The Neverending Pandemic
This week, speculations about reinfection with the novel coronavirus became reality when a documented patient was reinfected in Hong Kong. The entire world is watching to see what happens next.
Most of the hope for ending the pandemic is in the development of vaccine that is both safe and effective. Unfortunately, reinfection with the novel coronavirus after only a few months is now a concrete reality, indicating that the length of vaccine-conferred immunity is likely to be limited. This poses significant societal challenges for the eradication of COVID-19. We have to face the fact that things might never be normal again.
We have to face the fact that things might never be normal again.
In the documented case of reinfection, the patient was completely asymptomatic during the second infection after four months of (presumed) immunity . This is potentially good news- it may indicate that the patient’s immune system protected him against recurrent symptoms, and the immunity conferred by vaccination is likely to be stronger and longer-lasting. However, one of the main reasons that the novel coronavirus has ignited a global pandemic is asymptomatic transmission. There is some danger that vaccinated individuals could become infected and spread the virus unknowingly, thinking that the vaccine has protected them. In light of reinfection, it is difficult to predict exactly if and how a vaccine will end the pandemic. I will unfold three different scenarios to elaborate on this point.
In light of reinfection, it is difficult to predict exactly if and how a vaccine will end the pandemic.
SCENARIO 1: JUST LIKE THE FLU
In March and April of 2020, many people downplayed the pandemic potential of COVID-19 and claimed that it was like another flu. In some ways, it is like the flu. Similar to influenza, we will probably need vaccinations at regular intervals to prevent infection. The summer of 2020 has demonstrated that COVID-19 has the potential to kill people throughout the entire year, compared to primarily in the fall and winter like the flu. Therefore, vaccination intervals for the novel coronavirus are likely to be required more frequently than once a year.
What does vaccination for influenza look like? The CDC reports that in the US 2018–2019 flu season, 45% of adults 18 years or older and 63% of children 6 months through 17 years old got the flu shot. For the same year, the CDC reports ~34,000 flu-related deaths in the United States. In contrast, COVID-19 has killed ~180,000 people in the United States since the first death was reported here (175 days prior to writing this article). That is almost half of one year ago.
If coronavirus vaccination follows the trajectory of influenza (around 50% compliance), and assuming that people die at a similar rate in the fall and early winter, we could easily still lose ~180,000 US citizens to COVID-19 each year, even after a successful vaccine is developed. This is more than the number of people who died from anything other than heart disease or cancer in 2017, potentially making COVID-19 the third leading cause of death in the United States forever.
… we could easily still lose ~180,000 US citizens to COVID-19 each year, even after a successful vaccine is developed.
SCENARIO 2: MANDATORY VACCINATION
The best way to extinguish the novel coronavirus is through compulsory vaccination. While plausible in more authoritarian countries, in the United States compulsory vaccination is a logistical nightmare. The public school system and publicly funded daycare facilities have done a decent job ensuring vaccine compliance among young children, overall. However, in 2019, there was such a large population of unvaccinated children that a measles outbreak caused the governor to declare a state of emergency in Clark County, WA last year.
States can legally mandate vaccination, yet are unlikely to do so. Even noninvasive mandates to slow the spread of the pandemic, such as wearing masks, are controversial and politically divisive. People are even less likely to comply with a mandate for an invasive procedure (vaccination), especially when the requirements to prove the safety and efficacy of the vaccine have been drastically relaxed.
People are even less likely to comply with a mandate for an invasive procedure (vaccination), especially when the requirements to prove the safety and efficacy of the vaccine have been drastically relaxed.
Half of all students in the US will be learning virtually this fall. This means that the public school system won’t be nearly as effective at ensuring vaccine compliance as it has been for other types of vaccinations. Parents are becoming accustomed to virtual learning because of the pandemic, and the anti-vaccination movement is popular. Therefore many parents could elect to homeschool (and not vaccinate) their children even after the public schools reopen.
… many parents could elect to homeschool (and not vaccinate) their children even after the public schools reopen.
The best way to ensure a high percentage of vaccination is a federal mandate that is enforced. Yet, even with such a mandate, many people are likely to dodge vaccination. We can look to examples such as the completing the US census and filing federal taxes and see that between 5% and 15% of people don’t comply with federal mandates. However, this is still the best option for ending the pandemic (optimistically assuming that the vaccine is safe, effective, and plentiful).
We can look to examples such as the completing the US census and filing federal taxes and see that between 5% and 15% of people don’t comply with federal mandates.
SCENARIO 3: NO VACCINE
While some people may criticize this possibility as pessimistic, the reality is that we have never successfully created a vaccine to protect humans from any other type of coronavirus before. Even if it is possible, normally the timeline for vaccine production is about 10 years. Reinfection means that hoping for herd immunity without a vaccine is no longer a possibility. Even with a successful vaccine, the short-lived immunity to the novel coronavirus means that herd immunity will still be difficult to achieve.
Does that mean this pandemic quasi-lockdown will go on forever? Many aspects of our everyday lives have been impacted by COVID-19. Travel is restricted. The economy is tanking. School, fitness classes, shopping, conferences, and happy hour are all happening online. Working parents have calendars that are squeezed tighter than ever before. Our favorite restaurants are closing their doors, permanently. Beaches and parks are closed. No crowds are permitted, which means that sports, concerts, festivals, and religious gatherings are also restricted or prohibited.
Does that mean this pandemic quasi-lockdown will go on forever?
The restlessness we feel is almost painful, and some of us are even taking action against the prohibitive quarantine life. The length of this pandemic could provoke exasperated people to try to go back to the way that things were before, regardless. Life is accompanied by risks. We eventually accept that there are risks associated with our behaviors. Every time you get in a vehicle, you risk having an accident (prior to COVID-19, accidents were the third leading cause of death in the US). Maybe we will start sending kids to school, going to the gym, eating in restaurants, and going to concerts because we accept the associated risks. However, even if we do this in the United States, will the rest of the world accept this choice?
Maybe we will start sending kids to school, going to the gym, eating in restaurants, and going to concerts because we accept the associated risks.
The US joins a list of countries that are unable to control the spread of the novel coronavirus (India, Brazil, Mexico, Spain, Peru, Argentina, Columbia, and Russia have the most new cases this week). Other countries such as New Zealand, Fiji, and Papua New Guinea have completely eradicated the virus. International travel restrictions are pervasive. Yet, these restrictions cannot continue indefinitely. Some countries, such as Fiji, rely heavily on tourism. Eventually, the borders will crack. The tourists will return, and they will bring the virus with them.
Americans want to vacation and be together, in spite of the pandemic. While COVID-19 deaths were surging in Florida, tourists threw caution to the wind and flocked to Florida’s sunny beaches. Clearly, some of us have already accepted the potential risks and elect to proceed as usual, even if that means sacrificing their lives or the lives of loved ones. I cannot begin to predict how long it will take for most of us to reach that point, but in the absence of a vaccine, that day will eventually arrive.
This article is for informational purposes only and should not be considered medical or legal advice.