More than 2 years into the COVID-19 pandemic, it remains unclear when and how it will end. The global outcome is dependent on multiple factors: the level of cooperation between governments; equitable access to vaccines, testing and therapeutics; local government action and the response of citizens; and competing outbreaks, conflicts or natural disasters. Ending the pandemic will also require a focus on the elderly and other vulnerable populations, as well as those in low- and middle-income countries (LMICs).

Divergent policies

Many governments recalibrated their COVID-19 strategies in response to the global surge of infections with the SARS-CoV-2 Omicron variant, but considerable international variations in public health approaches remain. There are broadly three types of approach: removing all restrictions (exemplified by the United Kingdom); continuing to implement mitigation measures to protect the vulnerable (for example, South Korea); and pursuing a suppression, or ‘zero COVID-19’, approach (for example, Hong Kong and mainland China).

Where the transmission of Omicron rose sharply, but then decreased, governments relaxed mandates and limited population-wide intervention of some public health and social measures. In these populations, the relative epidemiological risk of COVID-19 to vulnerable groups to severe infection is likely to reduce, due to high levels of vaccine-induced and/or naturally acquired population immunity. This should also enable the effective reproduction number to stabilize below 1, with the potential to increase again if SARS-CoV-2 becomes a seasonal virus. For example, the overall seroprevalence was 73% in Gauteng, South Africa, before the Omicron wave1. In the United Kingdom, the proportion of adults who tested positive for antibodies across all nations is estimated to be around 98% (ref. 2). Delta previously had a devastating effect on the United Kingdom, and so hospitalizations and deaths3 were much lower for the Omicron BA.1 variant wave than for the Delta wave.

The UK government will see all public health and social measures abolished in England by Spring 2022, including the need to isolate and the availability of free testing4. The rationale for this is the substantial cost burden of maintaining COVID-19 policies, such as testing, and the adverse effect that these interventions have on other essential public services, such as education and mental health support4.

It is possible that many other countries will adopt similar relaxation approaches as they emerge from Omicron waves. However, it should be noted that many groups in the world will remain vulnerable to severe infection, such as the elderly, the immunocompromised, and patients with medical conditions that include chronic kidney disease, chronic lung disease and cardiovascular disease5.

From suppression to mitigation

Most governments have retained non-pharmaceutical interventions to mitigate infections. As of 12 February 2022, the use of face coverings in all public spaces was required in 152 countries, whereas mass asymptomatic testing was operational in 114 countries. Contact tracing continues in 136 countries, 77 of which perform comprehensive tracing of all cases6.

Some governments, mainly in East Asia and the Pacific7, are continuing with a suppression strategy to eliminate SARS-CoV-2 infections, but this is challenged by the transmissibility of Omicron. Given the large numbers of immunologically naive people, governments with a suppression approach may shift to a mitigation approach to protect the operational capacities of their national health systems7.

Chile, Hong Kong, New Zealand and South Korea, all of which have large elderly populations, are all currently confronting substantial cases of the Omicron variant (Table 1). South Korea previously adopted a maximum suppression approach with success8, but it has pivoted toward a targeted ‘Living with COVID-19’ strategy — one that prioritizes vulnerable and elderly patients for testing and free medical kits, and promotes treatment at home for mild cases and the use of designated clinics for more severe cases9. The onset of Omicron, coupled with the relaxation of several COVID-19 mitigation measures in South Korea, has seen cases rise, although high vaccine coverage has helped keep the number of hospital admissions and deaths to manageable levels.

Table 1 COVID-19 profile and response measures in selected locations
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New Zealand has had a similar experience, wherein the phasing out of a COVID-19-elimination strategy at the same time as the emergence of the Omicron variant resulted in a surge in cases. However, a recently highly vaccinated population and vaccine mandates for essential workers have helped minimize intensive care unit (ICU) admissions and deaths. In contrast, Hong Kong has continued to pursue a suppression approach but is experiencing substantial hospital admissions and the highest death rate from COVID-19 in the world. This is presumably due to relatively low population immunity in high-risk groups, either from past infection or from vaccination; only 30% of those over 80 years of age are vaccinated. Chile, a country that utilized strict non-pharmacological measures such as lockdowns throughout the pandemic, has also experienced high ICU admissions and death rates from Omicron. The halting or reduction of key public health measures in Chile, such as social distancing, testing and isolation requirements, has probably contributed to this fifth surge in cases.

New variants

The emergence of new variants remains a concern for all of the world. Although the existing vaccines remain effective against the emerging Omicron sublineage BA.210, and reinfection by sublineage BA.2 after infection with BA.1 appears to be rare11, there is no guarantee that vaccines will work against future variants. Thus, governments that have relaxed restrictions, either partially or completely, will need to remain vigilant and agile in responding to situational changes, with a view to escalating mitigation measures in the event of resurgence. If a new variant emerges, high-income countries (HICs) that have robust health systems, access to effective antivirals such as ritonavir-boosted nirmatrelvir, and updated booster vaccines should be able to respond effectively. On the other hand, LMICs with fragile health systems and limited access to antivirals or vaccines will face a considerable challenge if a new variant becomes prevalent.

Unlike the United Kingdom or South Africa, the United States observed a record number of hospitalizations as a result of the Omicron variant, as one-third of the population had not yet been vaccinated and few booster doses had been administered. Furthermore, Omicron cases peaked while the Delta variant was still circulating. Vaccinations, the availability of antivirals and other treatments, free mass testing, and the use of stringent public health measures seem to have reduced the proportion of infected people admitted to ICU and the death rates, compared with past waves. A focus on vaccinations, boosters and targeted public health measures for addressing Omicron may provide an indication of future responses to new variants.

Scenarios for ending the pandemic

The trajectory of vaccination coverage and government responses signal three possible scenarios for an end to this global pandemic (Table 2). The most optimistic scenario is that the pandemic will end soon and simultaneously in both HICs and LMICs. A second, more likely scenario is that the pandemic will be less disruptive sooner in HICs than in LMICs. The worst scenario is the emergence of a new variant that is more transmissible and has considerable ability to evade the immune system, which prolongs the pandemic.

Table 2 Three possible scenarios for ending the pandemic
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There are three priorities that governments should focus on to help end this pandemic in all countries, as well as to prepare for a worst-case scenario wherein the pandemic continues into 2023 and beyond.

First, equitable production, supply and distribution of COVID-19 vaccines is critical for expanding full vaccination coverage and building immunity across countries (current vaccination rates, Fig. 1). Vaccine donations are commendable but not sustainable12. The low vaccine uptake in LMICs is slowing the end of the pandemic (scenario 2, Table 2). As of 25 February 2022, the projected vaccine coverage (at least one dose) was 61% globally, but this rate dropped to 15% in the World Health Organization African Region, although vaccine supply provided by the vaccine-access facility COVAX has finally exceeded demand. Lack of vaccine equity suggests that COVID-19 will continue to affect LMICs disproportionately, even if HICs observe an end of regional epidemics.

Fig. 1: Vaccination coverage rates in high- and low-income countries.
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‘Partially vaccinated’ indicates the proportion of people who have not completed an initial protocol, and ‘fully vaccinated’ indicates people who have completed an initial protocol. Our World in Data (https://github.com/owid/covid-19-data/tree/master/public/data), accessed 27 February 2022.

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Local and regional vaccine research and manufacturing needs to be supported and strengthened in LMICs through emergency waivers of intellectual property rights and licenses, as well as the sharing of technicological know-how13. The mRNA technology hub in South Africa is facilitating the transfer of technology and licenses to manufacturers in LMICs and is a leading exemplar of much-needed global collaboration for vaccine equity14. Research on vaccines that prevent infection with variants and provide longer immunity needs to be funded and made accessible globally. While building capacity for locally produced vaccines will take time, governments can mobilize resources to produce essential equipment, medicines and devices without intellectual property limitations, and to diversify supply chains, repurpose medicines and encourage public–private partnerships15. Rapid, low-cost testing that accurately detects SARS-CoV-2, combined with the provision of low-cost antiviral pills, such as molnupiravir and ritonavir-boosted nirmatrelvir, that are readily accessible to the public, will potentially be a game-changer to end the pandemic in LMICs.

Second, individual governments need an evidence-based public health plan16 that can rapidly respond in the event of a potential threat from an emerging variant. This should include the following: regular risk assessment through surveillance; the ability to reintroduce effective and low-cost public health measures such as masking; preventing disruptions to essential health services; and, most importantly, rebuilding public trust in government17 through transparent, timely and clear risk communication. Within countries, provinces, states or devolved nations might lack the ability to implement timely actions because of federally made financial decisions, so plans for decentralized decision-making need to be supported with fiscal autonomy.

Third, the most vulnerable must be protected. This is both an ethical imperative and essential for ending this pandemic. Two types of vulnerable populations should be considered: those who are more susceptible to SARS-CoV-2 infection (such as healthcare workers), and those who are at risk of severe COVID-19 (such as the immunocompromised). In addition to prioritizing those who are vulnerable to severe infection, healthcare workers must also be safeguarded; they have suffered from stress, anxiety, burnout, depression, insomnia and other mental and physical health consequences, both from the risk of infection and from an increased workload18. Governments and healthcare institutions need to safeguard healthcare workers through occupational health support, ensuring rest and practical support, proactive organizational policies and a culture of support19. Resources must also be allocated to address post-acute consequences of infection, the so-called ‘long COVID’, including a multidisciplinary approach to assessment and management of disease, appropriate support systems, especially at the primary care level, as well as employment rights, sick-pay policies and disability benefits20.

Pandemics do not end with a parade or a negotiated armistice. They end when the disease fades into the background and other, more pressing daily concerns come to the forefront. Ultimately, countries will need to define and decide what levels of transmission are acceptable and how to control the virus without burdening health systems and avoid adverse health and socio-economic consequences, all in an interconnected world.