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February 28 marks four years since COVID-19 was in Aotearoa New Zealand. Many of us are probably surprised this virus is still causing a pandemic.

The World Health Organization refers to COVID-19 as a . As Scientific American put it recently, it “has been the elephant in every room – sometimes confronted and sometimes ignored but always present”.

It wasn’t meant to be like this. The 1918 influenza pandemic in eight weeks, killing 9,000 people – almost 1% of the population. Then it was gone, returning as a new seasonal flu virus.

In doing so, it defined how pandemics were expected to behave. This model was written into pandemic plans and collective thinking across the globe.

But COVID is four years after New Zealand reported its first case, and more than two years after the Omicron variant arrived and infection became widespread.

Constantly present, it is also occurring in waves. Unexpectedly, the current was larger than the , suggesting we can’t rely on the comforting assumption that COVID will get less severe over time.

Unpredictable evolutionary shifts

These waves are driven by the interaction of the organism (SARS CoV-2 virus), the host (human characteristics such as immunity and behaviour), and environmental factors (such as indoor ventilation).

Continuing viral evolution is a major contributor to the changing dynamic. The virus has demonstrated an ability for large, unpredictable evolutionary shifts that dramatically alter its genome and spike protein.

The result is an enhanced ability to evade prior immunity and infect more people. This jump was seen with the highly mutated in mid-2023.

Its offspring, JN.1, has acquired additional changes and is causing such a wave of new infections it could potentially be the , with its own Greek letter. It is now driving epidemic increases across the globe, . This dominance by a single subvariant takes us back to the first year of Omicron in 2022.

Under-counting the pandemic impact

The pandemic continues to have a large, visible health impact. It is a leading cause of serious illness and death, mainly in older populations and those with existing long-term health conditions.

In 2023, it caused more than in New Zealand.

But COVID-19 also has an important and largely unmeasured as the cause of long COVID, which may become its biggest health impact. A growing number of studies are describing an estimated incidence of long COVID of 5% to 15% of all infections.

For example, a recent of almost 200,000 Scottish adults reported that, after adjustment for factors that might confuse the results, long COVID prevalence following an infection was 6.6% at six months, 6.5% at 12 months, and 10.4% at 18 months.

These findings illustrate an important feature of long COVID: recovery can take , with over time.

An integrated respiratory disease strategy

New Zealand now needs a strong, integrated response to COVID-19 and other respiratory infections.

The major pandemic interventions have not changed: vaccination, public health and social measures to prevent infection, and antivirals for more vulnerable groups. The evidence has firmed up that long COVID risk is , but research is less certain for antivirals.

But growing pandemic complacency from political leaders and the public has changed things. Some of this apparent indifference can be put down to understandable fatigue with response measures. But it remains dangerous in the face of a continuing pandemic.

One way to keep a focus on prevention and control would be to include these measures in an . This would combine COVID-19 control measures with those used to protect against influenza, respiratory syncytial virus (RSV), and other respiratory infections.

Measles could be added to the list, given the rising from a global resurgence of the disease.

This would include vaccination, promoting testing and self-isolation when sick, and measures to reduce transmission in critical indoor environments such as healthcare, public transport and education settings.

Such a programme would need to be supported with community engagement, education, surveillance and research.

Structural inequalities mean Māori, Pacific peoples, and those living in relative deprivation, are less vaccinated, less protected from infection, less tested and less likely to have antivirals.

Consequently, they are more likely to be hospitalised and . These inequities are currently not being systematically tracked and acted on.

Ignoring it won’t make it go away

As we enter the fifth pandemic year, we need a change in thinking about COVID-19. This infection has in common with the other severe coronaviruses (SARS and MERS).

It is wishful thinking to imagine it will suddenly transform into a common cold coronavirus. As a recent concluded:

Transition from a pandemic to future endemic existence of SARS-CoV-2 is likely to be long and erratic […] endemic SARS-CoV-2 is by far not a synonym for safe infections, mild COVID-19 or a low population mortality and morbidity burden.

In the face of this continuing pandemic threat, we need a response that is evidence-informed rather than evidence-ignored.

Michael Baker is a member of the Ministry of Health’s COVID-19 Technical Advisory Group (TAG). The University of Otago receives funding from the Health Research Council of New Zealand and the New Zealand Ministry of Health for his research on COVID-19 and other infectious diseases.

The University of Otago receives funding from the Health Research Council of New Zealand and the New Zealand Ministry of Health for research on COVID-19 and other infectious diseases.

Matire Harwood was a member of the Ministry of Health COVID-19 TAG. She receives research funding from Health Research Council, ³Ô¹ÏÍøÕ¾ Heart Foundation and ³Ô¹ÏÍøÕ¾ Science Challenge-Healthier Lives. She also works at Papakura Marae which received funding for COVID-19 testing, vaccination and management.