then causes richer nations to hoard more vaccine doses, which in turn worsens the global vaccine inequity, leading to even newer variants emerging.
"It is a vicious cycle that can only be broken if there is a concerted effort to address this global vaccine equity."
COVID-19 ANTIVIRAL DRUGS
Dr Vinod said the new antiviral drugs may aid in the fight against Covid-19 in 2022 and increase survival chances for coronavirus patients suffering severe conditions.
He said recent results from pharmaceutical companies Merck-Ridgeback Biotherapeutics and Pfizer on their oral drugs Molnupiravir and Paxlovid, respectively (two antivirals, with different mechanisms of action), represent a material advancement and increase the chance that the impact of the Omicron variant can be controlled.
He said Pfizer, in its final study, reported that Paxlovid reduced the risk of hospitalisation or death by about 89 per cent for high-risk patients and about 70 per cent for standard-risk patients.
"Such therapies are also easier to administer in lower-resourced regions than injected or infused treatments are.
"Furthermore, manufacturing small molecules rapidly is faster than the process for monoclonal antibodies.
"Initial evidence indicates that the efficacy of these therapies is unlikely to be reduced by the mutations present in the Omicron variant."
Dr Awang Bulgiba said these drugs were useful in the early treatment of infected patients, or for the prevention of Covid-19 infection in people whose immune systems do not respond well to vaccines.
However, he said, antiviral drugs and monoclonal antibody treatments cannot replace vaccines, which stimulates people's immune systems to be better prepared to fight off the virus.
TRANSITION TO ENDEMICITY AND COVID-19 RESTRICTIONS
An endemic disease, Dr Awang Bulgiba said, is defined as "the constant presence of a disease or
infectious agent within a given geographic area or population group, and it may also refer to the usual prevalence of a given disease within such an area or group".
"An endemic state does not happen just because we declare it to be so. It can exist with intermittent outbreaks, which may be mitigated by effective treatments, vaccine boosters and targeted measures and the economy can be kept open with minimal disruption.
"If, however, treatments and vaccines become ineffective, NPIs (non-pharmaceutical interventions) will return. Should an endemic state occur without intermittent outbreaks, two things may happen.
"If endemic levels of disease are low, normal life may resume, but if endemic levels remain high, NPIs will remain in some form or the other."
He said NPIs need to remain in place, be strictly enforced and may need to be tightened throughout 2022 until the fundamental problems that continue to plague the pandemic are tackled.
Dr Vinod said only when the majority of the Malaysian population are boosted (at least 70 to 80 per cent of the population, especially the vulnerable groups) and with the availability of the currently approved effective oral anti-Covid-19 drugs, such as Molnupiravir and Paxlovid, to supplement treatment in hospitals can Malaysia think about entering endemicity.
"The main goal is to remove the severity of the spectrum of the disease for us to live with the virus."
He said next year, Malaysia and much of the world will need to continue with effective measures as the virus transmission is brought under control.
This, he said, includes getting three doses of the vaccines, wearing N95 face masks, observing psychical distancing, hand hygiene, improving indoor ventilation, testing to identify potential asymptomatic spreaders, isolating patients, increasing whole-genome sequencing of SARS-CoV-2 samples in circulation, and disallowing large gatherings.
"We cannot let our guard down and remove any standard operating procedures and public health measures.
"Have we not seen enough the effects of removing restrictions earlier in the United Kingdom, and the surge of cases involving increased hospitalisations?"
VACCINATION CERTIFICATES OR PASSPORTS
Dr Awang Bulgiba said vaccine passports could be a prerequisite for local and international travel next year.
Local use of vaccination certificates, he said, is less problematic as it involves a country's internal affairs and is limited to access to facilities or localities within one's own country.
"However, there will be people who, for medical reasons, cannot yet be vaccinated. Children are being vaccinated now. but there are still some age groups for which most vaccines have yet to be approved.
"There will also be the question of what type of vaccination certificate that can be accepted, electronic or paper or both, the question of authenticating those certificates, the definition of 'fully vaccinated' (double-jabbed or with booster), and whether those 'partially vaccinated' should be allowed the same privileges as those 'fully vaccinated'."
For international travel, he said, an international vaccination verification system or vaccine passport involves several issues, such as the sovereignty and rights of nations, as well as individual rights.
There are also questions of the feasibility of establishing such a system, its trustworthiness and its effectiveness in the face of potential virus mutations, he said.
"The variability in vaccine effectiveness and whether all vaccines can be recognised as being equivalent in effectiveness also come into play. Reciprocal recognition of regulatory approvals from different countries will be needed which may prove to be a stumbling block."
Dr Rafdzah, meanwhile, said to expedute higher coverage of vaccination at the global level and prevent cross-border infection, vaccine passports should be mandatory.
"The only way of controlling and preventing border spread is through monitoring travellers."
LONG COVID AND MENTAL HEALTH
Dr Rafdzah said an emphasis on tests and treatments for "long Covid" are on the horizon in 2022 as patients suffer from some combination of post-Covid-19 symptoms.
She said while mild or moderate Covid-19 infection lasts about two weeks for most people, others may experience lingering health problems even when they have recovered from the acute phase of the illness.
"SARS-CoV-2 can attack the body in a range of ways, causing damage to the lungs, heart, nervous system, kidneys, liver and other organs.
"Mental health problems can arise from grief and loss, unresolved pain or fatigue, or post-traumatic stress disorder after treatment in the Intensive Care Unit."
The most common lasting symptoms, she said are fatigue, shortness of breath, cough, joint pain and chest pain. Other issues include cognitive problems, sleep problems, difficulty concentrating, depression, muscle pain, headache, rapid heartbeat, loss of smell or taste and intermittent fever.
She said doctors and therapists could address specific symptoms and it would require a multidisciplinary team to support the recovery of people with long Covid.
"Breathing exercises, physical therapy, medications and other treatments can help improve the symptoms but be prepared for a gradual recovery."
She added that as the recovery period for mental health takes longer than physical health, services on mental health and social support need to be strengthened for 2022.
Dr Vinod noted that about 10 to 30 per cent of people infected with SARS-CoV-2 may develop symptoms that last beyond four weeks.