Last night, as I said goodnight to my father-in-law, he told me that it was the longest night of the year. On the 21st of December, the northern hemisphere sinks into its deepest point of darkness but onward there is ever-increasing daylight.

It is a time when change and hope are renewed.

As of December 21, there have been over 274 million confirmed cases of Covid-19 reported globally, including 5 million deaths. Pakistan has reported over a million confirmed cases of Covid-19 with 28,878 deaths since January 2020. Approximately 142 million vaccine doses have been administered in Pakistan, but only a quarter of the population is “fully vaccinated”.

Vaccination: the silver bullet

This time last year, we were hoping that through vaccination and “herd immunity” we would be able to eradicate Covid-19 from the world, as we did smallpox, and are trying to do against polio.

To eliminate a virus, you need a few key ingredients. You need an effective and prompt surveillance system, a vaccine that will produce strong, effective, and long-lasting immunity, and sufficient number of people vaccinated (vaccine coverage) to stop transmission and hence, the number of infections. If we reduce the number of infections, we decrease the probability and opportunity for the virus to mutate, and the emergence of variant strains. It’s a race that can only be won if there is social and political will for the greater good. We have to think and act as a community, both at the local and global level.

The lockdowns, social distancing and mask wearing have been exhausting and frustrating for everyone. There is a fine line between hope and hype. As hopeful as we were for the vaccine to allow us to be free again, we didn’t give it a fair chance. Public health measures needed to stay in place long enough for us to put all our ingredients together.

Rolling out the vaccine

In Pakistan, the Covid vaccination programme has been successful and well organised. The government procured over 40 million Covid-19 vaccine doses from the World Health Organisation, China, the US, the UK and Germany. The target was to vaccinate about 70 million people by the end of 2021. A week to go, we stand at approximately 62 million fully vaccinated individuals.

Uptake of the vaccine was slow, so we started to see the introduction of mandatory vaccination policies. You have to be vaccinated to go to work, to school, travel, eat at a restaurant and buy fuel. Our medical record of vaccination and testing is linked to our CNIC adding to the growing list of ethical issues that have challenged us during the pandemic.

The vaccines themselves became passports. Sadly, the Chinese and Russian vaccines were quickly given the status of a Pakistani passport. Many countries placed a requirement of a specific vaccine for permission to enter.

The conversation has now shifted to boosters, additional doses and revaccination. A booster dose is giving a vaccine after the vaccine series has finished. It is meant to bring back immunity to an acceptable level to increase memory cell pool and improve avidity. Additional doses develop immunity in those who may not have developed a response initially. Revaccination is giving another vaccine series, for logistical reasons such as travelling.

We have also seen a shift in the use of the term vaccine efficacy to vaccine effectiveness. Vaccine efficacy is determined using clinical trials conducted in selected individuals in a controlled setting as opposed to vaccine effectiveness, which is calculated using real time data. There was a difference for a number of reasons, more people hence more variability, logistics and timing of doses, including storage and availability of doses. In addition, the level of community transmission and prevalence during vaccine roll out. Translating vaccine effectiveness into meaningful outcomes was also challenging, the figures change depending on the outcome of interest, death, severity, or infection. To compound this, there was an urgency that perhaps drove an optimistic interpretation of vaccine data before we really understood the immunity provided by vaccines.

Many have suggested that accessibility problems and inequity in the global distribution of vaccines have hampered efforts to control the pandemic. The WHO’s Global Covid-19 Vaccination – Strategic Vision for 2022 has outlined a framework to ensure a more cohesive approach to countrywide and global vaccination programmes. The report is critical of countries that adopted plans with an exclusive national focus that disregarded the global nature of the pandemic, which ultimately undermined efforts to limit the spread of the virus.

Anthony Costello, professor of global health at UCL, and a former director at the World Health Organisation, says: “The contrast is stark: the current share of people fully vaccinated in high, upper-middle, lower-middle income and low-income countries is 69 percent, 68 percent, 30 percent and 3.5 percent, respectively.”

The WHO has made it very clear that the “lack of global coordination will affect future availability of resources for research and development, manufacturing, purchase and delivery of vaccines. Uncoordinated target-setting also risks further increasing inequities with dire health consequences, particularly in low-income settings and economic consequences for all countries.”

Emerging Covid-19 variants

Early studies from South Africa suggest that Omicron may be producing less severe infections than previous variants such as Delta, but it is more contagious. This could be because so far it has circulated in vaccinated individuals and in an age group that is less likely to succumb to a serious infection. Only time will tell.

Data is still awaited on how various vaccines will respond to the Omicron variant. Some reports suggest that the mRNA vaccines have reduced efficacy.

We need to give the vaccines the best possible chance to work by at least controlling and reducing community transmission. We need to continue to use non-pharmaceutical interventions such as masks and social distancing. We need to improve our surveillance of travellers coming into Pakistan and genomic sequencing of strains circulating in Pakistan.

Viruses evolve at a faster pace than humans, they are survivors. As a virus adapts to us, we have to adapt to the virus. However, we also need to change and adapt our objectives and set new collective goals for ourselves because this virus is here to stay.

The wedding season in Pakistan is nigh, we need to implement the same control measures to keep gatherings small, to ensure masks in public spaces and to have our tracking system ready to respond. We still have a long night ahead.

In the immortal (and slightly edited) words of Gloria Gaynor:

Oh no, not I, I will survive

Oh, as long as I know how to change,

I know I’m still alive

I’ve got all my life to live, and I’ve got

lots of variants to give

And I’ll survive, I will survive…

The writer is a consultant molecular biologist at the Aga Khan University Hospital regional laboratory in Lahore. The institution may not necessarily subscribe to the views expressed by the author