The passing of the delta variant rampage raises hopes of an accelerated 'truce' with the corona virus. Although there are still concerns about the emergence of a new variant, the current delta variant can be considered the peak of the viciousness of Covid-19. By consistently preventing and treating this disease, as well as continuing to develop herd immunity, it is hoped that the direction from the pandemic to endemic will be clearer.

The deadly dance of the delta variant has receded. Although the community activity restrictions (PPKM) continue to be extended, the number of areas with significant level of danger is decreasing. However, epidemiologists warn that, even though the situation is improving and mass vaccinations continue to be carried out, we should not be careless and excessively euphoric.

The experience of delta variant attack that resulted in the second wave has given a very painful lesson. The recklessness of the citizens and the weakness of the government's enforcement of health protocols must be paid dearly. Contagion exploded, the number of patients and deaths soared, and the healthcare system nearly collapsed.

Now, the main indicators, such as new cases and deaths, bed occupancy ratio (BOR), and positivity rate, have decreased significantly. New cases from a peak of 56,000 per day in mid-July 2021, have fallen to the level of around 2,000 cases per day. The number of deaths has also decreased significantly. From peak 2000s to 150s per day. The situation was like before the delta variant rampage.

However, vigilance and discipline in carrying out health protocols are absolute requirements to prepare for life in the new era of adaptation. This new era from pandemic to endemic is marked by the compulsion to live side by side with the corona virus with all its anticipation. The Covid-19 attack has been increasingly managed, although that does not mean it is completely under control.

The government has carefully started relaxing public activities gradually, starting to live a life in a new era with the remaining virus. Some tourist and entertainment places have started to be allowed to open with a limited capacity. Likewise with other economic and trade activities.

Schools have begun to be allowed to open face-to-face learning activities, also with limited capacity and of course with strict protocols. In essence, economic and social activities are slowly starting to be relaxed so that the economy does not plummet. Incidentally, in the last few months the prices of our two main commodities, CPO and coal, have continued to rise sharply on the international market, thereby increasing export earnings.

Coping with evolution-mutations

To understand adaptation from pandemic to endemic, we need to recall the nature and behavior of the coronavirus. Like bacteria, viruses are living microorganisms that have natural habitats and mechanisms to maintain their lives, reproduce, and survive in the face of competition, predators or attacks that endanger their survival.

The father of evolution theory, Charles Darwin, said that every living thing will face natural competition and develop self-defense mechanisms to survive and only the superior can continue to survive and develop (survival of the fittest). One way to survive is to evolve, a mechanism to change genetically to adapt to a new environment and to deal with constantly emerging dangers.

The corona virus with the name SARS-CoV-2, which produces the Covid-19 disease, also continues to evolve until it eventually causes a pandemic. This adds to a long list of dangerous pathogens that are wreaking havoc and already killing more people, such as smallpox, influenza, rabies, dengue fever, marburg virus, ebola, HIV/AIDS, SARS, swine flu and MERS, and the current Covid-19 .

With this great 'intelligence', once out of its original area in Wuhan, and then spreading to all corners of the world, this virus continues to update its genetic makeup. There are dozens of mutations or new variants with a variety of different characters, ranging from weak to vicious. WHO classifies it into a variant of interest (VOI) for those that need to be monitored and a variant of concern (VOC) for those that really need to be watched out for because of its malignant character, such as the delta variant. Lastly, WHO warns to be wary of the new mu and lambda variants.

This corona virus is dealing with humans, the smartest creatures on earth. From the very beginning, experts have been trying to avoid and overcome them. Keeping a distance, avoiding crowds, washing hands, wearing masks are examples of prevention to avoid transmission. Meanwhile, those who have been infected, are treated starting from self-isolation, being supplied with multivitamins and immunity-boosting supplements, or perhaps having to enter the ICU to use a ventilator as a form of curative action.

On the other hand, experts are competing for research to develop vaccines using various methods, such as inactivated viruses and mRNA, as well as research on convalescent plasma, dendritic cells, and others. These various studies aim to generate immunity to ward off, contain, and weaken the ability of viruses to attack humans.

After more than a year of racing in research competition, the first generation of vaccines for COVID-19 was created, including Sinovac, Sinopharm, Astrazeneca, Moderna, Pfizer, Johnson-Johnson, and Sputnik V, which have received an emergency use permit by WHO. Other vaccine findings have already started to be used in their respective countries, such as Turkovac (Turkey), Abdala (Cuba), and Coviran Barekat (Iran).

With this, mass vaccination was launched worldwide. Theoretically, if 80% of the population in an area has received a complete dose of vaccination, herd immunity will be created and in general this population is relatively safe from virus attack.

Because the attack was successfully warded off by the immune system produced by the vaccine, the virus is constantly looking for ways to survive. Viruses are constantly mutating and evolving, seeking to renew their efficacy by changing their genetic makeup. This is like a prolonged war between the corona virus and humanity around the world.

If vaccinations can be carried out simultaneously and in mass at the beginning of the pandemic, the chance of the virus to mutate is smaller. However, at the start of the pandemic there was no vaccine. The vaccine was still in the development research stage, not yet produced. As a result, when the vaccine is ready, mass-produced and injected, the virus has already spread, evolved, and reproduced.

Some of these first-generation vaccines are able to ward off the massive attack of the corona virus for now. However, the vaccine is not necessarily effective for the future. One day a new variant of the virus will appear that is resistant or immune to this early generation vaccine. If then vaccine research continues to find new vaccines that are more effective against new variants, the virus will also try to revitalize itself genetically so that it can escape the obstacles of this newer generation of vaccines.

Truce phase

Thus, the process will continue and repeat itself so that in time new conditions will be achieved, when the various variants of the corona virus are already at a genetically stable stage, no longer fluctuating as they are today. This is a period of new balance, when the war between humans against the corona virus can be said to have reached a truce.

As in truce between warring countries, sometimes there are occasional rocket attacks or incidental fire from the parties, but the attacks are not massive, and are immediately responded to by the opposite-parties.

Likewise in the truce between corona and humans. Sometimes there are new variant mutations that suddenly attack, but the impact of the attack is not so dangerous. The herd immunity generated by the initial mass vaccination, and later by newer generation vaccines, is quite effective against viral attacks. The virus attack later may only cause a small cough, a slight fever, accompanied by fever and mild flu. At this stage the corona virus will evolve into a common cold. It can appear, but not so dangerous.

Perhaps it will be similar to the transformation of the 1918 influenza pandemic or the Spanish flu that killed tens of millions of people. The Spanish flu pandemic was triggered by a virus known as influenza A that originated in birds. After that pandemic, all subsequent flu pandemics were caused by the influenza A-derived viruses that have proliferated and circulated throughout the world and infect millions of people every year.

In the end, the pandemic caused by mutations in the lineage of the influenza A virus gradually turned into a regular seasonal flu, when most of the world's population already had immunity, either by vaccination or by direct exposure. The seasonal flu is still ongoing today, exposing millions of people, and can be fatal in severe cases. Still in general, the common cold is far less dangerous than it was at the beginning of the Spanish flu pandemic. The evolution of genetics like this is what the experts predict will happen in the Covid-19 pandemic.

Beware of hyperendemics

Experts project that under these conditions the pandemic will gradually become endemic. This means that the virus will continue to circulate in pockets of the global population for many years, depending on the extent to which the virus has evolved and the type of herd immunity that exists in the area. Thus, the virus will also become endemic with a more local character and not as vicious as the delta variant.

The delta variant rampage has become the darkest days during this 1.5 year pandemic. This variant has four malignancies when compared to the previous one. First, the speed of transmission is extraordinary. Second, its attack power is so great that it can make a patient exposed to the delta variant die in just three days, making it difficult for medical personnel to provide help. Meanwhile, in non-delta variant it can be up to 10 days, the patient still has time to be helped.

Third, the delta variant can reduce the effectiveness or efficacy of the vaccine from 95% to drop to 50%, thereby reducing the hope of achieving herd immunity and causing the need for a third dose of vaccine for booster. Fourth, this delta variant is the result of a very smart mutation that can reduce the sensitivity of the diagnostic tools by tricking the host. This was proven through exploration of the autopsy process after the patient died.

The medical service system which almost collapsed because it was not strong enough to deal with the delta attack has been seen, among others, in India and Indonesia. In some developed countries, delta variant attacks have indeed made cases soar. However, in the following period after the delta attack was successfully handled, the condition improved and stabilized, as happened in the UK during June-July 2021, in the US and several other countries.

Some experts put forward the hypothesis that the delta variant, apart from attacking ferociously, actually ushered in the transition process from pandemic to endemic. This means that the transition process cannot quickly return to normalcy as this massive spike in cases makes herd immunity more difficult to achieve in general and, on the contrary, forces the authorities to delay lifting restrictions on community activities.

Moreover, recent data from Israel, the UK and the US have led to important questions about the vaccine's ability to prevent infection with this delta variant. This is why the offer of booster doses to high-risk populations has emerged. In addition, data from serial tests suggest that immunity can decrease relatively quickly.

A pandemic will transition to an endemic. Endemic is defined as a disease that always recurs to attack a population in a certain area, such as malaria which previously attacked tropical countries. Epidemiologist Dicky Budiman from Australia's Griffith University warned that if the Indonesian government slackens again in handling Covid-19, enforcement of discipline becomes weak, mistakenly chooses policy priorities, or only relies on vaccination, a hyperendemic is feared to occur.

Epidemiologists define hyperendemic as a disease that appears in a certain area with high intensity, affecting a large population and continuous. Meanwhile, the Robert Koch Institute in Germany defines hyperendemic not only associated with high intensity. An endemic area may show low transmission rates, but has a high risk of infection for immigrants. However, whatever the definition, its management must still take into account the possibility that there is still a great risk of the emergence of new, more infectious variants (with severe morbidity and mortality) that are even more capable of infecting people who have been vaccinated with varying degrees of complications.

Whatever the definition, we hope that the pandemic can quickly transition, at least to endemic. At this point, the hope of a herd immunity is not unnecessary, but in parallel what is needed now is how the condition of this covid attack can be managed properly as an endemic disease.

We hope that the downward trend in the curve over the past two months will continue to be accompanied by the right policies and strategies, not being reckless, and maintaining strict and measurable discipline. Hopefully, the pandemic will gradually transition to become endemic, not hyperendemic. Thus, we can prepare ourselves to live side by side with the remaining generation of the corona virus which is no longer vicious, towards a new era of balance so that the darkest days of the pandemic are really over.

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

Translated from Indonesian Language:
“Menuju ke Endemi dan Keseimbangan Baru" by Djoko Santoso
Media Indonesia, 28 September 2021