We are not safe unless everyone is safe. Otherwise, this virus will keep coming back.

On 30 January 2020, when the World Health Organization declared the outbreak a Public Health Emergency of International Concern, the Global Alliance for infections in Surgery, wrote an editorial stating that, it was the time for facts and not fear, that it was the time for science and not rumors and it was the time for solidarity and not stigma.  After almost 5 months, although no one yet knows what the future holds for Covid-19, most experts seem to agree that it isn’t going away anytime soon and that editorial is still current. In terms of the scale of transmission and exerted impacts, countries can be classified into three main groups: the first group has already witnessed the peak of the pandemic, the second category is in the middle where cases are reaching the peak, and the third cluster is experiencing the beginning of escalation. Countries in the first category are fearing a potential second wave of the outbreak after easing the preventive measures put in place, such as lockdowns and the revoking of travel permissions. The virus caught the global community off guard, and its future course is still highly unpredictable; there is no crystal ball to tell us what the future holds and what the “end game” for controlling this pandemic will be. in order to visualize how Covid-19 could evolve in next future, the Global Alliance for Infections in Surgery, in a previous editorial, analyzed three possible scenarios. Of course, other developments can influence these scenarios, leading to different outcomes.

Scenario 1

The first wave of Covid-19 in spring 2020 may be followed by a series of repetitive smaller waves that occur through the summer and then consistently over a 1- to 2-year period, gradually diminishing sometime in 2021. The occurrence of these waves may vary geographically and may depend on what mitigation measures are in place and how they are eased. Depending on the height of the wave peaks, this scenario could require periodic reinstitution and subsequent relaxation of mitigation measures over the next 1 to 2 years.

 Scenario 2

The first wave of Covid-19 in spring 2020 may be followed by a larger wave in the fall or winter of 2020 and one or more smaller subsequent waves in 2021. This pattern will require the reinstitution of mitigation measures in the fall in an attempt to drive down spread of infection and prevent healthcare systems from being overwhelmed. This scenario is similar to what was seen with the 1918-19 pandemic. During that pandemic, a small wave began in March 1918 and subsided during the summer months. A much larger peak then occurred in the fall of 1918. A third peak occurred during the winter and spring of 1919; that wave subsided in the summer of 1919, signaling the end of the pandemic.

Scenario 3

The first wave of Covid-19 in spring 2020 may be followed by a “slow burn” of ongoing transmission and case occurrence, but without a clear wave pattern. Again, this pattern may vary somewhat geographically and may be influenced by the degree of mitigation measures in place in various areas. While this third pattern was not seen with past influenza pandemics, it remains a possibility for Covid-19. This third scenario likely would not require the reinstitution of mitigation measures, although cases and deaths will continue to occur.

Whichever scenario the pandemic follows (assuming at least some level of ongoing mitigation measures), we should be prepared for at least another 18 to 24 months of significant Covid-19 activity, with hot spots popping up periodically in diverse geographic areas. As the pandemic wanes, it is likely that SARS-CoV-2 will continue to circulate in the human population and will synchronize to a seasonal pattern with diminished severity over time, as with other less pathogenic coronaviruses, and past pandemic influenza viruses have done. The ongoing patterns and nature of Covid-19 make it highly clear that there remains a considerable possibility for the next wave(s) of infection. Healthcare workers, governments, and international organizations, must become fully prepared to keep the viral spread under control so that to mitigate the impact the second-wave. Disinformation, rumors, and conspiracy theories must be countered with easy access to correct and helpful information. Simultaneously, it is indispensable that all healthcare systems should be greatly prepared in advance for any potential second wave to diagnose cases and offer the required treatment. The vaccine will be able to greatly impact the course of the pandemic but it will not be very soon. We already know that as a public-health intervention, vaccination is one of the most impactful and cost-effective. It has eradicated smallpox, nearly eradicated polio and, in recent decades, reduced the incidence of infectious diseases that once killed millions every year, such as measles, helping to halve child mortality. It is now accepted that the only way to end Covid-19 pandemic, minimize loss of life and return to some semblance of normality is through vaccination. However, vaccine development is a lengthy, expensive process. We will just have to wait and health systems will have to do everything to protect people until Covid-19 vaccines are shown to be effective, produced in unprecedented quantities, and make sure that everyone has equal access to them. In the face of such an unprecedented situation in recent history, the creativity of the response must match the unique nature of the crisis – and the magnitude of the response must match its scale. No country will be able to exit this crisis alone. In this context the success will be ony achieved when all people in all countries around the world are protected and safe from Covid-19.

Let us be clear with everyone: we, more than almost anyone, would love to see that world is open and safe from Covid-19, but that simply is not what the data is telling us at this time.

We are not safe unless everyone is safe. Otherwise, this virus will keep coming back.