“It is clear that the virus remains with us for some time, if not forever. It is less clear how often and how much it will continue to impact our health and well-being.” This sober assessment comes from California’s new state plan unveiled on February 17, by Governor Gavin Newsom who candidly confessed that “We have all come to understand what was not understood at the beginning of this crisis, that there is no end date, that there is not a moment where we declare victory.”

The initial war cry of vanquishing the virus has yielded to the realism of ‘living with it’ as the virus exhibits Houdini-like skills in evading all attempts to shackle it, springing our locks with more infectious and immune evasive variants. It has delivered humbling lessons that respiratory viruses cannot be eradicated but can only be steered by evolutionary biology to become less virulent even as they ensure their survival by becoming more infectious and vaccine-evasive. The sage advice of Joshua Lederberg (Nobel Laureate discoverer of microbial genetics), to eschew militaristic language against microbes and find ecological and science-based pathways of coexistence with least harm, stands affirmed.

This does not mean surrender to the virus. We still need to do our best to tame it and reduce its potential to harm large numbers of humans. California’s new strategy spells out key components of the response to Covid as it moves towards endemicity. The acronym SMARTER, which stands for Shots, Masks, Awareness, Readiness, Testing, Education and Rx (treatment) is a wry reminder that we need a strategy that invokes more brain than bravado.

India’s own strategy, replete with several acronyms, has placed us at a stage where Omicron is more a breeze than a tornado like Delta. However, it is too early to raise the all clear flag of stable endemicity, as the virus is still active in several parts of the world and could further evolve to throw more variants at us. Even in an endemic state, waning immunity in some sections of the population (especially the elderly and immunologically naive children) will give rise to periodic outbreaks. So, we do need to maintain vigil and be prepared to limit the damage of such outbreaks. Studying our own preparedness, using the lens of California’s strategy, is useful in that regard.

We are well positioned in vaccine administration. As per a recent government report (February 18, 2022), 97% of the eligible adults have received at least one dose, 80% have received a second dose and 72% of the 15-18 year age group have received at least one dose. While the initial high-decibel boast of mRNA vaccines in Western nations has been muffled to a whimper of multiple boosters because of short-lasting immunity, the vaccines used in India appear to have provided considerable protection against severe illness and hospitalisation during the Omicron wave. The imminent entry of new sub-unit protein vaccines, a DNA vaccine and even an India made mRNA vaccine into the domestic vaccine supply chain will augment our ability to expand vaccination coverage to other age groups, for both primary and ‘protective’ (booster) vaccination.

Masks need to be worn, in both indoor and crowded outdoor locations, for some months. While vaccines mainly offer protection against severe illness, masks provide protection against even the initial infection. While resuming most of our activities, we must be wary of the possible emergence of a new mutant with higher levels of infectivity, immune evasion capability and virulence than Omicron. While the anticipated trajectory of evolutionary biology in corona viruses is to become less virulent over time, it may not necessarily run to script.

As Donald Burke from University of Pittsburgh writes in a recent commentary on ‘clever’ corona viruses (STAT News, February 16), there are other less probable yet possible pathways by which the Covid virus may still pose danger. It can evolve to infect new cell types in the human body. New recombinant coronaviruses can emerge when the present variant exchanges genetic material with another virus which is also present in the body of an infected person (usually immunocompromised), in an animal, or in the sewage system. Antibody-dependent enhancement, known to occur with some viruses like dengue, can provide the virus inroads into human cells by binding to antibodies on their surface.

Awareness of the methods to protect individuals and communities, from viral transmission and severe illness, is a priority in the SMARTER strategy. California intends to promote vaccination, masking and other mitigation measures in all its 58 counties, while engaging with at least 150 community based organisations. In India too, there is a need for scaled-up, sustained and energetic engagement of community based organisations, elected local bodies and citizen networks at the grass roots. This can build platforms for people-partnered public health, to strengthen India’s health programmes well beyond Covid.

Readiness calls for being equipped with tools, resources and supplies that will enable a prompt response to a public health emergency. Surveillance of circulating viruses in humans, animals and sewage must continue, to detect outbreaks and emerging variants. California intends to “maintain wastewater surveillance in all regions and enhance respiratory surveillance in the healthcare system, while continuing to sequence at least 10 per cent of positive Covid-19 specimens.” Our primary healthcare personnel should conduct routine symptom based surveillance. Testing needs to be done for symptomatic individuals needing clinical care.

Education, as a continuing commitment, is stressed by California’s plan. We need to resume school and college education, with proper precautions like masking, ventilated spaces and staggered schedules providing protection till it is safe to lift all restrictions. Schools can also serve as vaccination centres, if younger age groups become eligible for vaccination. Treatment should become available as needed, to ill persons with active illness or ‘long Covid’, with clinical guidelines updated as per emerging scientific evidence.

While California’s plan has several familiar elements, it signals a recognition of the reality that we have to deal with the virus as co-habitant of our world. Living with the virus means that we strike a deal on our terms: Nudging it to become less threatening in its traits by denying easy access to susceptible humans, while acquiring greater protection against several illness through scientific advances and public health measures.

The author, a cardiologist and epidemiologist, is president, Public Health Foundation of India (PHFI) Views are personal.