Infectious disease expert and clinical investigator Rodger MacArthur, MD, considers what we know now that we didn't on March 12, 2020.
SARS-CoV-2, the virus responsible for COVID-19, is still out there. It hasn’t gone away. In fact, we are being told that the newest Omicron subvariant is responsible for an increasing percentage of all new infections in the United States. So why now for an epilogue?
Because, for the vast majority of us in the US, it seems like the virus has gone away. Life is getting back to normal, mask usage is decreasing by the day, and hospitalizations are way down in most areas. So, what better time to write this epilogue, focusing on 10 lessons learned along the way?
Remember when the focus was on bacteria? Remember when it was considered good news if it was “just a virus” that caused our infection? Well, we have learned that viruses can make us really, really, sick. We have learned that viruses are hard to kill. We have learned that viruses replicate at astronomical rates. And we have learned that viruses mutate: last’s year’s variant really does seem like your parents’ variant.
If the virus doesn’t kill us directly, our own immune response might finish the job. While a “healthy” immune response to invading pathogens is considered to be (mostly) beneficial, an overly vigorous response (aka “cytokine storm”) often is responsible for much of the damage. Corticosteroids do seem to work in this setting, even though they typically have failed to help in the setting of sepsis caused by bacteria.
Viruses have multiple targets for blocking by newly developed drugs. But even with multiple antivirals available, it is challenging to completely shut down viral replication. And if a virus is replicating, it is mutating. In addition, antivirals are unlikely to have much effect on damping the host immune response. It might be possible to develop a safe and effective preventive antiviral (think pre-exposure prophylaxis for HIV), but we’re not there yet.
Sometimes they work, sometimes they don’t. They are expensive, require intravenous dosing, but they do appear to be safe. Currently, there is a limited supply available, such that “prioritization strategies” need to be employed to make sure there is enough available for those at greatest risk for bad outcome.
The speed with which the mRNA vaccines were developed was truly astounding. And they had amazing efficacy, at least for a while (see the discussion about mutating viruses above). While initial reports of greater than 90% efficacy haven’t held up, these vaccines are substantially more efficacious than the annual influenza vaccines, which, on average, are about 40% efficacious. This year, the influenza vaccine has been estimated to have been only about 10% efficacious. In addition to impressive efficacy, the COVID-19 vaccines were impressively safe and well-tolerated. Nevertheless, vaccine hesitancy has limited their uptake, as has the need for multiple doses. It seems to me that a public health strategy that “requires” (at least for some) 2 or more doses per year, every year, is not going to have a lasting impact on the number of new infections in the near future.
Herd immunity was the topic du jour about 18 months ago. It may actually be beneficial. The problem with herd immunity, though, is how to get it without losing folks to death or disability along the way. It does seem that one reason that cases are decreasing is that the virus is running out of “targets.” Even if protection is not complete against newer variants, reduction in disease severity is likely. Furthermore, naturally acquired immunity may be longer lasting than vaccine-induced immunity. Note, however, that the longest-lasting protection may come from a combination of vaccine-induced and naturally acquired immunity.
We have known for decades that underfunding of public health initiatives and infrastructure limited our ability to respond effectively to outbreaks of many important diseases, including syphilis, gonorrhea, chlamydia, and tuberculosis. But the “system” completely broke down during this pandemic. State and County Departments of Health did not have the resources available to do effective contact tracing. Personal protective equipment (PPE) was in short supply. Stores ran out of hand sanitizers, masks (for a while) and COVID-19 test kits (supply chain issues, perhaps). One can only hope that the US has learned from this pandemic the importance of providing adequate funding for this vitally important, but often overlooked and underappreciated, area of health care.
Whether racially- or geographically-based, these disparities often impacted who got sickest. These disparities date back decades. Think lack of adequate diabetes management in those who cannot afford or access the drugs. Think lack of adequate blood pressure control in those who cannot afford the drugs or access the health care system. This topic has been discussed at length in the literature, but it seems to me that effective solutions are still many years away. We urgently need to continue the dialogue so as to benefit the overall quality of health care for all of us.
The virus devastated residents of these facilities early in the pandemic. Perhaps the lack of PPE, or lack of adequate training in effective infection prevention strategies in these facilities, was to blame. Whatever the explanation, I believe that we cannot let it happen again. We must understand that institutionalized persons, typically with multiple co-morbid conditions, comprise a very vulnerable population at risk for infection with multiple dangerous pathogens.
As a society, we survived. Health care providers worked long hours to combat the devastation caused by the virus. Medical students volunteered to educate communities about vaccines and help in countless other ways. As survivors, we cannot forget the conflicting guidance about prevention strategies (eg, masks) and the politization of the pandemic. It seems to me that confidence in the CDC, Federal Government, and science in general, took a hit that will take quite some time to recover. And lest we forget, almost 1 million Americans died of COVID-19 or COVID-19-related complications. Worldwide, that figure was more than 6 million. Thousands of others in the US are left with symptoms of so-called “long COVID,” such as memory loss, blood-clotting complications, and heart and lung disease. Life expectancy in the US at age 65 declined by almost a full year. Yes, we survived, but very few of us are left unscathed.
So those are my 10 ten lessons as of now. I would love to hear from others about lessons they, their colleagues, and their families learned.
We are all in this together, and together we prevailed and will continue to prevail.