Winter is Coming: How the holidays, vaccination resistance and a new variant might impact our COVID 19 future
It’s hard to believe, but we are rapidly closing on two years since the disease now known as COVID 19 first appeared in China. It has been postulated that the first cases of SARS CoV-2 infection emerged in China’s Hubei province between mid-October and mid-November 2019, with the first defined cluster of COVID 19 cases being discovered in association with the Hunan seafood markets in late December 2019 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7709179/ ). The pandemic resulting from that virus has since ravaged the entire world, infecting 260 million individuals and directly leading to 5.2 million deaths (including nearly 800,000 deaths in the United States (https://www.worldometers.info/coronavirus/#countries ). We all know people who have had it, and most of us know people who have died from it.
This time last year, things were very uncertain. Schools were struggling with various mixtures of socially distanced in-person and virtual learning modalities, with inconsistent results. Lockdowns loomed, store shelves were intermittently empty, businesses were closing and there was a general air of uncertainty about what the future held. Music concerts and festivals? Not happening. College football games? All at one-quarter capacity or less. Many of us were still not going to restaurants at all, except for take-outs. And we were still waiting for the first round of COVID vaccines, which had been developed and tested in record time.
But then, at the very end of 2021, hope broke on the horizon. The approval of the first COVID-19 vaccines gave us our first real glimpse of a COVID-free world. As vaccinations rolled out and the virus began to recede, we could finally see the light at the end of a very long tunnel.
But here we are, a little less than a year later, and it’s like “déjà vu all over again.”
As winter approaches, COVID-19 has begun rising across Europe and in the American Midwest and Northeast (https://www.telegraph.co.uk/world-news/2021/11/18/europe-faces-full-lockdowns-contain-fourth-wave-covid/ ). Hospitals in Michigan have been overwhelmed, and some hospitals in the Northeast have begun restricting elective surgeries. The U.S. is now reporting more than 94,000 new COVID 19 cases per day—up by 47% since October. Hospitalizations due to COVID are also on the rise, with over 53,000 currently hospitalized across the country. This is over 7000 more than were hospitalized earlier this month (https://www.newsbreak.com/news/2444939382770/why-are-coronavirus-cases-and-hospitalizations-on-the-rise-in-the-us?noAds=1&_f=app_share&s=i0 ).
Why is this happening? There appear to be four variables at work here.
First, only 59% of Americans are vaccinated. This means there are ~100 million unvaccinated persons with little or no immunologic protection against COVID 19 infection (https://www.mayoclinic.org/coronavirus-covid-19/vaccine-tracker ). And while some of these individuals may have immunity due to prior COVID infection (it is estimated that ~49 million Americans, or around 15.5% of the U.S. population, has had COVID 19 thus far during the pandemic), the efficacy of that immunity alone varies from person to person, particularly as more contagious or more virulent viral strains emerge. Studies have shown that people who previously had COVID infections have a lesser risk of subsequent reinfection after vaccination
( https://www.cdc.gov/mmwr/volumes/70/wr/mm7032e1.htm ). And while we are seeing more vaccinated individuals become ill from COVID 19 due to waning vaccine efficacy over time (more on this later), unvaccinated persons still comprise over 90% of infected and/or hospitalized COVID-19 patients. The risk of dying from COVID 19 is a startling 11X higher for unvaccinated individuals (https://www.cnn.com/2021/10/15/health/cdc-covid-risk-higher-unvaccinated/index.html)(https://www.washingtonpost.com/health/2021/09/10/moderna-most-effective-covid-vaccine-studies/).
Second, it has been shown that vaccine-related immunity wanes over time. This is the reason that there has been a recent push for so-called “booster vaccines.” A recent study showed that Pfizer vaccine antibody levels waned significantly after seven months, corroborating internal Pfizer data which came out earlier this summer (https://www.biorxiv.org/content/10.1101/2021.09.30.462488v1 ). Booster immunizations with either of the FDA-approved mRNA vaccines has been shown to spike antibody levels significantly—but to date, only ~15% of the U.S. population has received a COVID vaccine booster (https://www.economist.com/by-invitation/2021/09/17/naftali-bennett-on-why-israel-is-giving-booster-jabs-for-covid-19 ). This places many individuals who completed their initial vaccine sequences over 6 months ago at greater risk for infection.
Third, it is increasingly apparent that COVID 19 is a seasonal virus. Like many respiratory viruses, it thrives in colder weather, during situations where individuals are more likely to be crowded indoors into a closed space. This is almost certainly why we are seeing a rise in cases in the American Midwest and Northeast right now. When you combine this situation with a more global relaxation of mask mandates and social distancing measures, you get a perfect storm for a spike in cases of a highly contagious airborne infectious pathogen like COVID 19 (https://www.theatlantic.com/health/archive/2021/11/covid-seasonal-winter/620766/).
Fourth, people are abandoning viral mitigation strategies such as mask-wearing and social distancing. To get one issue off the table, universal mask-wearing works in the prevention of the spread of respiratory diseases in general and COVID in particular. The literature is very clear on this, and there is no longer any viable scientific debate on the matter
( https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/about-face-coverings.html ). However, as COVID cases fell across the U.S. and Europe this fall, mask mandates and edicts on social distancing fell by the wayside. Travel has increased, too. The result is predictable: Increased viral spread.
So what’s next?
What is most apparent to most infectious disease experts at this point is this: It is highly unlikely that we are ever going to achieve the elusive viral nirvana of “herd immunity” from COVID 19. The SARS CoV 2 virus is too contagious, too adaptive and too pervasive for that. Instead, we are going to have to learn to live with COVID 19 for years to come, adapting our behaviors during the outbreaks which will inevitably occur, getting vaccinated for any more resistant or more contagious variants which may emerge, testing ourselves when we think we may be infected, and getting specific treatment when we are diagnosed with it. It’s going to become an endemic, seasonal illness like the flu (https://apple.news/A5CJ45ZStRB2gK7P_SoIYRA ). That is our most probable shared future with SARS CoV-2 (https://apple.news/AoOrPsL-sTy2d4ExEMYM4AQ ).
There are two competing dynamics at work here. First, the possibility that highly-resistant and/or highly virulent strains of COVID 19 can emerge is very real. Viruses mutate to try to survive, and the more people who are infected, the more opportunities for favorable mutations can occur. A recent highly mutated variant called B.1.1.529 isolated in South Africa has elicited some concern by virtue of the degree of mutation seen, changes which may make it simultaneously more contagious and more vaccine-resistant (https://apple.news/AvxlYF9UnQKuL-VcmWiIa6w). This new strain, designated by the World Health Organization as the Omicron variant, has also been detected in Hong Kong, Israel, Germany, the U.K. and Belgium (https://www.nytimes.com/live/2021/11/26/world/covid-vaccine-boosters-variant?campaign_id=60&emc=edit_na_20211126&instance_id=0&nl=breaking-news&ref=cta®i_id=129500496&segment_id=75403&user_id=49e4ae5fe6017805bbfe7789828d8109&referringSource=articleShare). Newly-emerging strains such as omicron are potentially counterbalanced by the extraordinary adaptability of the mRNA vaccine platform, which can be used to manufacture variant-specific vaccines in a matter of months. Pfizer, for example, has stated that they could have a variant-specific vaccine ready for distribution in about 100 days.
So in the short term, we should expect an uptick in cases this winter. Family gatherings and travel will combine with the above variables and winter weather to produce yet another wave of cases. And yet despite all of the hoopla about the omicron variant, there is still cause for optimism. Vaccination can still provide us with a flexible means of combatting new strains as they arise. New post-infection therapeutics are soon going to be available which may be able to eliminate more severe cases of the disease (https://www.ajc.com/news/nation-world/merck-asks-fda-to-authorize-promising-anti-covid-pill/QGBNDJVCVJG2PHZIQVZYEW52N4/ ). With the expected winter surge, we are likely entering the final phase of the true pandemic era of COVID-19 and transitioning into the more long-term portion of our experience with this virus. COVID 19 will likely be with us for the foreseeable future, but in a form that allows us to detect it and adapt to its various permutations. How soon we get to the point that things are back to "normal," whatever that is these days, is largely up to us. The conflict which will define what the future holds with COVID 19 will be the race between the vaccines and the variants (https://www.theatlantic.com/health/archive/2021/11/pandemic-winter-surge-three-unknowns/620738/). Resolve that, and we can resolve everything.