The Next Phase of the Pandemic

We are now entering a phase in which the widespread distribution of vaccines to combat SARS CoV-2 (coronavirus) is not in question. We’re approaching 2 million people a day vaccinated in the U.S. and 3 million is a reasonable target as manufacturing facilities continue to scale and distribution systems become more efficient. At the same time, there is no doubt that the complex system of manufacturing, distribution and injection will require time for full deployment.

During this phase, the appropriate allocation of vaccines to people at highest risk (elderly and medical comorbidities) makes sense. But this plan will leave a large proportion of adults and children at the back of line, perhaps going without vaccination until late spring or summer. Universities and schools will be managing a mixed population of vaccinated and unvaccinated people for six months to a year. And since a significant portion of the employed population is younger and healthier, management of the workplace will be a key issue.

In addition, we are experiencing the anxiety that comes from the realization that coronavirus mutates and that some of these mutations lead to increased infection spread, increased clinical risk or partial or complete “escape” from the currently available vaccines. We cannot take for granted that simply rolling out the current batch of vaccines will solve the problem. Most experts believe that SARS CoV-2 will become “endemic”, meaning that it will be part of our medical concern for a long time to come.

So, what do employers and people who are not at the front of the line need to consider?

Don’t break the line for vaccination, but when your turn comes, move quickly

The orderly rollout of the vaccine is critical. As the data about risk is increasingly combined with the database for who has been vaccinated, rollout teams can work through the wait list with increasing efficiency. Once we have vaccinated the elderly and groups at high medical risk, employers, churches, neighborhood groups, educational institutions and health systems should work together to create a compelling societal mission to vaccinate the population. This will take a combination of science education, enthusiasm and discipline with particular attention to the profound disparities in current vaccination rates. One way of thinking about this would be to think: when your turn comes, move quickly, but also go out of your way to help others move quickly.

Continue non-pharmaceutical interventions (NPIs)

Masking, social distancing and better ventilation until the pandemic is under control will be essential. Given the difficulty with “pandemic fatigue”, it’s essential that we focus on the critical behaviors that really matter. We have good evidence that consistent messaging has an effect. See the change in mask wearing between November and now below.

Institute for Health Metrics and Evaluation. http://www.healthdata.org/covid. Feb 2021.
Institute for Health Metrics and Evaluation. http://www.healthdata.org/covid. Feb 2021.

As we learn more, we can focus the message to reduce wasted effort on ineffective practices like incessantly scrubbing down surfaces. We can also expect the government to make higher quality masks available to reduce inadvertent spread and to work diligently with state and federal governments to be consistent in policies and messaging.

Testing will continue as a key part of the landscape

Diagnosis is essential when people are sick, especially now that we know that multiple treatments have been proven to be effective (especially monoclonal antibodies for high-risk patients). Testing can identify people who have Covid-19 so they can be routed to effective treatments and isolated from others during their contagious phase.

We need to increase awareness that testing has another critical role — enabling us to return to more normal activities (i.e. school, work, social activities) safely. The science and technology is continuing to evolve and much less expensive tests, combined with better science like pooled testing, will enable us to sample populations and catch outbreaks early to guide effective contact tracing. This testing strategy will evolve and get more systematic over the next few months and the Covid rescue plan, when funded, will allocate significant funding to enhance testing capacity.

A strategic approach to testing will be critical to battle the emergence of variants. If we can detect the variants quickly, we can develop specific antibodies for treatment and modified vaccines for prevention. Different strategies will be needed for individual households, workplaces and schools, and these strategies will need adjustment based on community prevalence and transmission dynamics, specifics of the workplace and evolution of the technology.

Low cost and rapid turnaround antigen tests will be useful for detecting outbreaks and more accurate PCR tests will be well-suited for systematic evaluation of schools and workplaces. In systematic testing, pooled samples can be used to reduce costs. Another form of testing that is gaining evidence is waste-water testing to measure the overall level and genetic composition of the virus in a geographic area.

Support schools

There is a bipartisan political consensus that we need schools to open up, particularly for younger children. While there is serious debate about how quickly we can do this and how to protect teachers, we should reach an agreement soon about how to proceed. As the new cases continue to diminish and vaccinations accelerate, we should be able to vaccinate teachers and school workers and invest in infrastructure in schools to make them safer with better ventilation and spacing. An investment in public school infrastructure will pay off in many ways for the future.

Track the combination of vaccination and previous infection

At every level our goal should be to stay as safe as possible while reaching a point where the combination of vaccination and prior infection exceeds 70–90% of the population. This is a useful depiction:

Via Youyang Gu, https://covid19-projections.com/. Feb 2021.

The looming issue is the impact of variants due to mutations in the virus that enable it to “escape” the vaccines and can lead to re-infection in people who were previously infected with the older variants. We are familiar with this scenario — it’s the way the flu affects us every year. Previous episodes of the flu do not totally prevent us from being infected again, nor do flu vaccines totally prevent new infections, but immunity reduces the risk of serious negative outcomes.

We can all do our part with friends and family, but there is also an important role for employers, school administrators and leaders of organizations to continue to optimize vaccination rates, ensure adherence to NPIs and employ judicious use of testing as we gradually resume activities.

As we hope for the scenario to return to nearly normal activity over the next 3–4 months, we need to prepare for a longer-term coexistence with the virus. The government and scientific community are now investing heavily in platforms that can produce updated vaccines, antibody and antiviral treatments. We need to do our part with preventive measures, vaccination and testing, supporting schools and supporting each other.

cardiologist, trialist, outcomes researcher, former FDA Commissioner