Scrolling through social media these days, you’ll see that loud extremists continue to dominate COVID-19 discourse. At one pole are the denialists who argue—incorrectly—that COVID is “just a cold.” At the other are those who suggest that no meaningful progress has been made in controlling its devastation. The truth, of course, is somewhere in the middle.
We have not yet extricated ourselves from the peril of SARS-CoV-2, and wishing COVID-19 gone does not make it so. Surging case numbers provide opportunities to produce the next variant as the virus evolves to escape antibodies accumulated from vaccination and prior infection. (There is no way to predict the severity of disease caused by a future variant, though immunity undeniably helps.) Some portion of these cases will be severe, fatal, or result in disabling long COVID. Absenteeism among infected healthcare workers creates unsafe staffing ratios, and the transportation industry, such as airlines and the Staten Island ferry, are being affected by high levels of infection among staff. Conversely, the lack of universal paid sick leave continues to be a barrier to COVID-19 control in the U.S., as infected people are forced to choose between their livelihood and the safety of coworkers and the public.
Still, we must recognize that science has brought us far from where we were in 2020. We now have a solid understanding of how SARS-CoV-2 spreads and how to interrupt that spread. We don’t have to deal with testing bottlenecks. We have effective antiviral therapies, even for the latest variants like BA.5. Antibody cocktails like Evusheld can help protect immunocompromised people unable to mount their own antibodies in response to vaccination. We have very safe, highly effective vaccines, including for children as young as 6 months, that saved more than 20 million lives globally in their first year of use alone. Although variants have been able to side-step vaccine immunity against mild infections, protection provided by vaccines against severe disease, hospitalization, and death remains extremely robust and durable against all known variants. Vaccination also provides substantial protection against long COVID.
Yet, despite the progress we have made, the current levels of illness, deaths, and long COVID warrant more aggressive action. We have been disappointed in the lack of clear messaging from the Biden Administration on the steps that are needed.
First, we must intensify our actions to tackle the profound inequity, domestically and globally, in access to the tools we now know can curb the pandemic: vaccines, boosters, antiviral therapies (like Paxlovid and Evusheld), diagnostic testing (including rapid tests), high filtration masking in public indoor settings, investing in indoor ventilation, humidification and air filtration, and wastewater surveillance. We must keep in mind the big picture that until these tools are equitably accessible to control infections globally, the world remains vulnerable to the emergence of new variants that could potentially reverse our progress against the virus.
Second, increasing booster uptake by older Americans in particular should be seen as a public health priority. The Biden Administration is right to put boosters at the heart of its plan for tackling BA.5, but its distribution strategy needs more focus and urgency. A targeted campaign is needed to bring boosters to communities that have low coverage and especially to older people, such as in nursing homes. The model, say Anne Sosin at Dartmouth College and colleagues, should be one of “bringing vaccines to people rather than people to vaccines, and should include strategies that include door-to-door vaccination programs.” Among Americans who are 50 or older, those who have had a second booster shot are 42 times less likely to die from COVID-19 than unvaccinated people. Yet booster uptake in the U.S. remains very low—only 34.2% of those over the age of 5 have had a first booster shot. Around 3 in 10 people aged 65 and older—the age group at highest risk of death if they get infected—have yet to receive a first booster. While residents of nursing homes are among the most vulnerable to hospitalization and death, too many nursing homes are doing poorly at boosting their residents and staff. There are also persisting racial inequities in who is being offered boosters.
Being boosted provides significant protection against infection—e.g., three doses of Pfizer vaccine can reduce the risk of infection by about 70% —and widespread boosting would have an important population-level effect on infection numbers, hospitalization, and deaths, especially at the start of a surge. While the protective effect of boosters against infection wanes over time, most individuals will remain protected against severe COVID-19.
Third, we must ensure that vulnerable people are receiving medicines that could keep them out of the hospital if infected—especially antivirals like Paxlovid, and monoclonal antibodies like Evusheld and bebtelovimab. Right now, that approach is inadequate. Paxlovid needs to be taken within five days from symptom onset to be effective. It remains underused in the U.S., in part due to limited access to testing and insufficient knowledge among prescribers. New York City has rolled out mobile testing units where you can get a free COVID test and Paxlovid on the spot—we need to scale this kind of “Test and Treat” approach nationwide. Permitting pharmacists to prescribe Paxlovid is a smart way to remove barriers to access, doubly so because these healthcare professionals are the experts at assessing for potential interactions with other medications, which is one of the barriers to using the drug. Another effective biomedical intervention that remains underused is Evusheld, a long-acting monoclonal antibody cocktail that can be protective for at least a few months. Many physicians, including those who care for the most vulnerable patients (who are likely to derive the most benefit), remain unaware of the drug, and some immunocompromised patients have reported having to tell their physicians about it. Using monoclonal antibodies against SARS-COV-2 is a bit like a game of whack-a-mole, however, and newer variants may emerge that are evade their effects. Diversification of our monoclonal stockpile can hedge bets in this arms race. Another medicine, bebtelovimab, is the only other FDA-approved monoclonal antibody that remains active against newer variants, but it is in limited supply, and is unavailable outside the U.S.
Aside from these measures, while there is a strong case for mandating indoor mask use in a surge, unfortunately, we see little political appetite for the return of such mandates. Two cities—Los Angeles and Seattle—were considering re-imposing mask requirements in indoor public settings, but we don’t expect many others will follow. Guidance from the CDC on masking has become confusing and contradictory. On the one hand, the CDC director Rochelle Walensky now says “if you are living in an area that has high community transmission of disease, we really do suggest that you wear a mask,” but on the other she says “masking policies happen at the local and the jurisdictional level” and so federal guidance can be rejected. This statement is in keeping with a flawed rhetoric of personal responsibility trumping population-based public health that the CDC has promoted since May 2021.
Scientific research has transformed the pandemic in places that have access to control tools. But further transformations are needed in two priority areas. The first is to develop improved COVID vaccines—including broader vaccines (to protect us not just against all SARS-CoV-2 variants but also against other coronaviruses), and mucosal vaccines that better block transmission. Operation Warp Speed-style funding could pay massive dividends to public health if we can achieve these goals. Yet the Biden Administration and Congress have dropped the ball when it comes to funding the COVID-19 response, failing to reach a bipartisan deal that would have funded next-generation vaccines and therapeutics.
The second is to improve our understanding and treatment of long COVID, an umbrella term for a range of conditions of varying severities found to occur after infection by SARS-CoV-2. While vaccination lowers the risk, it does not abolish it, meaning minimizing case numbers needs to remain a priority (a key principle in infectious disease is that a small percentage of a huge number means a still very large public health burden). For example, the latest survey from the United Kingdom’s Office of National Statistics found that about 4% of adults who were triple vaccinated reported that they still had symptoms at 12 weeks after infection with the Omicron BA.1 or BA.2 variants. It is more than two years since long COVID was first described, and we still have a ways to go to improve the three Rs: recognition, research, and rehabilitation (including developing specific treatments). And long COVID is not just a medical issue—patients also need social support, sick pay, and access to disability benefits.
All pandemics end, and this one will too. We will be able to reach low endemic levels of illness, akin to what we see with influenza. We have the means to make it so, if we respond with commensurate force against this virus.
August 9, 2022 at 04:46PM Edward Nirenberg, Gavin Yamey and Ilan Schwartz