Covid-19: The When, What & How of an Endemic

Yoong Khean
6 min readOct 5, 2021


Author’s note: The Covid-19 series is a series of articles related to the current pandemic.

Photo by Matteo Jorjoson on Unsplash

“Living with the virus” is currently the new buzz phrase. After nearly 2 years in the pandemic, the world is realising Covid-19 is here to stay, and a Covid-zero situation is unattainable and unsustainable. The new approach is to tackle the disease as an endemic, defined as an infection that is constantly present in a geographical area or population with a predictable transmission rate, much like how the Influenza virus is endemic in temperate regions or Dengue is endemic in tropical regions.

But merely deciding that a new approach is not going to change anything as the virus does not follow our whims and fancy. How then do we safely change our approach? This article outlines three issues that are key to shift in approach.

Timing of the change

The first issue is when do we consider changing our approach to an endemic from a pandemic. Many experts before me have articulated a typical but comprehensive list; daily incidence of the disease (new cases), the morbidity and mortality rates (hospitalisation and number of deaths) and vaccination coverage. These are all useful indicators to consider but every country is in a different situation with different demography and resources. Therefore it is hard to make an accurate decision, or even find a reference for it. Furthermore, each of the indicators has deeper layers of complexity; new cases can be further categorised to various levels of severity from asymptomatic to severe illness, hospitalisation depends on ICU capacity or oxygen supplementation, death is the laggiest of all indicators, something we need to keep in mind and vaccination coverage within a country is uneven due to access and demography. To complicate the matter, new variants like the Delta variant changes disease patterns and vaccination strategies.

Accepting Covid-19 as an endemic means accepting a baseline number of infections at any given time. But what is the acceptable rate of daily infections, ICU admission or even deaths? Should we try to lower this baseline with more aggressive vaccination strategies before considering an endemic approach?

The question of when is not as simple as it seems and requires a thorough understanding of the overall situation, keeping in mind all the indicators above which are interdependent of each other.

Preparation for an endemic

Failure to plan is planning to fail. The what refers to the preparation. Similar to the overall approach, three areas should be in place before changing the approach.

The Find, Test, Trace, Isolate and Support, otherwise commonly known as FTTIS is an effective framework during a disease outbreak. In an endemic, this framework will need some tweaking. Testing in an endemic situation will scale down, especially in asymptomatic, low-risk contacts, but access to testing should increase. Rapid antigen test kits should be made widely available to the masses. Contact tracing is a tedious, resource-intensive exercise so it needs to be targeted at only close, high-risk contacts. Automation using technology like location-based data or proximity alerts can help. Isolation and support will be shifted from healthcare based facilities to either community care based facilities and home isolation or recovery. This will need clear, consistent and transparent communications between health authorities and the public.

Photo by Mat Napo on Unsplash

The second area of interest is vaccination. Mass vaccination centres were useful in an outbreak to rapidly scale up the uptake but in an endemic, access again is the more important factor. The strategy should shift to a marathon from a sprint, allowing community clinics to offer the vaccine at any time for the longer term. Mobile vaccination units and outreach units will need to be intensified to ensure nobody is left behind. But the infrastructure of the vaccination centres still needs to be kept, as there will be changes to how vaccination is being rolled out, for example, third doses/boosters, new age groups being approved for the vaccine or even new vaccines for new variants.

The last is a disease surveillance system. One silver lining in this pandemic is the wealth of data we’ve accumulated. Using this data, disease modelling can predict Covid-19 hotspots, identify high-risk populations and areas of low vaccine coverage for public health interventions. Genomic surveillance should be the norm to identify and monitor the circulating strains of SARS-CoV-2 in the population. There should be different monitoring systems as well, for example, wastewater sampling for the virus to detect potential outbreaks.

Transitioning into an endemic

How refers to the transition into an endemic approach. If deciding when requires a sound judgement and preparation is to have foresight, transitioning into an endemic will need some courage. Balancing the acceptable number of new cases, hospitalisations and deaths without burdening the healthcare system and creating anxiety among the public will not be easy.

The key in transitioning will be communications. Having a plan to implement with clear communications to all stakeholders will be crucial to the transition. There will be expected complications and hiccups will be a certainty but authorities need to have the conviction and the belief that the transition is momentary. If communications are unclear, there will be confusion and this will lead to a breakdown in executing the plan. The transition will require a whole of society approach, and a healthy level of trust, something which is mostly lacking since the pandemic began.

Endemic worsens inequity

Living in an endemic means you can get your vaccine easily when it’s available, constantly monitor your health, maybe grab a rapid antigen test kit on the way back from work if you are worried about having close contact with a Covid-19 positive person. If you are positive but asymptomatic or just having mild disease, home recovery is a good option, with self-isolation in your second bedroom. If you need to be hospitalised, the nearest hospital is only thirty minutes away and maybe your insurance plan will even cover your hospital stay. Back to work after that short downtime and life goes on. Does this sound possible in your life? If yes, congratulations, you are most likely a middle to high income earner, privileged compared to most.

But a person in a lower income group may not have the same access as you. Rapid antigen test kits are too expensive, being away from work means no income to feed the family. Isolation at home? There are two rooms with five or six family members living together. Hospitalisation? Maybe a six hour wait just at the emergency department of a public hospital. Let’s not even discuss insurance.

Like lockdowns, an endemic approach without considering the vulnerable and marginalised population will only widen the inequity gap. Covid-19 will be a disease defined by socioeconomic status, much like how tuberculosis is. And while tuberculosis is a highly curable disease, Covid-19 is arguably a preventable disease. There is no reason why there should be inequity when there is only benefit when all groups in a population have access to testing, treatment, support and vaccines.

Photo by Hanson Lu on Unsplash

“Living with the virus”

An endemic does not mean there will be no outbreaks. Like Influenza and Dengue, outbreaks will continue to occur. So previous public health measures like widespread testing, mass vaccinations, field hospitals or even lockdowns are still a possibility. But hopefully, with better preparation, the scale will be lower. Being in an endemic does not mean abandoning all measures and accept the course of nature. It just means being prepared with better, more efficient tools to deal with the disease in the long term.

This article comes back to the phrase “living with the virus”. In truth, there is no “living with the virus”, at least not with the SARS-CoV-2 virus. The phrase suggests a commensalistic relationship but the virus-host unit is more of a parasitic relationship, where the virus benefits from the infection and the host is trying to get rid of it using its immunity. It is basically a molecular arms race, the virus trying to propagate itself, and the host trying to minimise damage.

Therefore, it is still “surviving the virus” more than “living with”. Accepting a baseline number of infections in the population does not mean we can let it spread unchecked. Will we survive Covid-19 with minimal damage to our world? We can, provided we have the right measures, messaging and mindset.



Yoong Khean

Medical doctor by training & an MBA graduate. Has since hung up my stethoscope & currently working in a global health research institute in Singapore.