After weeks at a two-year low, COVID cases are on the rise again in some countries. In the United States, there were 100,000 daily new infections, on average–up from 30,000 in mid-March.
The trend is intensifying an important debate in epidemiological circles. What’s the best strategy for preventing 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 guide us into the pandemic’s fourth year. But there’s a catch, of course. Public health costs money. And in the world’s richest country, the United States, a few right-wing politicians are doing their damnedest to make sure no new money is available to speed up development, production, and distribution of new vaccines and therapies.
Vaccine development is stalling. 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 But by the time these boosters are ready in the fall, Omicron is likely to have been replaced by a new and more dangerous variant.
Two years ago the world worked together to develop highly effective messenger-RNA vaccines, and fast. Today there’s less money and less urgency, meaning vaccine development is slowing at precisely the moment the virus is speeding up.
Experts warn the potential for disaster, later this year or next, is growing.
To be clear, the COVID increase for now is slight. In the U.S. alone, there were 800,000 daily new cases on average in mid-January. And hospitalizations and deaths aren’t increasing at the same rate as cases, owing to high levels of vaccination as well as natural antibodies from past infection.
But the uptick in cases in some countries—driven by what appear to be ever-faster mutations in the SARS-CoV-2 virus—is a reminder that the pandemic isn’t over. The virus keeps changing—and finding new ways to get around our wall of immunity.
There’s a lot of uncertainty here. “The virus may, or may not, evolve in the short term towards ever-greater vaccine-evasion,” Eric Bortz, a University of Alaska-Anchorage virologist and public health expert, told The Daily Beast.
Epidemiologists aren’t taking chances. They’re looking ahead, trying to project how the novel-coronavirus might evolve, and what we should do about it. They’re nearly unanimous that the pathogen will be with us for years. But they disagree over what we should do about it.
There are options in the event SARS-CoV-2 makes a big evolutionary leap and evades the protective effects of our vaccines and antibodies. This is the nightmare scenario, and the one driving the most intensive debate.
New lockdowns are one option, but the least likely owing to the deep unpopularity of tough limits on schools, businesses and travel. China’s disastrous experience with strict lockdowns in recent months has only underscored the perils of major new COVID restrictions.
The most viable options are pharmaceutical. Vaccines. Antiviral drugs.
The vaccines we’ve currently got are a mixed bag. They include old-fashioned Russian and Chinese jabs that use cold viruses as vectors for fragments of the coronavirus or contain whole killed SARS-CoV-2. There’s not a lot of good data on these vaccines, and many experts are skeptical of their effectiveness.
But then there are the top Western vaccines, including the latest messenger-RNA jabs from Moderna and Pfizer and a cold-virus-vector vax from Johnson & Johnson. The data are clear. These vaccines offer strong protection against serious infection—70, 80, or 90 percent, depending on who got jabbed, how long ago and whether they also got boosted.
“The reality is that 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 immunity wanes.” All vaccines and natural antibodies fade over time. But a daisy-chain of increasingly contagious novel coronavirus variants and subvariants—Omicron last fall followed by the Omicron subvariants BA.1, BA.2, BA.4, BA.5, BA.2.12 and XE—have accelerated the decline in immunity.
A second booster of an existing two-dose mRNA vaccine could restore and prolong the jab’s effectiveness. Some of the leading vaccine makers are even working on Omicron-specific boosters.
The inherent flexibility of mRNA vaccines makes that possible. The basic mRNA-vaccine formula is the same for any disease or variant of a disease. You just swap in new genetic material, depending on the thing you want to prevent. “We could use it to change the vaccine in a short time,” Ali Mokdad, a professor of health metrics sciences at the University of Washington Institute for Health, told The Daily Beast. “But it all depends on how fast the virus is mutating.”
The seemingly accelerated rate of viral evolution in COVID could mean the disease outpaces the processes for tweaking mRNA. It’s possible that, by the time Omicron-specific boosters arrive, Omicron and its closest offspring will have disappeared and some highly mutated new form of SARS-CoV-2 will be dominant.
Instead of chasing after COVID variants with boosters, we could change course and erect totally new defenses against the virus. There are two major new vaccine types in 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, administered by a spray, induce immunity in the mucus tissues of the nose and throat—where a COVID infection generally begins. Existing COVID vaccines are all injected into muscle tissue. The antibodies they produce, while effective against the virus, might be less effective than antibodies originating in the nasal passage.
Where a nasal vaccine is highly optimized for a respiratory virus like COVID, a pan-coronavirus takes the opposite tack. It aims to be universal rather than specific. “The best solution is a universal pan-COVID vaccine,” Bortz said.
The rationale is that there are lots of coronaviruses besides SARS-CoV-2. There are even scientists who argue that the latest Omicron subvariants are so highly evolved that they should qualify as a brand-new coronavirus. “There are sublineages of Omicron that are already immunologically distinct,” Bortz said.
A vaccine that works against all or many coronaviruses could get ahead of the mutations in any particular pathogen. The upside is that a single vaccine, periodically boosted, could offer some protection against the current COVID pandemic and the next one. The downside is that any universal COVID vaccine might be less effective than a vaccine tailored for a specific coronavirus. Jack of all trades, master of none.
Oh, and a safe and effective pan-coronavirus vaccine, like a nasal vaccine, “may be years away,” Bortz pointed out.
There are a few epidemiologists who think therapies, rather than vaccines, should be the main effort as SARS-CoV-2 continues mutating. After three years of crash development, there are certainly a lot of 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 authorized it for emergency use for certain patients back in December. After testing positive for COVID, you can take a course of paxlovid at home and cut your chances of severe illness by half.
A therapy-first strategy represents a kind of surrender, however. Therapies are reactive; you get them after catching COVID. It’s obviously safer for a greater majority of people to prevent an infection rather than take a chance on swiftly treating it.
Realistically, different countries are going to pursue different public health strategies—and most are going to want a mix of vaccines and therapies. Jabs to prevent most of the worst infections. Therapies for the unvaccinated and breakthrough infections. “Vaccines 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 quantities the world requires, is a political problem—and a tough one.
To keep lockdowns off the table and sidestep the hardest choices about COVID strategy, governments could fund all the options. What’s worrying is that, in the country with the most to spend, a right-wing fringe is working hard to keep the federal wallet closed.
The administration of President Joe Biden wants $10 billion in new funding to keep fresh supplies of today’s vaccines and therapies flowing, while also accelerating development of tomorrow’s vaccines and therapies. But Republicans in the U.S. Senate, whose votes are necessary for approval of the money, have insisted on lumping the funding request together with an unrelated measure to block asylum-seekers at the southern border.
That a fight over immigration could weigh on America’s COVID strategy, at precisely the moment that strategy might need to shift.