Moving from Pandemic to Endemic

Experts project that this pandemic will gradually become endemic. Therefore, early on, we prepare a roadmap so that we can deal with the endemic more smoothly without turmoil.

The next step after the second wave of Covid-19 subsides is to continue to put health into priority (healthy oriented). Lessons from the imposition of restrictions on community activities deserve to become a stepping stone on the road map to endemic. It turns out that strict and measurable restrictions on activities can ease the rampage of the corona, so that it can open up opportunities for economic revival.

This must have related with the government's attitude that is more open to receiving suggestions and criticism. The current restriction is clearly a more healthy-oriented policy, which is different from the misguided economic-oriented policy that was implemented at the beginning of the pandemic. At that time the government did not close the door to arrivals from abroad, desperately invited foreign tourists, financed buzzers, there was indifferent and slow response of the health authorities, the lack of tracing and testing, and the lack of concern for the heavy burden of health workers and health filities.

By shifting the pendulum to a healthy-oriented direction, even though it feels heavy, alhamdulillah, thank God, it shows good results. Coupled with the intensified mass and widespread vaccination, the situation is getting better.

The second wave of explosions, which reached its peak with the addition of 56,000 daily positive cases in mid-July, is getting less and less. Now the condition is relatively stable below 10,000 new cases per day, even on September 9 the data fell again to 5,990 cases. The decline was gradual for about two months from July 2.

Thus, it becomes feasible to discuss how to design a further treatment roadmap.


Expand the Sea of Immunity

There are two phases that we can discuss. The first phase is how to keep this downward trend going so that it can reach an epidemiologically safe level. For example, full-dose vaccination has reached more than 80% of the population, the addition of new cases is under 1,000 per day, the positivity rate is below 5%, and the mortality rate is below 2-3.

The way is, of course, by continuing to boost mass vaccinations, maintaining and increasing the number of tracings, examining specimens, enforcing adherence to health protocols, and maintaining physical fitness.

Various other policies, such as lowering the tariff for antigen and PCR tests, facilitating payment of hospital bills and incentives to health workers, maintaining control over the entrance of arrivals from abroad, and so on, have greatly assisted in achieving the above targets.

If vaccination is intensified, it is not impossible that the herd immunity target can be achieved before 2021 ends. After that, gradually economic activity can be relaxed, with a measurable priority scale.

With policies that are more health-oriented, each success stage will encourage the easing of economic and social activities, so that conditions will improve, and the economy will slowly recover. At this stage, the pandemic can be said to be under control, although that does not mean that Covid-19 is completely gone.

Next is the second phase, how do we design a road map as requested by President Jokowi the other day, living side by side with Covid-19 which has not yet been destroyed. Activities and mobility in all sectors of life are adjusted and adapted to the new era, side by side with Covid-19, which is predicted to no longer be a pandemic, but will decrease to an endemic level.

When herd immunity is achieved with a vaccination rate of 80% or more, we feel psychologically safer. Vaccination that is carried out massively and quickly at the beginning of a pandemic will reduce the chances of the virus to evolve. As an illustration, massive vaccination will produce a sea of immunoglobulin antibodies that will surround the virus land so that the virus is not free to evolve and mutate.

Thus, the chance of mutation into a new, more virulent variant is getting smaller, although that doesn't mean it's completely closed. New variants will still appear, because this is a natural evolutionary process. Viruses that are increasingly pressured by the sea of antibodies resulting from massive vaccinations will continue to try to survive and reproduce. However, the space for movement is getting narrower, hindered by the increasingly solid herd immunity.

Thus the curve will be more sloping, the addition of daily cases and the death rate will also decrease. At some point, a pandemic (an outbreak that spreads globally at an exponential rate) will degenerate into an endemic (regional range of transmission, and the rate of transmission is linear, not exponential). However, new mutation variants may emerge, either as softer or as more virulent one. But with the establishment of herd immunity, the threat level becomes smaller.

If vaccine research continues, a new generation of more potent vaccines will emerge, able to block the emergence of new, more virulent variants. If Covid-19 drug research has succeeded later in finding an effective formulation, it is possible that later Covid-19 will have a status like the common cold. Of course this cannot be achieved in a short time. It takes hard work and consistent enforcement of health protocols.

This is where the roadmap that will regulate social, political, economic, religious activities, and others, needs to be designed by adapting to the situation of an epidemic that has decreased to an endemic level. The parameters are defined first, then the rules are set.

For example, the green zone. What has been decided by the authorities so far should be enforced. Although this zone is not affected by the risk of virus spreading, health protocols, 3-T programs and vaccination programs need to be carried out according to conditions. In this zone, all crowd-based activities are allowed to be carried out at 100 percent capacity, including teaching and learning, transportation, business, religion. The difference is, during the endemic phase, visitors must have a complete dose of vaccination. Then, the yellow zone is different. It needs stricter provisions. And so on.


Responding to New Variants

Even though we are planning towards an endemic, we must remain alert to the emergence of new variants. Now, it is widely reported that a new variant of Mu has emerged, which WHO has given the code B.1.621, and is categorized as a variant of interest (VOI) or one to be wary of.

Indeed, the mutation classification is not as critical as the Delta variant, which is a variant of concern (VoC). This Mu variant was first identified as appearing in Colombia in January 2021 and entered as VOI since the end of this August. As is known, WHO named the virus variants from Wuhan, China, in the order of the Greek alphabet, such as Alpha (A/α), Beta (B/β), Gamma (Γ/γ), Delta (Δ/δ) and so on. Mu (M/μ) is the 13th alphabet.

The Mu variant is said to have a constellation of mutations that exhibit potential traits to escape the immune system barriers created by vaccination. As an early information, the Mu variant may be able to penetrate the immune system's defenses in a similar way to the Beta variant.

Public Health England (PHE) reported that of the 32 cases of the Mu variant found in the UK, most were found in people in their 20s. A risk assessment released by PHE last August showed that the Mu variant is at least equal to the immunity-resistant Beta variant arising from vaccination. The Mu variant has spread in 40 countries. The government needs to guard the entrance to the country, so that the conceding of the Delta variant will not happen again.

How do we understand the emergence of these new mutation variants? As is known, a virus is a collection of new proteins that can live and develop if they have a host. In addition, viruses continue to evolve to adapt to their new environment. It is possible that the evolution and mutation of the corona virus could one day make it immune or resistant to vaccination.

Paul Duprex, Director of the Vaccine Research Center, University of Pittsburgh, as quoted by The New York Times (20/1/2021), stated “The beauty, the elegance, the evolution and the magnificence of a virus is that every single time it infects a person, it’s exploring that sequence space.” Several mutations make it stronger and more vaccine-resistant, while other mutations can weaken the original virus and make it fade away.

For us to know, the SARS-CoV-2 virus consists of proteins composed of several amino acids. Each of these amino acids is formed by 3 nucleotide bases which are transcribed by the cells of the human body. Mutation of one viral nucleotide base will destroy all parts of the virus causing it to not reproduce and die.

Uniquely, the corona virus mutation occurs simultaneously in three adjacent nucleotide bases, so that it can still survive without experiencing functional damage. This mutation is also able to provide additional power for the virus not to be recognized by antibodies previously obtained from vaccines or previous infections.

This is like a long-term war between humans and the corona virus. At first, the corona invasion broke human defenses so that hundreds of millions of people were exposed and several million people died.

Humans respond by carrying out health protocols, vaccine research, isolation for mild exposures, and treatment in hospitals for moderate or severe exposures. After vaccinations began to spread and the treatment of Covid-19 patients began to be comprehensive, the virus also held up a fight.

The virus mutates to have new, more frightening properties, able to spread faster, more lethal, more resistant to vaccines and antibodies than previous infections. However, humans represented by scientists also conducted research on vaccines capable of fighting these mutations.

This long-term war will continue and hopefully humans will finally win with herd immunity, even though there have been many victims who have fallen in this war.

After the emergence of several types of vaccines that passed clinical trials, mass vaccination was carried out. The result, at a certain point, achieved herd immunity which can generally protect humans from viral invasion. But the laws of nature still apply, evolution continues.

Corona virus is not a random virus. This virus is a formidable fighter that continues to evolve, mutate, looking for loopholes to penetrate the human defense barricades that are built with a combination of vaccination, treatment, maintaining a healthy lifestyle and health protocols.


“Local Content” Mutations

How great is the ability of the corona virus to continue to mutate? If vaccinations can be carried out simultaneously in bulk at the beginning of the pandemic, the chances of the virus to mutate will be smaller. The problem is, corona is a new virus.

Vaccine development research normally takes a long time, up to five to ten years. But right now the situation is an emergency because the corona has spread to dozens of countries in a short time, so the vaccine research method is compressed. As a result, in less than two years there have been six vaccines that have received an emergency use permit from the WHO. When vaccination started, the virus had already spread far and wide throughout the world, evolving and mutating into various variants.

This process continues to evolve so that it is possible that a new variant that is resistant or immune to one of the six vaccines that have received WHO approval (Sinovac, Sinopharm, Astra Zeneca, Moderna, Pfizer, Sputnik V) will emerge in the future, and a new vaccine that may later appear.

However, Dr. David A. Kennedy, an expert on viral resistance in Pennsylvania, United States, recently stated in PloS Biology, that there is resistance that is not due to vaccination, but a variant that has had immunity to vaccines since its birth.

This potent variant, referred to as the “cluster 5”, variant uses the animal mink as its host. Laboratory tests have shown that certain types of antibodies are less effective against this recalcitrant variants that live in minks. Viruses that go back and forth from animals to humans, then back to animals again, and then to humans again, have the opportunity to undergo genetic changes that make them resistant to certain vaccines, although not necessarily resistant to all types of vaccines.

The response to this "mink variant" is unique, because not all countries have a culture of keeping animals such as ferrets whose fur is the material for these luxurious clothes. Denmark, aware of this risk, immediately culled 4 million mink at the end of last year. Then the threat of cluster 5 subsides.

This is indeed a constant and careful vigilance. On the one hand, humans continue to conduct research so that new, more effective vaccines will appear periodically for the new variant of the corona virus. Likewise, the undergoing drug may one day produce efficacious drugs.

On the other hand, the resistance and fighting power of the corona will also continue to give rise to new variant viruses that are resistant to the old edition of the vaccine. For example, a variant A appears, and it is resisted by vaccine 1, another variant B appears and it is resisted by vaccine 2, and so on.

The resultant of this long battle is the emergence of viral mutation in many countries with their respective "local content". The response of local people is also specific because they already "know each other" with the behavior of the virus. Dr Michael Merson, a global health expert from New York University and former director of the WHO's Global AIDS program, said the pandemic would gradually become endemic, and the virus would become endemic with a weaker threat character. In the long term, the corona can become like the common cold.

Experts project that the pandemic will gradually become endemic. So early on, we prepare a road map so that later we can face the endemic more smoothly without turmoil. So that the wheels of the economy can spin optimally, educational activities and other activities can recover and social life can take place more normally.

Djoko Santoso
Professor, Faculty of Medicine, Universitas Airlangga
Chairman of Health Department, Indonesian Council of Ulama, East Java
Covid-19 Survivor

Translated from Indonesian:
“Bersiap dari Pandemi Menuju Endemi" by Djoko Santoso