What if we don't find a vaccine for Covid-19?

• With the world eagerly awaiting a Covid-19 vaccine, one has to consider what will happen if we don't get one.
• Health24 asked four local experts what to expect if there's no vaccine.
• Even if an effective vaccine is developed, it will take years to rid the world of the deadly virus.

"Things will get back to normal once we develop a vaccine."

This mantra has been repeated over and over again by governments and individuals – science's golden ticket out of the global pandemic and back to familiarity. But what if we don't find a vaccine soon – or never?

"We invest in 'the vaccine' because we want it all to go away and for life to get back to normal – whatever normal might have been – and that's not going to happen," says Professor Lenore Manderson, an expert in public health and medical anthropology at the University of Witwatersrand, who is stuck in Australia where she's an adjunct professor at Monash University.

"What we are doing now is paying the price for being a highly urbanised, highly developed society with a range of problems in daily life and, in a way, it is a rehearsal for other problems in the future." 

READ | How effective should a Covid-19 vaccine be for the world to turn 'back to normal'? 

How long will the virus be around?

Manderson believes the current version of the virus will be around for 18 months without an effective vaccine, after which infection rates will start to decrease, with lower-level strains still circulating among the population. 

On the other hand, director of the Wellcome Centre for Infectious Diseases Research in Africa, Professor Robert Wilkinson, remains optimistic about a partially effective vaccine being developed by the multiplicity approach that's been adopted worldwide.

However, he warns that we won't know anything for sure until a vaccine goes into Phase Three human trials and even if early results are moderate, we shouldn't lose hope. 

For context, from the time that a vaccine was discovered in the 18th century, it took almost 200 years to eradicate smallpox globally.

"You should plan for this being around for two to four years, and you should put it in the back of your mind as well that the way that this virus behaves is not quite like influenza in many respects, but that infections, once they are subjected to immune pressure, tend to start varying themselves so that they can come back," says Wilkinson.

Challenges for a vaccine

Mutating strains are just one of many other problems that vaccines face, even if they make it past the final stages of clinical trials. 

Public willingness to vaccinate, manufacturing delays, access, distribution channels, and many other factors will keep us in a "vaccine-free" world for longer than we anticipate even if one has been developed.

Professor Thomas Scriba, from the South African Tuberculosis Vaccine Initiative at the University of Cape Town, has already seen this in the fight against other diseases. 

"I think it is important to note that even if a highly efficacious vaccine is developed by the end of the year, that does not mean we will be able to eradicate SARS-CoV-2 very rapidly. We currently have a whole lot of effective vaccines for a number of infections that cause disease and death, yet these infections and diseases are still around." 

One of these include the BCG vaccine for tuberculosis. While important in the fight against the disease, it's still not 100% effective and we haven't been able to improve on it.

READ MORE | Russia’s Sputnik V Covid-19 vaccine only approved for use in small groups 

Hoarding

Another real issue would be vaccine hoarding. Richer countries will be buying up stock, leaving poorer countries like South Africa without access to the vaccine.

Manderson uses the bird flu outbreak in 2009 as an example. Tamiflu, an antiviral medication that was used to fight the disease, was hoarded by wealthier countries, and when the World Health Organisation (WHO) eventually secured some for poorer countries, the outbreak had already passed. 

"You've got the politics of commercial interests, the economics of the vaccine companies, the mobility, the deftness of the virus and the possibility that there won't be a vaccine anyway. So in all of those scenarios, what's more likely to happen is that the virus will eventually wear itself out in about 18 months, and it will be back to normal until it comes back again." 

And that resurgence is what will become part of our lives, and that we shouldn't cling too tightly to the image of a "vaccine in shining armour".

"I, therefore, think it is essential that the message gets out there that infection control measures, like hand washing, masks, avoiding large gatherings, are the only tools we as the public have in our arsenal against this virus," adds Scriba. "Resurgence of transmission is a very real risk." 

READ | Wits begins second Covid-19 vaccine trial – and you can register as a volunteer 

The question of 'herd immunity'

What about "herd immunity", I hear you say. The concept isn't as straightforward as one might think, according to the experts.

"I get worried about this 'herd immunity'," explains Wilkinson, "because as a concept it was specifically invented and put forward as a consequence of vaccination. So the whole idea that natural infection could lead to herd immunity is contrary to what was the initial concept of it.

"Nevertheless, notwithstanding that there's a report every day of someone who got SARS-CoV-2 twice, the overall reinfection rate seems to be quite low, so it does seem that there's some natural immunity.

"For something that is this infectious, there needs to be quite a high level of immunity to assume that significant transmission wouldn't rise again."

Dr Melinda Suchard, head of the Centre for Vaccines and Immunology at South Africa's National Institute for Communicable Diseases, shared similar sentiments.

"As countries move past the initial surge of infections, it is likely that herd immunity will develop.

"Although we don't fully understand immunity to Covid-19 yet, the pattern of the disease decreasing to lower levels after peak levels of infection, suggests that there is some form of immunity at a community level, even if each individual immunity may decrease over time."

She also adds that while herd immunity can make the virus less common, it will never eliminate the disease entirely. The virus will live on in low-level infections and she expects we won't see such large outbreaks as we did in 2020. 

A new strain of the virus has recently been discovered in Indonesia that already appears to be less deadly, although more infectious. 

But how is this going to impact our lives directly, moving forward?

READ | Understanding the basics of 'herd immunity' and fighting the coronavirus 

We might lose the care in healthcare

One of the startling impacts of the virus is on our healthcare systems. Resources were redirected from other sectors with a hyper-focus on detecting and treating Covid-19, and holistic healthcare was replaced by a vertical approach to treatments. 

"The effects of this have been highly deleterious because it has completely disrupted the care of every other condition," laments Wilkinson, especially in the case of HIV, tuberculosis and malaria. A six-month disruption of antiretroviral medication alone can lead to more than 500 000 extra deaths from Aids-related illnesses in sub-Saharan Africa, while a three-month lockdown can lead to 6.3 million more tuberculosis cases and 1.4 million deaths worldwide.

"You arrive with a cough, with the chance of it being tuberculosis, but are told it's probably Covid and to wait it out at home for two weeks," Wilkinson uses as an example.

Our experts, however, had some differing opinions on what post-pandemic healthcare would look like. Suchard believes healthcare will "eventually return to it's "pre-Covid levels", including the treatment of other diseases, with more emphasis placed on sanitation procedures. 

"The need for special personal protective equipment, over and above that used routinely, is likely to decrease as the speed at which the virus spreads decreases, except for health workers treating patients with confirmed Covid-19," adds Suchard. 

But Manderson estimates that we will start seeing a serious shortage of skills in the sector. People would become less willing to work in a sector with a high possibility of infection – especially if you have underlying issues – and we might see a serious decrease in the volunteer side of healthcare.

According to the WHO, in July about 10% of all cases in the world involved healthcare workers. 

Elderly care, disability care and community clinics will also be seriously impacted with the workforce decrease, and limited resources rerouted to other sections of the healthcare industry. 

So don't expect masks to go anywhere soon at hospitals and clinics. 

"If we have to protect healthcare workers we are going to have to insist on masks and what that does is take away the care from healthcare to some extent at least. Without the insistence on masks, we will lose our healthcare workers – and in South Africa, we already have a problem of not having enough healthcare workers," says Manderson.

READ | Even with PPE, risk of Covid-19 still high for frontline workers 

Self-medication and antibiotic resistance

As we have to look after our medical professionals' health in a vaccineless world, we also have to remember to look after our own health. Covid-19 has many people putting off going to the doctor for "normal" symptoms, too scared of catching the virus from a healthcare setting. 

With fewer check-ups, signs of other diseases, like cancer and diabetes, will be missed and premature deaths are likely to increase.  

"It will also open up the market for over-the-counter pharmaceuticals that are currently covered under essential drugs," says Manderson.

Taking an over-the-counter remedy for a cough and cold isn't such a big deal, but if antibiotics leak into the informal drug market, we might be stuck with an even bigger issue – antibiotic resistance. 

Antibiotics, like amoxicillin, are already being used to treat Covid-19 patients who end up with bacterial pneumonia alongside the viral disease.

"If we continue to do that, knowing it's a virus and not bacteria, we are going to precipitate mass antibiotic resistance in communities as well as at a hospital level, and then face even worse problems than we have right now."

For Manderson, this highlights a serious need for watchdogs in the pharmaceutical industry, managed by governments and even pharmacists themselves, to curb the expected rise in self-medication. 

READ | 'Superbugs' resistant to antibiotics could be strengthened by pollution 

Future generations

Currently, vaccines are only being tested on adults, which could leave children more open to infection, especially those born post-2020, without developed immunity.

Children who have no previous exposure would be susceptible to the weaker strains of the coronavirus, but luckily we know the severity of the virus is related to age and, according to Suchard, we won't necessarily notice the age shift in infections.

The pandemic might also have fundamentally changed our education systems – one cough and you might shut down a whole school.

"Society is always changing rapidly, as we can see from the differences between generations. The social changes that have occurred in response to the pandemic are likely to have long-lasting influences. For example, connectivity through online platforms, remote working, homeschooling and online shopping trends," says Suchard.

Peak life expectancy

Another way that things will shift in generations to come is that life expectancy will drop. For the last few years, researchers have noticed a drop in life expectancy in developed countries like Britain and the US, and Covid-19 might just be another cause of death to add to an already long list.

"We are going to have accept that some people will die from the coronavirus in the same way that some people die from the flu or pneumonia," says Manderson.

When she was younger, people used to say that pneumonia was "an old man's friend" because it took people out before other age-related health issues made them suffer. Well, now it might be Covid-19.

"That's a dilemma. The argument has been that people's attitude towards living with a level of disease and death is ageist – and in that respect, they are right because it will disproportionately affect the elderly – but against that we already live with that for other communicable diseases not effectively managed in the health system.

"This might be the beginning of a demographic transition people assumed we would have and are not prepared to accept."

However, one positive outcome of Covid-19 might be that we are a little better prepared for future pandemics, Suchard believes.

"Many systems have been put in place for Covid-19 regarding disease tracking, data collation and networking of other sectors with the health sector. Hopefully, the lessons learned from Covid-19 will put us in a better starting point should another pandemic arise."

READ | Ageism affects people around the globe 

What we can learn from other diseases

By looking at other diseases, like HIV, without vaccines, we might elucidate some lessons we can apply to Covid-19.

"On the science front, we learn to be humble and acknowledge that we don't fully understand immunity to any of these diseases," says Suchard.

"On a practical front, we can learn from HIV and malaria that the disease can be controlled with other interventions, such as lifestyle interventions and health education regarding risk factors." 

One of the biggest lessons to be learnt is the importance of testing, according to Wilkinson.

"You have to know who's got it so that you can take whatever measures necessary to prevent them from transmitting, and getting it treated."

For Scriba, HIV and malaria are less useful at providing insight because they're so different from coronavirus and instead, we need to look further back to the Spanish Flu pandemic. This virus went through multiple cycles of upward and downward infection rates and community spread over a few years, and was tied to infections peaking again in winter.

Covid-19 is expected to follow a similar pattern without a vaccine, and Scriba expects we'll have Covid-19 flare-ups for years to come.

"It is essential that we adjust to this new reality," adds Scriba.

"Other infections and diseases that affected and killed our population before the Covid-19 pandemic have not disappeared, and in many cases, have become worse because people have not had access to healthcare.

"This means that there needs to be real urgency to return to a more holistic view where we recognise and respond appropriately to all infections and diseases, not only Covid-19."

The new decade is definitely completely different from the world we knew, and while we can look to the horizon with hope for a vaccine, it's imperative that we learn to see in the dark.

READ MORE | The forgotten killers: Covid-19 destroying gains made in the fight against malaria, TB

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