The COVID emergency may be over but when will the pandemic end?

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• The World Health Organization is meeting to determine if COVID-19 should still be considered a global emergency.
  

• But while the emergency phase may soon be over, the pandemic isn't.
  

• Rising hospitalizations and new Omicron subvariants are raising concern for Canada's overburdened health-care system.

COVID-19 may no longer be seen as the global emergency it once was, but with highly contagious new subvariants emerging that have the potential to drive future waves at a time when the health-care system is already overburdened when will the pandemic end?

"So much of the world, so many of us just so desperately want this to be over, but unfortunately it's not," Dr. Maria Van Kerkhove, the World Health Organization's technical lead for COVID-19, said in an interview with CBC News.

"We're still in the middle of this, in a sense, but we have never been as close to the end."

The uncertainty around the end of the pandemic lies with the virus itself, which continues to rapidly mutate with more than 300 Omicron subvariants currently being tracked by the WHO worldwide, Van Kerkhove said.

"The virus is evolving and it's unpredictable," she added. "We don't know exactly what the characteristics of the next variant will be."

New Omicron subvariants derived from previous strains like BA.2, BA.4 and BA.5 are showing high levels of immune evasion, unlike anything we've seen before in the pandemic, but what exactly that means in terms of real world transmission remains to be seen.

"We're in the second act of a three-act play," Michael Osterholm, an epidemiologist and director of the Center for Infectious Disease Research and Policy at the University of Minnesota, said in an interview with CBC News.

"How can you declare the pandemic is over when we don't know what the next act is?"

Europe has entered a new COVID wave, while Ontario, Quebec, Manitoba,New Brunswickand B.C. are already seeing a rise in hospitalizations putting added pressure on the health-care system just as a resurgence of seasonal illnesses like the flu are expected to hit hard.

"We have the tools now to end the emergency of COVID in every single country," Van Kerkhove said. "The challenge of ending the pandemic is something different."

COVID isn't going anywhere

One thing is for sure, COVID isn't going anywhere. The virus continues to spread around the world in one form or another and has even taken root in animal reservoirs like white-tailed deer meaning eliminating it entirely is no longer possible.

But while the pandemic may not be over, the end of the emergency phase is still in sight.The WHO launched an ambitious plan earlier this year to end the COVID-19 emergency in every country in the world by the end of 2022 using available tools like vaccinations, antivirals and therapeutics to continue to prevent severe illness and death.

"Clearly we're in a very different situation now," WHO Director-General Tedros Adhanom Ghebreyesus said during a news conference Wednesday, ahead of a committee meeting to determine if COVID is still a Public Health Emergency of International Concern (PHEIC).

"But the pandemic is not over and there is much more work to be done."

Tedros said ongoing global risks due to large gaps in vaccination, reduced surveillance, low rates of testing and sequencing, and ongoing "uncertainties" about the impact of variants would weigh heavily into the decision of whether to declare the COVID emergency over.

"What we're trying to tell countries, the way that we can end the emergency is to be ready, to be agile, to use the tools the therapeutics, the diagnostics, the vaccines most appropriately for those most at risk in every single country," Van Kerkhove said.

"Vaccination plays a critical role, but if you look at vaccination coverage we have more than 12.7 billion doses of vaccines administered globally, but yet 32 per cent of the world's population has yet to receive a single dose so there is still this massive amount of inequity."

Health-care system overburdened

Experts have warnedthe pandemic's ongoing burden on the health-care system will be felt for years to come, with long COVID affecting a subsetof those infected,and delays to cancer screenings and surgeries causing massive backlogs just as COVID levels are expected to rise again.

"The last few years have left us with a lot of delayed procedures, lots of chronic conditions that have not had the attention they need," Bill Hanage, an epidemiologist at Harvard's T.H. Chan School of Public Health in Boston, said in an email to CBC News.

"And as a result things are stretched pretty thin in many places. Put COVID on top of that (not to mention flu) and we can expect there to be challenges."

WATCH |Quebec urgesboosters as COVID-19 levelsrise:

Quebec urges people to get boosters as COVID-19 cases rise

2 years ago

Duration 1:49

Quebec's health minister is urging residents to get their booster shots as COVID-19 cases slowly start to rise.

Raywat Deonandan, a global health epidemiologist and associate professor at the University of Ottawa, said that while COVID is becoming endemic in many parts of the world, waning immunity, new variants and dropping of restrictions could change that.

"Unlike previous waves, where one variant dominated over others, it now seems like soups of variants will be pestering us," he said.

"This will continue so long as we permit transmission to take place. And it seems like all our policy choices are signalling that we intend to allow transmission to occur freely."

Deonandan said ending the emergency phase of the pandemic is a "political definition" having to do with the allocation of resources for COVID and the level of death and severe illness society is willing to tolerate.

"We're currently at about 40 deaths per day (nationally), and the models suggest that that will not change substantially as this new wave evolves," he said, adding that this stability in the level of COVID-related deaths might be considered to be "the retreat of emergency."

"The other consideration, of course, is hospital staffing, which is definitely in an emergency situation. And I don't see that getting better any time soon, without some serious and creative governmental intervention."

Virus will continue to mutate

Given that the virus continues to throw evolutionary curveballs at us, with new variants emerging that have the potential to evade immunity and drive transmission globally, what exactly would it take to end the COVID emergency and the pandemic entirely?

"We would have to have a vaccine or infection immunity that would be relatively protective against new variants and that the protection would be something durable," Osterholm said.

"Right now, even if you take a look at what might be the annual immunization approach, we're seeing waning immunity happen long before that."

Pfizer said in a release this week its updated COVID-19 bivalent vaccine recently approved in Canada, which targets the original strain and the dominant BA.4 and BA.5 subvariants, showed a "substantial increase" in the neutralizing antibody response after 30 days.

"It seems safe to predict that updated vaccines will perform better than another shot of the same old thing," a new commentary published in the journal Nature points out, although data is limited so far.

And new research from Qatar released as a letter in the New England Journal of Medicine ahead of peer review, found a previous Omicron infection provided strong protection against future reinfections from BA.1 and BA.2 but less so from BA.4 and BA.5.

Meanwhile, a new Quebec study on hybrid immunitypublished in JAMA this week suggested that two or three doses of an mRNACOVID-19vaccine in people with prior infections provided strongprotection against Omicronhospitalization.

Hanage said that we can expect to see continued mutation of the virus in the future with selection pressure favouring variants "that are more readily able to infect people with some immunity" from vaccination and prior infection.

"What this means is that the virus is going to continue to be around, and it will be infecting lots of us," he said.

"We don't expect the consequences of those infections to be anything like as bad as what we have seen the last few years because of the immunity we have accumulated, but they won't be trivial. Older people especially should get boosters."

'Vaccines will be part of our future'

One thing that would be a "massively added benefit" would be the development of a nasal vaccine that could better reduce infection and transmission while continuing to prevent severe disease and death, Van Kerkhove said.

"That would be a game changer, because that would tackle the challenge that we have about this intense circulation of this virus and the evolution of this virus that continues," she said, adding that the vaccines we do have still work against severe disease and death."But we don't have that yet."

A new nasal version of the AstraZeneca-Oxford vaccine suffered a major setback this week after human clinical trials didn't produce the immune protection researchers had hoped for, and was actually weaker than that from its shot, but there are others in development.

"We need to educate the public even more about the fact that given this virus will be with us, vaccines will be part of our future. They're not the only solution, but vaccines, the need for additional doses, is something we're going to have to deal with," Van Kerkhove said.

"How often that occurs? We don't know yet."

She said ultimately the virus will remain with us, and not in the same way that flu does given that it's a completely different virus that continues to evolve to evade immunity, and we still don't have any "predictability" with it.

"We have to live with COVID responsibly," she said. "I really have a distaste for this phrase 'living with COVID' because many have used it as a sense to give up but we don't need to. We have tools that exist right now."