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People in masks, coats and hats gather outside a shop.

People queue outside a Beijing pharmacy for COVID-19 treatments. Models suggest China could see up to one million deaths in 2023.Credit: Kevin Frayer/Getty

In many places, life took on a semblance of pre‑COVID normality in 2022, as countries shed pandemic-control measures. Governments ended lockdowns, reopened schools and scaled back or abandoned mask-wearing mandates. International travel resumed.

There were optimistic proclamations, too. In January, Danish Prime Minister Mette Frederiksen declared that SARS‑CoV-2 no longer poses a threat to society. In September, US President Joe Biden remarked during an interview that the pandemic was over. Even Tedros Adhanom Ghebreyesus, director-general of the World Health Organization (WHO), has expressed hope that COVID-19’s designation as a global emergency will end in 2023.

This belies the devastation that the disease continues to cause. The starkest example is in China, one of the last countries to ease pandemic-control measures in the face of the fast-spreading Omicron variant. Scenes emerging from Chinese hospitals now are reminiscent of the havoc that Omicron wrought in Hong Kong nearly a year ago. China might have seen widespread transmission regardless of whether President Xi Jinping had dropped the zero-COVID policy in December. But models suggest that the country faces the prospect of up to one million deaths over the next year, not to mention widespread workplace absences and disruptions to the Chinese — and global — economy.

Most people in China are immunologically unprepared for Omicron, the dominant strain now in circulation. They have had no exposure to any SARS-CoV-2 variant and, if vaccinated, have received vaccines only against the virus’s original strain. China is likely to discover what other countries with limited previous exposure to the virus have found over the past year: that there won’t be a single ‘exit’ wave to mark the lifting of pandemic restrictions. Further waves of infection and death are likely to follow, either from new variants that arise in the population, or from variants imported as the country opens its borders to visitors.

Renewed responses needed

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Elsewhere, repeated surges in infection and death are giving way to a constant thrum of loss, as well as debilitation caused by long COVID. A focus on COVID-19 has also affected the fights against AIDS, malaria and tuberculosis. Although precise counts are difficult to obtain, overall death rates in many countries remain higher than before COVID-19 hit.

COVID-19 vaccination rates have stalled in many nations. In some, the uptake of boosters has been dismal, even though these substantially reduce death and severe illness.

One path to renewing vaccination efforts lies with technology. Development of mucosal vaccines is under way. These are designed to be delivered through the nose or mouth and it’s hoped they can trigger sterilizing immunity that blocks transmission — not just severe illness. China has approved an inhalable booster dose and a nasal vaccine, and India a two-dose nasal-drop primary vaccine. Iran and Russia have also each approved a mucosal vaccine. But researchers are awaiting data to check whether any of these deliver on their promise of stopping SARS-CoV-2.

One thing that could shake COVID complacency is the emergence of one or more ‘variants of concern’ (VoCs). New variants of the virus will emerge over the next year, as they did in 2022. But a VoC designation (and a corresponding Greek letter from the WHO) will be given only if a variant is better at evading the immune system, causes more severe disease or is much more transmissible than those currently circulating. A new VoC must spur action to ensure that fully vaccinated people — especially those who are older or immunocompromised — receive booster doses.

A new variant must also prompt redoubled vaccination efforts in lower-income nations. Global collaborations, such as COVAX, were established to deliver vaccines equitably. But they faltered as wealthy nations prioritized vaccinating their own populations. Too often, vaccines for low- and middle-income countries (LMICs) were delivered sporadically and close to their date of expiry, exacerbating the challenge of rolling them out in places with limited health-care infrastructure.

The result is that only one-quarter of people in low-income countries have received at least one dose of a coronavirus vaccine. Many low-income countries need to get back to tackling neglected priorities such as malaria, tuberculosis and infant mortality, all of which were sidelined as the worst of the pandemic swept through. But ignoring COVID-19’s continued toll risks stymieing these efforts, too.

The global community must reckon with the politics and power dynamics that undermined initiatives to ensure that all nations had access to vaccines when they needed them. Unless that happens, future global agreements could be similarly undermined in times of crisis. In May, the WHO’s intergovernmental negotiating body will deliver a progress report on deliberations over an international instrument — the nearest thing to a treaty — on pandemic preparedness and response. Countries that missed out on timely access to COVID-19 vaccines, tests and treatments will be arguing that the agreement should ensure more equitable access to resources when the next pandemic threat emerges.

But as attention moves to preparations for ‘disease X’ — the as-yet-unknown pathogen that could cause the next pandemic — COVID complacency is inflicting death by a thousand cuts on health-care systems reeling from the past three years. The public-health community must continue to strengthen vaccine-manufacturing capacity in LMICs. And it mustn’t forget what experience has shown since 2020: that health-care systems under stress are little able to deal with new threats.



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