COVID-19: What Lies Ahead?

The fight against SARS-COVID-2 is unpredictable, with challenges that make moving forward difficult.

SARS-CoV-2 is a sneaky foe. Just when we think we’re on track to contain it, the virus emerges in a new, more transmissible form, ensuring its survival and dealing us a new setback. Such was the case with this summer’s Delta variant. After more than a year of stay-at-home orders and measures to prevent the transmission of SARS COV-2, California lifted all restrictions on June 15. People discarded masks and physical distancing to enjoy their renewed freedom, to breathe fresh air and to return to relatively normal lives. By July 4, the state appeared to be on a positive path. Meanwhile, the Delta variant was quietly working its way into the population, and less than two weeks later, the entire country was facing a significant surge of new infections, mostly in unvaccinated individuals, demonstrating how coronaviruses are unpredictable and can catch us off guard.

All viruses are made up of genetic material, and in the case of coronaviruses such as SARS-CoV-2, that material consists of ribonucleic acid (RNA), a substance that is present in all living cells. The bundles of RNA have a protective coating of protein, and when an individual inhales infected airborne droplets, the protein binds onto a cell, allowing the virus to replicate and infect more of the host’s cells. If a virus gets past the immune system and infects enough other cells, the person who is the host becomes sick. Sometimes a random copying error occurs during the replication process, creating a new strain such as the Delta variant, which was first detected in India in February and subsequently spread around the world. We don’t know when or where to expect variants to emerge or how they might behave, but coronaviruses continually mutate, and they become endemic, so we need to find ways to live with them.

Vaccines and variants

The Pfizer and Moderna vaccines received Emergency Use Authorization in December 2020, less than a year after the virus emerged in the United States, and Johnson & Johnson received similar approval in February. All three companies produced vaccines in record time, but that doesn’t mean the process was rushed. Stanley Deresinski, M.D., clinical professor of medicine in the Division of Infectious Diseases and Geographic Medicine at Stanford University, explains that the technology for creating mRNA vaccines has been in development for 20 years, so Pfizer-BioNTech and Moderna had a head start. In addition, he explains that the companies were able to develop vaccines quicker than usual because they received government funding and didn’t have to take a financial risk (although Pfizer-BioNTech opted out of parts of this program). “It’s a model for going forward for other vaccines in the future,” he says. He further explains that all the vaccines were rigorously tested, and to obtain Emergency Use Authorization, their makers had to demonstrate a compelling need and provide an overall assessment that the benefits outweighed the risks. Full final FDA approval is an enormously complex process, and he describes the number of boxes to check as approaching infinity, making it extremely time-consuming. “Everybody knows the vaccines are going to be approved,” he says, but the FDA and CDC are being extra cautious, possibly in reaction to the knowledge of their previous response to political pressures. Meanwhile, more than 339 million residents of the United States have received at least one dose of vaccine, and 186 million are fully vaccinated with very few negative outcomes, showing that the vaccines are safe and effective, according to Our World in Data, a resource from the Oxford Martin School, a research and policy unit at the University of Oxford.

How long immunity will last is an open question, and Deresinski explains that the only way to determine the duration of protection is to follow a large number of vaccinated individuals over time. An important way of rapidly predicting such protection is to take blood from vaccinated individuals at regular intervals to check their antibody levels. As immunity decreases over time, a booster shot might prove to be necessary, and Pfizer announced in July that it was in the process of developing one. Some breakthrough cases—infection in people who are fully immunized—occurred this summer as expected since the mRNA vaccines are 95%, not 100% effective, but the role of vaccines is to reduce the risk of severe illness and death, and vaccinated individuals who develop COVID-19 usually have mild cases and avoid hospitalization.

Deresinski points out that other countries are slow in obtaining vaccines while new variants are developing simultaneously, so recovering from the global pandemic will be a long process. He explains that the 1918 influenza pandemic had three waves, and even though a vaccination wasn’t available to stop it, the flu eventually petered out. “Presumably, enough people had immunity, so there was no one left to infect,” he says. However, the flu didn’t disappear entirely and keeps coming back in different mutations. Measles also caused a pandemic in the U.S., but “Now we only see the introduction by travelers from other countries,” he says. It might be rare, but measles hasn’t been eradicated, and the same will be true of SARS COV-2. It’s here to stay, and because some infected people never show symptoms, it can spread easily.

He believes the best way for people to protect themselves is vaccination. “The current vaccines work,” he says. “They keep people alive and out of the hospital.” Convincing eligible people to change their minds when they’re resistant to the idea of vaccines is a challenge. Plenty of studies are available to inform them about the safety and the science involved, but Deresinski believes their opinions are often part of a larger belief system rather than a rational argument, so they remain skeptical. He suggests that a more effective strategy might be to combine “story with science”—to provide direct information but to combine it with vivid descriptions of potentially horrible outcomes of infection in those who have not been vaccinated. He points out that as more viral replication occurs, more variants will appear and the unvaccinated are their accomplices because they help them spread. He references southwest Missouri as an example, where the vaccination rate was low, and the Delta variant ran rampant among the unvaccinated early this summer, putting people who can’t get vaccinated, such as children age 11 and under and those with valid medical reasons, at risk. “What doesn’t get said enough is that people who are eligible but don’t get vaccinated are selfish. You can make an argument that they can decide that they are willing to risk their lives, but do they really have the option of putting other people at risk?” he asks. Vaccines are a public health initiative, he says, and the whole basis of public health is tradeoffs of individual rights for societal rights.

Reaching out

Most people in the North Bay are fully vaccinated, which means having the requisite inoculation and waiting two weeks for it to take effect, suggesting that they take both their personal wellbeing and civic responsibility seriously. By the middle of July, 69% of Sonoma County’s eligible residents had been fully vaccinated, and in Napa County, the total was 71%. In Marin County, 74% of the population age 12 and over was fully vaccinated, and 85% had received the complete series, while 92% had received at least one dose, giving Marin the distinction of being the most vaccinated county in the nation. Deputy Public Health Officer Lisa Santora, M.D., attributes the success rate partly to Marin’s demographic profile, which tends to be well-educated and liberal, but partnerships also played an important role.

Lisa Santora, M.D.

“We’ve had strong partnerships since the beginning,” says Santora, explaining that the community-wide effort included healthcare organizations, education and businesses, and they forged the way for Marin County to ensure equitable access to the vaccines, making the Latinx vaccination rate one of the highest in the country. The initial strategy was placing sites throughout the county to allow mass vaccination. “We call it debulking, getting the highest number of people vaccinated possible,” she says. Then, after debulking, when the supply of serum was greater than the demand, they developed a mobile strategy in partnership with the community response team to identify hotspots where more people needed to be vaccinated. In Novato, for instance, young men had a low vaccination rate, so the mobile unit went to Moylan’s, a local brewpub, to offer a convenience-based service. She reports, however, that vaccine resistance is a concern, because 20,000 eligible people haven’t been vaccinated, and they are often part of social networks with the potential to become hotspots for outbreaks.

Napa County also adopted a model that depends on partnerships. “We’re doing more community-based clinics,” says Public Health Officer Karen Relucio, M.D., who explains that public health and healthcare partners held immunization clinics in schools to offer vaccines to students 12 and over and their families at the end of the academic year. In addition, public health held vaccine clinics at churches and mobile home parks and are working with community organizations, which already serve impacted populations to provide services and now offer vaccinations as well. “They’re helping us to do in-reach as well as outreach,” says Relucio. In addition, the public health team is focusing its efforts on specific areas with low vaccination rates to educate people, dispel myths and help individuals who decide to get vaccinated.

Sonoma County is also offering clinics in targeted areas throughout the county, which include locations such as the Roseland Library and Coddingtown Shopping Center in Santa Rosa, La Luz Center in Boyes Hot Springs and Healdsburg High School. In addition, the county is working on genotyping at a county lab to determine whether infections are the result of variants. “It will allow a much quicker turnaround time,” says Sundari Mase, M.D., the health officer and public health division director of Sonoma County, and it will also give a better picture of variants locally.

Protecting kids

While the push for vaccination continues, children under the age of 12 are vulnerable, because a vaccine is not yet available for them. “We’ve learned that children have less severity in disease and fewer deaths,” says Jenna Bollyky, M.D., a pediatrician specializing in infectious diseases at Stanford University. However, she adds that COVID-19 is one of the top 10 causes of death in children. “It’s a serious disease, and some children who are diagnosed with COVID are hospitalized.” Thus, Stanford is currently conducting clinical trials for Pfizer to see how well the vaccine protects children under 12, and find appropriate dosages.

Bollyky explains that vaccines for children are the same as those for adults, but the dose is smaller. Whereas adults get 30 mg., kids age 5 and older get a 10 mg. dose, and those 6 months to 4 years old receive 3 mg. (Babies under six months have immunity from their mothers.) Starting with adults and then extending studies to children is the standard process for new medicines, but enrolling a child is a family decision. “They have to report anything that happens to a child. If a child breaks a leg or falls from the monkey bars, they have to report it,” Bollyky explains. If a child has a fever or a sore throat, someone from the medical team will go out to gather a specimen for testing. In addition, clinical trials are random, so for every two children who get the vaccine, one gets a placebo. “I think a family has to decide that it’s OK to get a placebo and be part of the scientific process,” she says. Despite the demands and conditions, 3,000 families expressed interest in participating in the trials, and 51 children were enrolled. “I feel lucky that we’ve got to participate and have amazing families who are helping move us out of the pandemic,” says Bollyky.

With kids unprotected and a new school year starting, it’s important to be vigilant. For children age 12 and over, “The benefits of vaccination outweigh the risk. I recommend having your children vaccinated,” says Bollyky. She also suggests that children, as well as adults, follow all the effective practices we’ve learned: proper handwashing, physical distancing and wearing masks.

Santora believes that the return to classrooms is a good thing because schools provide a structured, supervised environment. People who gather and travel pose a greater risk, because they might be exposed to emerging variants that are more contagious, even if they’re vaccinated. “The risk would be an emerging virus that the vaccine doesn’t handle,” she says.

Confusion and anxiety

As the pandemic continues, information keeps changing, raising stress levels for many individuals. “Public health and the medical community are still learning more about COVID-19,” says Relucio, explaining that information is dynamic, and will be confusing. She advises checking CDC information and public health websites for current information and following guidelines, as well as using common sense and engaging in low-risk activities. Outdoor activities, for example, are better than those indoors. So, “If you’re unvaccinated and at risk for complications of COVID-19, it might not be a good idea to go to a large indoor concert,” she says. She also recommends that people take care of themselves by adopting better diets, getting regular exercise and doing what’s necessary to reduce the risk of COVID-19. If the stress becomes overwhelming, it’s best to talk to a health professional.

Karen Relucio. M.D.

In a talk to the Commonwealth Club in July, Jessi Gold, M.D., assistant professor of psychiatry and director of wellness, engagement and outreach, Washington University School of Medicine in St. Louis, described the pandemic as a collective trauma that everyone is going through at the same time. While it’s a shared experience, however, everyone has different stressors and different ways of coping. “In a time like this, you should have feelings,” she says. “Look at how you’re feeling every day, and don’t judge yourself.” She reports that 40% of people have anxiety and depression issues, so you’re not alone and shouldn’t hesitate to seek help if you feel the need for it. She explains that therapy helps you understand reactions and why you’re having them and is a way to talk things out and help you navigate your life better. It’s difficult to reach out for the first time and can be frustrating, sometimes with problems getting an appointment or insurance issues, but be patient and persevere. She wishes people knew that mental health struggles are just as valid as physical struggles. “It doesn’t make you weak; it makes you aware.”

The end of the pandemic isn’t in sight, but we’ll eventually get there. Meanwhile, we do know how to take precautions and take care of ourselves and each other. “I would encourage everyone to do their part at this time, so we can get back on track,” says Mase. It’s a simple, but a wise suggestion. Putting aside our differences and working together for the common good might be the best advice yet for defeating a cunning adversary and making us feel whole.

 

Early Treatment

Robert McCullough, M.D., a practicing internist, cardiologist and professor of medicine at Texas A&M University became concerned about the lack of a program for early treatment in the first months of the pandemic. In a talk to the Commonwealth Club of California in San Francisco in July, he observed that patients who test positive for COVID-19 are told to stay home, but don’t often have a plan for treatment. “Managing patients at home is far better than the hospital,” he says, explaining that it stops the virus from spreading because people don’t come into contact with others and being at home is better for the patient than being isolated in a hospital. He recommends a combination of drugs. “A single drug doesn’t work,” he says. “It has to be in combination.” He reports that monoclonal antibody treatment has a dramatic impact and takes only an hour to infuse. “The essential thing is to get some treatment,” he says because it really makes a difference.

 

Fighting disease

Dealing with COVID-19 is time-consuming, but it’s not the only infectious disease public health officials have to contend with. “We already have 90 other infectious diseases that we investigate,” says Karen Relucio, M.D., Napa County’s public health officer. Napa County’s public health division’s communicable disease unit does contact tracing and outbreak investigation to stop the spread of SARS CoV-2 and prevent additional cases of COVID-19. However, it’s a major undertaking. “It will definitely increase the workload.”

The Communicable Disease Unit is responsible for:

Monitoring and reporting more than 90 different diseases

Case investigation

Planning and prevention programs

Public health laboratory support

Addressing any circumstances or issues related to communicable disease and public health.

 

How Does It Work?

Vaccines are the most effective means for preventing COVID-19, the disease that SARS COV-2 causes. Messenger RNA vaccines, such as those from Pfizer/BioNTech and Moderna, use a tiny bit of genetic coding from the protein in the virus’ distinctive spikes, which is large enough to provoke an immune response, but too small to create a virus. An injection of the vaccine in the upper arm causes the muscles to create a piece of the virus’ spike protein, which activates the immune system and causes it to attack the vaccine as though it were the disease. Johnson & Johnson’s Janssen viral vector vaccine uses a disabled adenovirus to produce a similar response. Adenoviruses are common and cause cold-like symptoms, but because they’re deactivated in the vaccine, they can’t replicate in one’s body and will not cause a viral infection. Essentially, all three vaccines instruct human cells to make a protein that triggers the immune system to go into action to repel the invader.

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