It is a world many of us can scarcely imagine. After two years of cancelled plans, QR codes and nose swabs, the end of the coronavirus pandemic in the UK still feels like a distant prospect.
And yet, cabinet ministers have claimed a post-pandemic future is within touching distance. Boris Johnson on Wednesday announced that people who test positive for the virus will no longer legally be required to self-isolate by the end of the month if “encouraging trends” in the data continue.
As such, ministers have suggested the disease could soon become “endemic” in the UK – a term once confined to virology textbooks but now gaining traction in Westminster and in newspaper columns.
Dr Mike Ryan, the director of the World Health Organisation’s health emergencies programme, has defined an endemic disease as one that is “circulating at a lower and more predictable rate in the population”.
But it is not as simple as flicking a switch. Though the public may have tired of lockdowns and daily case numbers, scientists warn the transition to “endemicity” is complex.
The Standard asked some of Britain’s top epidemiological experts how the virus could become endemic in the UK – and what “living with the virus” could really look like.
‘The change to endemic is about government response’
The introduction of the word “endemic” into the Covid discussion represents a political attempt to reframe the future of our public health response, one scientist tells the Standard.
It joins a long list of epidemiological buzzwords that have entered the public lexicon in the past two years - including herd immunity, exponential growth and droplet transmission.
“A critical point is that these terms are imposed as much as diagnosed,” says Professor Graham Medley, an expert in infectious disease modelling at the London School of Hygiene and Tropical Medicine.
“Endemic usually means that the disease is in the population all the time, but also carries the political and policy meaning that governments do not take any special action. Healthcare services provide special diagnostics and treatment but it’s certainly not an emergency.”
Influenza and the four human coronaviruses that cause common colds are endemic, but they do not prompt significant public health interventions. Prof Medley says the transition is “largely about the government response as much as the epidemiology”.
“Endemic does not mean that the virus or the disease has changed, just that the response to it is different,” he continues.
“A lot of it is about the public attitude to the disease. There will not be a clear time when it changes - it will be gradual.”
‘The transition to endemicity has already begun – but it could take decades’
Coronavirus may not fade into obscurity as quickly as ministers might like but the country is “on the road” to endemicity, says Professor Mark Woolhouse, the Chair of Infectious Disease Epidemiology at the University of Edinburgh.
“I think we are at the beginning of the transition to an endemic virus, but this could take decades rather than years,” he tells the Standard.
“However, I don’t expect those decades to be like 2020 or 2021 – the situation will improve as we go through the transition.”
Rather than the virus melting away, Prof Woolhouse imagines a future in which people contract coronavirus multiple times during their childhood – enabling a gradual build-up of immunity which will act as a buffer against severe illness.
“This is a very different picture to our current situation, so we need to get from this huge pulse of infection to something that we experience through childhood and becomes less serious as we get older,” he says.
“That is why I believe this will take decades. It will take an awfully long time before people have had the virus two or three times during their childhood.”
‘Endemic does not mean mild or severe’
Conversations around the transition of coronavirus to its “endemic” phase do not mean it is becoming milder, warns Professor Paul Hunter, an expert in infectious diseases at the University of East Anglia.
This despite the Omicron variant proving to be less severe but more infectious, with the UK’s case to fatality ratio falling compared with waves of previous strains. However, Prof Hunter warns that endemicity and severity must not be confused.
“You get the impression that people are using endemic now to mean that it is a mild infection,” he tells the Standard. “That is not implied in the term endemicity.
“Malaria is an endemic disease and that kills hundreds of thousands of children each year…Nobody would say it is mild.”
Prof Hunter claims that infection levels will eventually reach a stage of “endemic equilibrium”, when case numbers are constant across the population and do not show rapid surges or falls.
However, this will remain under threat from “escape variants” – such as Omicron – that can evade our natural immunity.
Prof Hunter says the variant is an evolutionary “step in the right direction”, as it poses less risk of hospitalisation, but it will “certainly not be the last step” as the virus continues to mutate.
‘Masks, testing and isolation will be scaled back’
Though the virus will continue to circulate in its endemic phase, the need for mandatory public health measures will diminish over time, argues Prof Hunter.
“At some point we will have to scale back the provision of testing, but I don’t see this happening before Easter,” he says. “It might even happen this summer or get pushed back until next year.
“However, I can’t see us doing the same amount of testing, isolation, and reporting of cases that we’re currently doing in five years time.
“It would be political suicide to abandon these measures now – while we are recording 60,000 daily cases – but at some point we will have to.
“That isn’t to say that testing should eventually stop, but we can’t continue to spend billions on it forever.”
Prof Hunter says that scrapping self-isolation rules entirely for those who test positive for coronavirus will be “difficult” due to lingering anxiety over contracting the disease, even as its case-to-fatality ratio drops due to vaccination, natural immunity and better treatments.
“There will remain a degree of nervousness around infections that lasts longer than the severity would merit,” he adds.
As for mass vaccination programmes, Prof Hunter says that vulnerable people may continue to be offered boosters in future – but stresses the situation could change.
“I would be very surprised if we are revaccinating younger people in the long-term,” he says.
In order to facilitate the transition into endemicity, Prof Woolhouse says that ministers will have to shift public health restrictions “from emergency mode into something more sustainable”.
Asked what measures may remain, he says infection controls in hospitals are likely to stay on given high levels of transmission in clinical settings, while care homes may retain some curbs to prevent outbreaks.
He adds: “I think mask-wearing will continue to some degree for some people particularly those who feel vulnerable.
“Testing will also be used – less in the community but focused on people in vulnerable settings. I suspect it will be scaled back but will still be there”.
However, he believes that some form of mass vaccination programme is likely to remain at least in the near future.
“We don’t vaccinate against other coronaviruses, but I don’t think we will stop it in the foreseeable future.”
‘The way we track the disease will change’
The British public has rarely, if ever, been so engaged by data. Millions of people follow the government’s daily 4pm statistics update and the progression of the pandemic at home and abroad is constantly being analysed in the media.
This attitude will eventually change, says Prof Woolhouse, as the virus fades from the news bulletins and general political discourse.
“It might still be one of the diseases we worry about the most, but I don’t think we’ll be doing anything like the amount of confirmatory testing for less severe cases or general surveillance,” he says.
“However, it is useful that we’ve given ourselves the capacity to do that so we can ramp it up again if needed.”
Prof Woolhouse also says a key factor will be the media’s interest in reporting the virus. “The pandemic will end when you and I aren’t having this conversation,” he adds.
“When the virus is no longer news.”
