Thursday, 2 September 2021

Is There a COVID-19 Endgame?

Laurie Garrett Author, Policy Analyst Former Senior Fellow at the Council on Foreign Relations 

 While much of the world struggles to access COVID-19 vaccines, many countries are beginning or expanding their efforts to administer third doses of vaccine to boost immune responses against the virus. On August 12, the U.S. Food and Drug Administration (FDA) amended the Emergency Use Authorizations for both the Pfizer/BioNTech and Moderna mRNA-based vaccines to include a third booster dose for immunocompromised individuals. Booster doses for additional populations are expected to be authorized and recommended in the coming weeks, particularly for the elderly and healthcare workers who were among the first to be vaccinated. The U.S. FDA and its Advisory Committee on Immunization Practices are currently reviewing the data.


The urgency around COVID vaccine boosters is largely fueled by the spread of the highly contagious Delta variant, which is responsible for an uptick in COVID-19 cases and hospitalizations worldwide, especially among the unvaccinated. Previous studies indicated that the Delta variant was two times more transmissible. Now, a recent study in The Lancet shows that unvaccinated individuals infected with the Delta variant in the U.K. were more than twice as likely to be hospitalized than those infected with the Alpha variant. In this study, hospitalization rates were too low among vaccinated individuals infected with the Delta variant to draw any conclusions for this group. But there was some reassuring news on this front from New York City. Recently released data from the City’s Health Department indicate that only 0.3% of fully vaccinated residents have been diagnosed with COVID-19 as of August 7th, and only 0.02% of those fully vaccinated have been hospitalized for COVID, even with the Delta variant surging. 


To catch us up on all this news and to ask what an endgame for COVID-19 might look like, HVP Editor Kristen Jill Abboud recently spoke with Laurie Garrett, a veteran science journalist, former Senior Fellow of the Council on Foreign Relations, and member of HVP's Futures Council. An edited version of our conversation appears below.

Are vaccine boosters necessary because of waning immunity induced by the mRNA vaccines?


I’m not completely convinced that what we are seeing is actually waning immunity. The New York City data is startling. Those data are from a period when the Delta variant was overtaking the city, and if it were the case that the vaccines were failing to protect against this variant of the virus, we should have seen a steady escalation in the number of hospitalized and dying individuals who were fully vaccinated. But in fact, over that time period, only 0.003% of those who had succumbed to COVID in the city had been fully vaccinated. That is absolutely mind blowing. Honestly, if you were to compare that to many of the childhood vaccines, I think you would find that many of the routine vaccinations are not performing as well. That’s quite striking.

But on the waning immunity question, it strikes me that there is a failure to appreciate exactly what constitutes successful vaccination. If you’re successfully immunized against Polio with the oral Sabin vaccine, you would expect a child administered that vaccine would have recoverable neutralizing antibodies against key epitopes of the polio virus in their bloodstream for some period of time—weeks, maybe months—and then you would expect to see an immune response with time that is the result of immune memory. I am convinced that what we are looking at is a response against COVID that has gone to the B-cell memory compartment and that these people who are exhibiting zero neutralizing antibodies in their blood are still fully protected through memory responses, they just take longer to show up.

What worries me about Delta is the speed with which this virus moves in the human body. I think what we are seeing with the breakthrough infections is individuals whose immune response is fully relying on memory, and when they are exposed to the Delta variant of the virus it overwhelms them before they are able to produce neutralizing antibodies from B-cell memory. It’s just a question of a time lag. Eventually, most people do mount a fully successful immune response. Unfortunately, it’s not fast enough.

Given that, does the data support the need for boosters in individuals who are not immunocompromised?

First of all, I am aware of lots of physicians already giving third boosters to their patients. A lot of people are finding ways to get their third shot, regardless of the data. There is already a tidal wave underway and it’s not waiting for dosing instructions from the FDA or a specific greenlight from the White House. And that is happening while we still have an enormous number of fully unvaccinated individuals in the U.S. Obviously, the Biden Administration has tried everything I can think of short of a national mandate to get people vaccinated. They’ve tried innovative programs that have never been previously experimented with. Having roughly 20% of the population unvaccinated, and a roughly 18%-20% that absolutely will not get vaccinated, looks terrible, but compared to other adult vaccination schemes, we’ve actually moved very quickly. That really leads to this question: If you have limited resources, where should you put your money, your effort, and your skilled personnel? If we take the focus away from efforts on primary vaccination and move them to tertiary boosters, what is going to happen to the whole effort to deal with the fully unvaccinated?  


Doesn’t a focus on boosting while the virus is spreading so extensively among the unvaccinated, both in the U.S. and around the world, only assure other variants will emerge?

 Of course. A couple weeks ago I published a piece arguing that we do need a third booster, despite the need to vaccinate the world, which I wholeheartedly believe in. But I’m still very concerned that the United States is becoming a brewing pot for mutant strains and that we will render the first-line defense vaccines useless so that by the time they reach Chad, or by the time they get to rural Cambodia, the virus population will be completely overwhelmed with mutant strains that have escape mutations, and so your initial form of vaccine is less useful.

Given all of this, what is the endgame for COVID-19?

That is the fundamental question. And it is the one I’ve been asking over and over. Instead of endgame, what even is our strategy? We’re playing football without a coach and without anyone even agreeing on which goal post we’re supposed to run to. We don’t have agreement on national elimination as a strategy versus global eradication, which is the other extreme. We also have no clear effort underway to genuinely ascertain zoonotic spread of this virus. With COVID, we know that the ACE2 receptor in one form or another is in every single mammal. What this tells us is that eradication is going to be incredibly difficult, probably impossible in terms of the firm meaning of the term. It is going to be a permanent part of our environment now and it will be reentering the human species in spillover events from animal populations for the rest of the 21st century.

We need to ask ourselves: what is a reasonable strategic goal? And then design everything accordingly. What we’re facing is a failure to have started with a strategic global plan to begin with. This is the same mess we’re in with climate change, and really all the great supra-national challenges of our time.

You don’t get to an endgame without a strategy. But asking about endgame matters because all military leaders will tell you that you don’t have a strategy until you have a strategic goal. If you don’t have a goal, then all you have is a list of tactics about which you will endlessly debate and that’s exactly where we are now. I don’t see how we easily get past this.

By Kristen Jill Abboud



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