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‘The pandemic is far from over – but this is how it ends’

A health worker fills up a syringe with a vaccines dose against COVID-19 as people queue at the Kya Sands informal settlement to be vaccinated by the Witkoppen clinic in Johannesburg - EMMANUEL CROSET/AFP via Getty Images
A health worker fills up a syringe with a vaccines dose against COVID-19 as people queue at the Kya Sands informal settlement to be vaccinated by the Witkoppen clinic in Johannesburg - EMMANUEL CROSET/AFP via Getty Images

Prof Salim Abdool Karim is all too aware that the public and even scientists are bored of the pandemic.

“I tell you, everybody is fed up of Covid,” the face of South Africa’s coronavirus response said at his office in his Durban office, which is adorned with diplomas and press cuttings from a long, illustrious career.

“I don’t know anybody who is still excited about Covid. They don’t want to hear about it. They don’t want to wear masks.”

The past two-and-a-half years of the pandemic have thrust the 62-year-old clinical infectious disease expert into the spotlight as one of the world’s leading global health figures.

After a long career tackling HIV in his native South Africa, he became the government’s top adviser on the pandemic. He has inevitably been dubbed his country’s equivalent of America’s Dr Anthony Fauci, or the UK’s Prof Chris Whitty.

Prof Salim Abdool Karim - RAJESH JANTILAL/AFP via Getty Images
Prof Salim Abdool Karim - RAJESH JANTILAL/AFP via Getty Images

Yet he warns that while fatigue towards the pandemic is widespread, it may have been rash for Joe Biden to declare the whole thing finished, as he did two weeks ago.

“The pandemic is over,” the United States president told a television interview on September 18. “We still have a problem with Covid. We’re still doing a lot of work on it… but the pandemic is over.”

“It’s a very brave person who is willing to say that,” countered Prof Karim, noting that the coronavirus still has plenty of potential to evolve.

But while that might leave nasty surprises in store, Prof Karim also believes that the other ingredients needed to reach a pandemic endgame are coming together.

As the UK’s Covid inquiry launches on Tuesday, the end – if not yet here – can be glimpsed.

‘Will we see new variants? Yes’

South Africa’s scientists have played a leading role in helping understand the pandemic and several of its laboratories have emerged as leading sources of insight.

Years of studying the rapidly evolving HIV virus had left the country well placed to monitor the spread and evolution of the new coronavirus. Indeed, it was South African laboratories that were at the forefront of identifying and publicising the first Covid variants in late 2020 – and also discovered the omicron strain.

Moreover its position as a hub for migration from African countries which themselves at first had little surveillance capability has made it a window to glimpse how the virus might be developing elsewhere on the continent.

That expertise suggests to Prof Karim that the current omicron sub-variants tearing around the world are unlikely to be the last. The extensive genome of the coronavirus has plenty of space for new evolution to take place, he believes.

“It hasn’t even explored a fraction of its potential,” he said. “Are we going to see Pi? That’s the next letter in the Greek alphabet. I don’t know. My money is yes. When? I don’t know. I thought it would be here by now.”

His caution is shared by Prof Alex Sigal, who studies Covid variants at the Africa Health Research Institute.

“You have to be careful where you don't get in this situation where you are calling something based on wishful thinking. Yes, we want to see this thing over, but the infection is all around us.”

The Africa Health Research Institute - Africa Health Research Institute
The Africa Health Research Institute - Africa Health Research Institute

As long as the virus persists, and large swathes of the population are infected, it is difficult to predict what will happen, he said. Any new variant must out-compete those still swirling around, so if one does emerge it will have to spread faster and be able to bypass immunity.

“I think that if there's going to be a new variant, Pi I mean, it's going to be faster and it's going to escape immunity,” Prof Karim said. “But we have no idea whether it's going to cause severe disease or not. Because we don't know what genetic mutations are associated with severity of illness.”

His hunch is that immunity built up from vaccinations and previous infections will still act as a barrier against severe disease, but it is not certain.

South African research has also cast light on how and where the new variants might be evolving. Researchers including Prof Sigal's team have found that the virus persists in people with weakened immune systems. Where a normal immune system might clear the virus in two weeks, in these people with damaged immune systems it can hang around for many months, replicating and evolving.

One theory is that this process played a significant role in how variants have arisen in the past two-and-a-half years. Immunocompromised patients such as cancer and transplant patients are all over the world, but Southern African countries also have a significant number of HIV patients whose immune systems are not working properly if they are not taking antiretroviral drugs.

How the pandemic ends

For all the unknowns about potential new variants, if one does arise, the world will not be back to square one, Prof Karim predicted.

At some point the virus will eventually reach evolutionary dead ends, he said, meaning there will be no new major variants. At that point it will switch from waves of infection to becoming endemic. Combined with widespread immunity, better treatments and new vaccines, that will mark the endgame.

If the first year of the pandemic was all about mass public health measures and the second was all about vaccines and variants, he says the third year has been about new treatments. There are currently 23 trials of drug treatments underway and the number is growing all the time.

“Come next year we will basically be treating Covid with combination antiretrovirals, just as HIV is treated,” he said.

The last stage will be a universal pan-coronavirus vaccine that works on all variants. Several are already in clinical trials. All this means that we are past what he calls the “pandemic emergency”.

“We are unlikely to go back into an emergency. Even if Pi comes along, it will be different from the first variant. We won't treat it like that.”

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