After weeks at a two-year low, cases of COVID-19 are on the rise again in some countries. In the United States, there were 100,000 new infections every day, up from 30,000 in mid-March.
The trend intensifies an important debate in epidemiological circles. What is the best strategy to prevent catastrophic mass death from the worst possible new COVID variants? New restrictions? New vaccines? New therapies? A mix of the three?
Whatever consensus takes shape could lead us into the fourth year of the pandemic. But there is, of course, a catch. Public health costs money. And in the richest country in the world, the United States, a few right-wing politicians are doing their utmost to ensure that new money is not made available to accelerate the development, production and distribution of new vaccines and therapies.
Vaccine development is stagnating. China is still pushing locally made vaccines that don’t work very well. The leading western vaccine manufacturers are focusing on developing boosters specifically for the recent Omicron variant. But by the time these boosters are ready in the fall, Omicron will likely have been replaced by a new and more dangerous variant.
Two years ago, the world teamed up to develop highly effective messenger RNA vaccines, and quickly. Today, there is less money and less urgency, which means vaccine development is slowing down, right at the same time as the virus is speeding up.
Experts warn that the risk of a disaster, later this year or next year, is increasing.
To be clear, the COVID increase is slight for now. In the US alone, there were an average of 800,000 new cases per day by mid-January. And hospitalizations and deaths are not rising at the same rate as cases, due to high vaccination levels and the natural antibodies from previous infections.
But the rise in cases in some countries — driven by what appear to be ever-faster mutations in the SARS-CoV-2 virus — reminds us that the pandemic isn’t over yet. The virus continues to change and find new ways to get around our immunity wall.
There is a lot of uncertainty here. “The virus may or may not progress in the short term into an ever-increasing vaccine evasion,” Eric Bortz, a virologist and public health expert at the University of Alaska-Anchorage, told The Daily Beast.
Epidemiologists don’t take any chances. They are looking ahead and trying to project how the novel coronavirus might evolve and what we should do about it. They almost unanimously agree that the pathogen will be with us for years to come. But they disagree on what to do about it.
There are options in case SARS-CoV-2 takes a major evolutionary leap and evades the protective effects of our vaccines and antibodies. This is the nightmare scenario and the most intense debate.
New lockdowns are an option, but the least likely due to the deep unpopularity of strict limits on schools, businesses and travel. China’s disastrous experience of strict lockdowns in recent months has only underlined the dangers of major new COVID restrictions.
The most viable options are pharmaceutical. vaccines. Antiviral drugs.
The vaccines we currently have are a mixed bag. They include old-fashioned Russian and Chinese jabs that use cold viruses as vectors for coronavirus fragments or contain whole killed SARS-CoV-2. There is not much good data on these vaccines and many experts are skeptical about their effectiveness.
But then there are the top western vaccines, including the latest messenger RNA shots from Moderna and Pfizer and a cold virus vector vax from Johnson & Johnson. The data is clear. These vaccines offer strong protection against serious infections — 70, 80, or 90 percent, depending on who was stung, how long ago, and whether they also got a boost.
“The reality is we have vaccines that still work really well,” James Lawler, an infectious disease expert at the University of Nebraska Medical Center, told The Daily Beast. “It’s just that the immunity wanes.” All vaccines and natural antibodies fade over time. But a series of increasingly contagious new coronavirus variants and subvariants — Omicron last fall followed by Omicron subvariants BA.1, BA.2, BA.4, BA.5, BA.2.12 and XE — have seen the decline in accelerated immunity. †
A second booster of an existing two-dose mRNA vaccine could restore and prolong the effectiveness of the shot. Some of the leading vaccine makers are even working on Omicron-specific boosters.
The inherent flexibility of mRNA vaccines makes that possible. The basic formula of the mRNA vaccine is the same for any disease or variant of a disease. You just trade in new genetic material depending on what you want to avoid. “We could use it to change the vaccine in a short time,” Ali Mokdad, a professor of health sciences at the University of Washington Institute for Health, told The Daily Beast. “But it all depends on how quickly the virus mutates.”
The apparently accelerated rate of viral evolution in COVID could mean that the disease is outpacing mRNA-modifying processes. It is possible that, by the time Omicron-specific boosters arrive, Omicron and its closest progeny will have disappeared and a highly mutated new form of SARS-CoV-2 will be dominant.
Instead of chasing COVID variants with boosters, we could change course and set up completely new defenses against the virus. Two major new vaccine types are under development: ‘mucosal’ nasal vaccines and universal ‘pan-coronavirus’ vaccines.
“I think vaccines will continue to play a very important public health role for the foreseeable future,” Paul McCray, a University of Iowa immunologist, told The Daily Beast. “Mucosal vaccines — intra-nasal — will be in the mix.”
The nasal vaccines, delivered by spray, elicit immunity in the mucous membranes of the nose and throat – where COVID infection generally begins. Existing COVID vaccines are all injected into muscle tissue. The antibodies they produce, while effective against the virus, may be less are more effective than antibodies coming from the nasal cavity.
Where a nasal vaccine is highly optimized for a respiratory virus such as COVID, a pan-coronavirus chooses the opposite. It is intended to be universal rather than specific. “The best solution is a universal pan-COVID vaccine,” Bortz said.
The rationale is that there are many other coronaviruses besides SARS-CoV-2. There are even scientists who argue that the latest Omicron subvariants have evolved so much that they should qualify as a brand new coronavirus. “There are sublines of Omicron that are already immunologically distinct,” Bortz said.
A vaccine that works against all or many coronaviruses may pre-empt the mutations in a particular pathogen. The upside is that a single vaccine, boosted periodically, could provide some protection against the current COVID pandemic and the next. The downside is that any universal COVID vaccine may be less effective than a vaccine tailored for a specific coronavirus. Man of everything, master of nothing.
Oh, and a safe and effective pan-coronavirus vaccine, such as a nasal vaccine, “could take years,” Bortz noted.
There are a few epidemiologists who think that therapies, rather than vaccines, should be the main effort, as SARS-CoV-2 continues to mutate. After three years of crash development, there are certainly many drugs to choose from: monoclonal antibodies, remdesivir, paxlovid.
The latter, a prescription pill, was a real breakthrough when the U.S. Food and Drug Administration approved it for emergency use for certain patients in December. After you test positive for COVID, you can take a course of paxlovid at home and cut your risk of serious illness in half.
However, a therapy-first strategy means a kind of surrender. Therapies are reactive; you get them after you contract COVID. It is clearly safer for a greater majority of people to prevent an infection rather than take the risk of treating it quickly.
Realistically, different countries will pursue different public health strategies — and most will want a mix of vaccines and therapies. Jabs to avoid most of the worst infections. Therapies for unvaccinated and breakthrough infections. “Vaccinations are crucial, but treatment should be a priority just in case,” Mokdad said.
The problem, of course, is that resources are limited. Paying for all these new vaccines and therapies, in the amounts the world needs, is a political problem — and a difficult one.
To keep lockdowns off the table and get around the toughest choices about COVID strategy, governments could fund all options. What’s troubling is that, in the country with the most to spend, a right-wing fringe is working hard to keep the federal purse closed.
President Joe Biden’s Administration Wants $10 Billion in New Funding to Maintain Fresh Supplies Today vaccines and therapies are flowing, while also developing tomorrow vaccines and therapies. But Republicans in the US Senate, whose votes are needed to approve the money, have urged to lump the funding request together with an unrelated measure to block asylum seekers on the southern border.
That a battle over immigration could weigh on America’s COVID strategy, right when that strategy may need to be shifted.