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‘The virus will be back’: Preparing for the second wave of Covid-19

Epidemics of infectious diseases can be unpredictable but they often come in waves. History has left hard lessons showing that a virus can quickly return – and with deadlier force.

Just over a century ago, the three-wave Spanish flu pandemic that claimed at least 50 million lives, killed more people in the more virulent second wave in the autumn of 1918 than in the first that spring, including in Ireland.

Public health responses during that pandemic were complicated by the fact that the world was at war. Regional inaction and the increased movement of people as the war drew to a close deepened the severity and death toll in 1918 and 1919.

Now, as Ireland reopens from a severe lockdown imposed to flatten the curve of infection and death, the risk of coronavirus infection rates rising again remains high with the increased interaction and movement of people. The risk is particularly high given that a vaccine to eradicate Covid-19 is some time, possibly years, away and seroprevalence studies which measure past rates of infection show little “herd immunity”, leaving large swathes of populations still susceptible to the virus.

The two-month steady descent from Ireland’s peak of deaths and infection in mid-April has allowed the country to move into the second phase of lockdown relaxations and accelerated the Government’s plan to reopen society and the economy. This will, inevitably, put more people in closer contact with each other and raise the possibility of new infections increasing again.

In the early stages of the pandemic, public health specialists were able to predict how infections would soar in an unmitigated scenario, where, based on the reproductive rate of a highly transmissible disease, one Covid-19 case would infect four or five others.

Now, even the experts admit they cannot predict how the virus will spread if it returns.

“I honestly don’t have a crystal ball on this one. I don’t know what we’re going to learn about this virus over the next six months,” Prof Philip Nolan, chair of the modelling advisory group on Covid-19, told the Oireachtas special committee on the pandemic response on Tuesday.

Opinion is divided on how an increase in infections could come or indeed whether it is even likely. The State’s chief medical officer Dr Tony Holohan has said that a second wave is “not inevitable”. He said he hoped the reopening could proceed “without seeing a change in the level of disease that causes us either to have to pause or go back on some of the [lockdown] measures we have used”.

“This virus will almost definitely come back again. It is not a case of ‘if’ it is almost guaranteed that it will be a case of ‘when’,” says Prof Sam McConkey, infectious diseases specialist at the Royal College of Surgeons in Ireland.

Given the prevalence of the disease in countries such as the United States, Rusia and Brazil, McConkey believes the virus will be circulating in the world for the foreseeable future, possibly for between five and 10 years, and that the State has to become better at keeping coronavirus out and, if it is discovered again in the community, identifying it quickly and managing its suppression again.

“If we do a really good job, it might be a second ripple rather than a second wave and there might be a second and third and fourth ripple. We might deal with it better. If we do a really bad job, it will be a second tsunami and then we have learned nothing,” says McConkey.

1 Tracing and testing

The view of most public health and medical specialists is that the second wave will be different.

The past three months of lockdown have been so traumatic for people and caused such an upheaval in their lives that the response the next time around, should the virus return, has to be less severe and managed differently.

“There are two issues: one is when it will happen and the other is how big it will be. With a little bit of luck it will be just a wave, not a surge, and that it will be entirely manageable.”

Among the advantages heading into any potential second wave is that there is now a greater understanding of the virus, how it spreads and presents itself clinically in sick patients.

In March the State struggled to test people for Covid-19; it has since built a capacity to test up to 15,000 people a day for the disease, turning around tests from swab to result in 1.2 days on average, and taking three days to trace contacts of the newly infected.

Some believe the rapid Covid-19 alert and surveillance system may need to go further.

McConkey says the State may need to extend checks to second- and third-degree contact tracing, similar to how Facebook generates contact suggestions for friends of friends and friends of friends of friends. He uses the example of his wife potentially getting infected and people he works with being her second-degree contracts and having to self-isolate.

“The aim there is to try to control the resurgences of the disease really thoroughly and in a way that prevents it spreading into the general population again, through more extreme isolation and control of the people in the immediate vicinity of others who have it, but then at the same time have more relaxation on the general population,” he says.

Few expect a return to full lockdown or “phase zero” should the virus return, not because of the likely public anger to such a response, but because there may be strong evidence that the risk of transmission of the virus is lower in creches and primary schools, for example.

“We used a big sledgehammer when we locked people into their homes,” says Motherway.

“It would be very hard to lock people down totally again but hopefully over the next few weeks we will learn which bits of those public health measures did the most to reduce the curve and which bits can be applied without interfering with our economic life as much as we have,” she says.

From his position on the modelling advisory group, Nolan said this week that “the management of the second wave will be different” and that there could be “more targeted measures introduced to control the future outbreaks before the sort of blanket measures that we have seen”. Contingency plans will be needed, he said.

In Asia, large second waves were averted by such targeted, quick actions. Nationwide lockdowns being replaced by ones on regions or sectors and the partial reimposition of restrictions.

“The lesson for Ireland here is that we must remain vigilant for new cases,” said David Higgins, an analyst with consultancy firm Carraighill which tracks and compares new Covid-19 cases against first-wave peaks. “We cannot rule out some restrictions being imposed again.”

2 Being vigilant about indoors and alcohol

Two issues identified as posing the greatest danger for a return of the virus are indoor crowds and alcohol. The State’s chief medical officer has warned about house parties – events that can combine the two.

“Alcohol is a distance inhibitor because it doesn’t take more than one or two drinks for us all to say, ‘Ah sure I’ll be grand, I’m only here for 10 minutes’,” says Favier.

“By three or four drinks, everybody is everybody’s best friend and everybody’s sharing a corner of the bar along with bottles, glasses, food and cutlery,” say the doctor. “That is the biggest one we have to negotiate: the impact of alcohol on our social inhibitions and our ability to self-monitor.”

In South Korea, a cluster of new infections was discovered in early May after weeks of almost no fresh cases and traced to Seoul’s nightclub district as social distancing was relaxed. Some 90,000 people were traced for contacts and almost 300 infections were linked to the clubs. The infection of more than 100 people was linked to a single person attending three clubs over one weekend.

3 Being sensible about individual behaviour

Personal responsibility and individual action – from adhering to physical distancing and respiratory etiquette to early awareness of symptoms and contacting a GP quickly – is seen as essential to building an early-warning system that could help avoid a second wave.

“All of us with sniffles, coughs or fevers should be getting our Covid-19 tests,” says McConkey. “Then if it does start to spread in Ireland again, we will see it at a very early stage, rather than waiting until there are thousands of cases.”

The low prevalence of the disease makes individual, preemptive action essential.

The reopening of society means public health officials can no longer rely on the few simple rules that applied during the lockdown for the multitude of risk scenarios facing the public.

“We have to rely on people’s individual decision-making and good sense in order to reduce the risk,” says Pete Lunn, head of behavioural research at the Economic and Social Research Institute.

“People need to be alert to and understand situations that are more risky than others and act to reduce the risk of transmitting the disease.”

4 Preparing the hospitals

The risk of a second wave of the Covid-19 pandemic coinciding with an outbreak of other infectious diseases, such as seasonal flu or measles, raises the potential for a “double wave”.

Doctors want the prepandemic “baseline” of 250 intensive care beds across the State’s hospitals doubled permanently and more isolation units to segregate Covid and non-Covid cases over the winter.

“You can’t do that in one season but they need to start making significant plans,” says Motherway, whose term as president of the Intensive Care Society ended last week.

Unlike during the first wave, when hospitals suspended non-Covid care to create capacity to cope with the pandemic, the acute care system must have plans to tackle a second wave of Covid-19 along with managing surgeries and accidents that were not happening in the first wave.

“We only got one shot at the first wave where we could just suspend everything. You can’t do that a second time. It is just not going to be tenable,” says Favier.

“The big challenge now with any surge is that we now have to run non-Covid work in parallel with Covid and our hospitals will really, really feel that strain. I would have more concern about that than we did in the first place with how many ventilators we had.”

She says there is now no situation that carries zero risk from Covid-19 and hospitals “need to find workarounds and doing the new normal” and to move beyond “this paralysed, rabbit-in-the-headlights of Covid” that is preventing the return of some regular healthcare.

5 Preparing the nursing home sector

The sector worst hit by the pandemic is the one facing the biggest challenge from a second wave. Many nursing home staff were forced out of work having contracted Covid-19, leaving care facilities struggling to cope with a virus that killed many elderly residents.

McConkey believes care homes will need at least 20 per cent extra staff for “surge capacity” for a second wave. This will inevitably result in some privately-run homes not being economically viable and the larger nursing home groups being able to staff-up more quickly and to cope better.

“Nursing homes have been chronically under-staffed for several years. They are going to have to start cherishing their staff as the most important thing they have,” says McConkey.

Given the risks to nursing homes from Covid-19, staying prepared generally, not just for a second wave, is essential to beating the virus, with increased focus on stringent restrictions on visitors, social distancing, hand hygiene and the wearing of personal protective equipment.

Regular, mass testing of care homes – or even batch testing of all nursing home staff and residents before testing individuals to identify the positive cases – is considered critical to being able to isolate Covid-19 cases and protect the most vulnerable group to the coronavirus disease.

Appetite for risk

Predicting how or when a second wave might emerge is even more unclear than preparing for the first wave because it comes down to the risks members of the public are willing to take.

“Some people will take more risk, some less. That is the nature of humans. They differ in how much risk they could take whereas before we just knew we had to get the number of cases down,” says behavioural economist Pete Lunn.

“The world has become more complex and then you are also in a far more complex set of rules for governing the behaviour so it has become much more messy and hard to predict.”

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Diet and Lifestyle

SUPPORTING EXAM STRESS and Kids going back to School.

stress

Tests and exams can be a challenging part of school life for children and young people and their parents or carers. But there are ways to ease the stress.

Watch for signs of stress

Children and young people who are stressed may:

  • worry a lot
  • feel tense
  • have headaches and stomach pains
  • not sleep well
  • be irritable
  • lose interest in food or eat more than normal
  • not enjoy activities they previously enjoyed
  • be negative and have a low mood
  • feel hopeless about the future

Having someone to talk to about their work can help. Support from a parent, tutor or study buddy can help young people share their worries and keep things in perspective.

Encourage your child to talk to a member of school staff who they feel is supportive. If you think your child is not coping, it may also be helpful for you to talk to their teachers.

Try to involve your child as much as possible.

Make sure your child eats well 

A balanced diet is vital for your child’s health, and can help them feel well during exam periods.

Some parents find high-fat, high-sugar and high-caffeine foods and drinks, such as energy drinks, cola, sweets, chocolate, burgers and chips, make their children hyperactive, irritable and moody.

Where possible, involve your child in shopping for food and encourage them to choose some healthy snacks.

Read more about healthy eating for teens.

Help your child get enough sleep 

Good sleep improves thinking and concentration. Most teenagers need 8 to 10 hours’ sleep a night. Learn more about how much sleep children need.

Allow half an hour or so for your child to wind down between studying, watching TV or using a computer and going to bed, to help them get a good night’s sleep.

Cramming all night before an exam is usually a bad idea. Sleep will benefit your child far more than a few hours of panicky last-minute study.

Be flexible during exams

Be flexible around exam time. When your child is revising all day, do not worry about household jobs left undone or untidy bedrooms.

Staying calm yourself can help. Remember, exams do not last forever.

The Family Lives website has more about coping with exam stress.

Help them study

Make sure your child has somewhere comfortable to study. Ask them how you can support them with their revision.

Help them come up with practical ideas that will help them revise, such as drawing up a revision schedule or getting hold of past papers for practice.

To motivate your child, encourage them to think about their goals in life and see how their revision and exams are related to them.

Talk about exam nerves

Remind your child that it’s normal to feel anxious. Nervousness is a natural reaction to exams. The key is to put these nerves to positive use.

If anxiety is getting in the way rather than helping, encourage your child to practise the activities they’ll be doing on the day of the exam. This will help it feel less scary.

For example, this may involve doing practice papers under exam conditions or seeing the exam hall beforehand. School staff should be able to help with this.

Help your child face their fears and see these activities through, rather than avoiding them.  

Encourage them to think about what they know and the time they’ve already put into studying to help them feel more confident.

Encourage exercise during exams

Exercise can help boost energy levels, clear the mind and relieve stress. It does not matter what it is – walking, cycling, swimming, football and dancing are all effective.

Activities that involve other people can be particularly helpful.

Support group Childline says many children who contact them feel that most pressure at exam time comes from their family.

Listen to your child, give them support and avoid criticism.

Before they go in for a test or exam, be reassuring and positive. Let them know that failing is not the end of the world. If things do not go well they may be able to take the exam again.

After each exam, encourage your child to talk it through with you. Discuss the parts that went well rather than focusing on the questions they found difficult. Then move on and focus on the next test, rather than dwelling on things that cannot be changed.

Make time for treats

With your child, think about rewards for doing revision and getting through each exam.

Rewards do not need to be big or expensive. They can include simple things like making their favourite meal or watching TV.

When the exams are over, help your child celebrate by organising an end-of-exams treat.

When to get help

Some young people feel much better when exams are over, but that’s not the case for all young people.

Get help if your child’s anxiety or low mood is severe, persists and interferes with their everyday life. Seeing a GP is a good place to start.

Some basic rules coming up to exam time

A quiet place to study – A suitable environment to study is important to help concentration levels.

A balanced diet – Good nutrition is essential at any time of year, but especially during exam time. Batch cook some healthy meals and stock up on nutritious snacks. Having some of the student’s favourite dinner to hand is important too.

Omega 3 is essential to fuel the hard-working brain at this time. Keep brain and vision in tip top shape by making sure to top up your good fats daily. Consider taking Cleanmarine® Krill Oil High Strength. It contains 590mg of concentrated, high strength Omega 3 Krill Oil. This concentrated formula of EPA, DHA, Astaxanthin and Choline provides the essential fatty acids required for the normal function of the heart, brain and vision. DHA contributes to the maintenance of normal brain function and vision, the beneficial effect is obtained with a daily intake of 250mg. Also eating 2 – 3 portions of oily fish a week will provides more essential fats for your body. Examples include salmon, mackerel and herring. Easy to cook in steam parcels in the oven with garlic, lemon and oil.

A good night’s sleep – Studying all night may seem like a good idea but if your child doesn’t get enough sleep, they are more likely to forget the information or under perform. When your mind is buzzing with exam questions, quotes and scientific theories, having something to help you switch off, relax and support deep sleep is a must. Try melissa-dreams which contains all-natural ingredients including the herbs lemon balm (Melissa officinalis) and Chamomile in combination with selected B-vitamins, Magnesium and the amino acid L-theanine. Magnesium contributes to a reduction of tiredness and fatigue while vitamins B6 and B12 contribute to the normal function of the nervous system. With no drowsiness or side effects the next day, Melissa Dream helps you to wake up rested and full of energy.

Exercise – Even a 20-minute walk will help your child to relax and destress their mind, this will also help oxygenate the entire body.

Stress is the biggest obstacle to overcome. It’s so important to get enough B vitamins in foods like broccoli. Kale, spinach. Getting your 5-a-day is bound to be the least of your worries as exam time approaches; ironically this is when your nutritional and energy needs are at their highest. Make sure you keep your nutrient and energy levels up with One Nutrition® Organic Power Greens. This is a unique combination of nature’s finest green foods including kale, broccoli, spirulina, wheat grass and barley grass juice powders in a handy capsule or powder to add to your morning smoothie.

Take time out to do something you love such as walking your dog, reading a magazine, chat online to your best friend. Journaling is also therapeutic, to put your thoughts and feelings onto paper. Try family time such as playing a board game to distract your mind from the books for a while.

Don’t forget to celebrate – when the exams are over, go out and celebrate together, hopefully everything will be back to normal by then.

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Research

Can vitamin D really prevent Covid-19? Here’s what the evidence says.


Vitamin D supplement sales have soared amid the pandemic as people try to curb their risk of contracting the novel coronavirus—but some experts are urging caution, noting that not enough research has been done to establish a definitive relationship between taking the supplement and fending off Covid-19.

What the research says about vitamin D and Covid-19

According to Sabyasachi Sen, a professor of endocrinology and medicine at George Washington University (GW), deficiencies of vitamin D are “not rare” and are especially common in older adults, obese people, and people with darker skin—some of the same populations most affected by Covid-19.

While vitamin D is known for protecting bone health, it also helps with the immune system, Sen said. It’s believed that vitamin D improves the function of certain cells, including T cells, which fight off pathogens and can assist in modulating inflammatory responses.

In addition, Sen continued, research has found vitamin D deficiencies have been associated with an increased risk of infection. “Now, what is unknown is whether it’s a cause and effect rather than an association,” he said.

According to the Washington Post, researchers studying the relationship between vitamin D and Covid-19 outcomes are interested in precisely that question: whether there’s a cause and effect relationship, or merely an association.

For example, one study, published in JAMA Network Open, looked at the health records of 489 people in Chicago and found patients with a vitamin D deficiency in the year prior to testing for Covid-19 were 77% more likely to test positive for the disease than those with normal vitamin D levels. Taking a converse approach, another study looked at a small group of Covid-19 patients in Italy who had been hospitalized with acute respiratory failure and found that 81% of them had a vitamin D deficiency.

Meanwhile, an experimental study in France at a nursing home with 66 people found that taking vitamin D supplements was “associated with less severe Covid-19 and a better survival rate.” Similarly, a study in South Korea of 200 people found that a deficiency of vitamin D could “decrease the immune defenses against Covid-19 and cause progression to severe disease.” And a small study in Spain involving 76 hospitalized Covid-19 patients found that those treated with calcifediol—an activated version of vitamin D, distinct from the over-the-counter supplement—seemed to curb the severity of the disease.

On the flipside, however, a recent paper considered by the National Institute for Health and Care Excellence in the United Kingdom looked at vitamin D levels from up to 14 years ago and didn’t find any correlation between vitamin D levels and Covid-19 mortality. And while the lead author of that study has in other papers called for further research on the link between vitamin D and Covid-19 outcomes, the researchers concluded, “For now, recommendations for vitamin D supplementation to lessen Covid-19 risks appear premature and, although they may cause little harm, they could provide false reassurance leading to changes in behaviour that increase risk of infections.”

Similarly, a double-blind randomized controlled trial of 240 patients in Brazil, which has yet to be peer-reviewed, found that one large dose of vitamin D didn’t reduce hospital stay length or mortality rates among patients with a severe case of Covid-19 compared with those in a placebo group.

Correlation—not necessarily causation

“We do know that people who have lower blood levels of vitamin D tend to have a higher risk of being infected with Covid-19 and having severe Covid-19 illness,” JoAnn Manson, chief of the Division of Preventive Medicine at Brigham and Women’s Hospital, said. “But as we say in epidemiology, ‘Correlation doesn’t prove causation.’ We don’t know for sure that the low vitamin D level is causing an increased risk of Covid-19.”

According to Natasha Chida, an infectious disease expert and assistant professor of medicine at Johns Hopkins University, people who have a vitamin D deficiency typically have other health factors that could affect how likely they are to develop a severe case of Covid-19—and people who do develop diseases such as Covid-19 often experience a drop in vitamin D levels.

“Unless you take into account all those factors and separate all those out and look at just vitamin D … it’s really hard to make any inferences about what vitamin D is doing here,” she said.

Chida added that there’s “some biologic plausibility” that vitamin D could help Covid-19 patients. “It’s just that despite years of research into the use of vitamin D in respiratory tract infections, there still hasn’t really been a clear, slam-dunk answer that there’s a benefit.”

Research into the relationship is ongoing, however. According to the Washington Times, about 70 clinical trials assessing vitamin D and Covid-19 have been filed in the U.S. National Library of Medicine database.

Should you take vitamin D supplements?

As of now, experts say people who know they have vitamin D deficiencies should continue their treatment, and those thinking about taking supplements should talk to their health care provider first, given there’s no firm evidence that vitamin D supplements curb people’s risk of infection or serious Covid-19 illness.

“People should be wary of taking mega doses of vitamins or unproven interventions specifically for Covid-19, because we don’t have good quality data yet to suggest that this is of any help,” Hana Akselrod, an infectious disease specialist at GW, said.

Instead of supplements, people can add more vitamin D to their lives by being outdoors for 15 or 20 minutes a day, Akselrod added. And some foods, such fatty fish or fortified dairy products, could also improve vitamin D levels, Manson said.

“There are all of the positive confluences around nutrition and outdoor exercise that aren’t just limited to the number of how many units of vitamin D you get every day,” Akselrod said. “And on top of that, people absolutely need to continue all the other safety precautions, like masking and safe distancing and avoiding gatherings, because we’re in the most dangerous phase of the pandemic yet”.

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COVID-19 will likely be with us forever. Here’s how we’ll live with it.

As COVID-19 continues to run its course, the likeliest long-term outcome is that the virus SARS-CoV-2 becomes endemic in large swaths of the world, constantly circulating among the human population but causing fewer cases of severe disease. Eventually—years or even decades in the future—COVID-19 could transition into a mild childhood illness, like the four endemic human coronaviruses that contribute to the common cold.

“My guess is, enough people will get it and enough people will get the vaccine to reduce person-to-person transmission,” says Paul Duplex, director of the University of Pittsburgh’s Center for Vaccine Research. “There will be pockets of people who won’t take [the vaccines], there will be localized outbreaks, but it will become one of the ‘regular’ coronaviruses.”

But this transition won’t happen overnight. Experts say that SARS-CoV-2’s exact post-pandemic trajectory will depend on three major factors: how long humans retain immunity to the virus, how quickly the virus evolves, and how widely older populations become immune during the pandemic itself.

Depending on how these three factors shake out, the world could be facing several years of a halting post-pandemic transition—one marked by continued viral evolution, localized outbreaks, and possibly multiple rounds of updated vaccinations.

“People have got to realize, this is not going to go away,” says Roy Anderson, an infectious disease epidemiologist at Imperial College London. “We’re going to be able to manage it because of modern medicine and vaccines, but it’s not something that will just vanish out of the window.”

The long road to another common cold

One of the essential factors governing the future of COVID-19 is our immunity to the illness. Immunity to any pathogen, including SARS-CoV-2, isn’t binary like a light switch. Instead, it’s more like a dimmer switch: The human immune system can confer varying degrees of partial protection from a pathogen, which can stave off severe illness without necessarily preventing infection or transmission.

In general, the partial protection effect is one of the reasons why the four known endemic human coronaviruses—the ones that cause a common cold—have such mild symptoms. A 2013 study in BMC Infectious Diseases shows that on average, humans are first exposed to all four of these coronaviruses between the ages of three and five-part of the first wave of infections that young children experience.

These initial infections lay the foundation for the body’s future immune response. As new variants of the endemic coronaviruses naturally evolve, the immune system has a head start in fighting them off—not enough to eradicate the virus instantly, but enough to ensure that symptoms don’t progress much beyond the sniffles.

“The virus is also its own enemy. Every time it infects you, it tops up your immunity,” says Marc Veldhoen, an immunologist at the Portugal’s University of Lisbon.

Past studies make clear that partial immunity can keep people from getting seriously ill, even as coronaviruses successfully enter their systems. Long-term, the same is likely to be true for the new coronavirus. Emory University postdoctoral fellow Jennie Lavine modeled SARS-CoV-2’s post-pandemic trajectory based on the 2013 study’s data, and her results—published in Science on January 12—suggest that if SARS-CoV-2 behaves like other coronaviruses, it will likely morph into mild nuisance years to decades from now.

This transition from pandemic to minor ailment, however, depends on how the immune response to SARS-CoV-2 holds up over time. Researchers are actively examining the body’s “immunological memory” of the virus. A study published in Science on January 6 tracked the immune response of 188 COVID-19 patients for five to eight months post-infection, and while individuals are varied, about 95 percent of patients had measurable levels of immunity.

“Immunity is waning, but certainly not gone, and I think this is key,” says Lavine, who wasn’t involved with the study.

In fact, it’s even possible that one of the cold-causing coronaviruses sparked a serious outbreak in the 1800s before fading into the litany of mild, commonplace human pathogens. Based on the spread of its family tree, researchers estimated in 2005 that the endemic coronavirus OC43 entered humans sometime in the late 19th century, likely the early 1890s. The timing has led some researchers to speculate that the original version of OC43 may have caused the “Russian flu” pandemic of 1890, which was noted for its unusually high rate of neurological symptoms—a noted effect of COVID-19.

“There’s no hard proof, but there are a lot of indications that this wasn’t an influenza pandemic but a corona-pandemic,” Veldhoen says.

The crucible of evolution

Though the carnage of past coronaviruses has faded over time, the road to a relatively painless coexistence between humans and SARS-CoV-2 will likely be bumpy. In the medium-term future, the impact of the virus will depend largely on its evolution.

SARS-CoV-2 is spreading uncontrollably around the world, and with every new replication, there’s a chance for mutations that could help the virus more effectively infect human hosts.

The human immune system, while protecting many of us from a serious illness, is also acting as an evolutionary crucible, putting pressure on the virus that selects for mutations that make it bind more effectively to human cells. The coming months and years will reveal how well our immune systems can keep up with these changes.

New SARS-CoV-2 variants also make widespread vaccination and other transmission-blocking measures, such as face masks and distancing, more crucial than ever. The less the virus spreads, the fewer opportunities it has to evolve.

We’re going to be able to manage it because of modern medicine and vaccines, but it’s not something that will just vanish out of the window.

ROY ANDERSONIMPERIAL COLLEGE LONDON

Current vaccines should still work well enough against emerging variants, such as the B.1.1.7 lineage first found in the United Kingdom, to prevent many cases of serious illness. Vaccines and natural infections create diverse swarms of antibodies that glom onto many different parts of SARS-CoV-2’s spike protein, which means that a single mutation can’t make the virus invisible to the human immune system.

Mutations may produce future variants of SARS-CoV-2 that partially resist current vaccines, however. In a preprint posted on November 19 and updated on January 19, Duplex and his colleagues show that mutations that delete parts of the SARS-CoV-2 genome’s spike protein region prevent certain human antibodies from binding.

“What I’ve learned from our own work is how deviously beautiful evolution is,” Duplex says.

Other labs have found that mutations in 501Y.V2, the variant first found in South Africa, are especially effective at helping the virus elude antibodies. Out of 44 recovered COVID-19 patients in South Africa, blood extracts from 21 of the patients didn’t effectively neutralize the 501Y.V2 variant, according to another preprint published on January 19. Those 21 people had mild to moderate cases of COVID-19, however, so their antibody levels were lower, to begin with, perhaps explaining why their blood did not neutralize the 501Y.V2 variant.

So far, currently authorized vaccines—which spur the production of high levels of antibodies—seem to be effective against the most concerning variants. In a third preprint published on January 19, researchers showed that antibodies from 20 people who had received the Pfizer-BioNTech or Moderna vaccines didn’t bind quite as well to viruses with the new mutations as they did to earlier variants—but they still bound, suggesting the vaccines will still protect against severe illness.

The new variants bring other threats as well. Some, such as B.1.1.7, appear to be more transmissible than earlier forms of SARS-CoV-2, and if left to spread uncontrollably, these variants could make many more people severely ill, which risks overwhelming healthcare systems around the world and even higher death tolls. Veldhoen adds that new variants also may pose a greater risk of reinfection to recovered COVID-19 patients.

Researchers are closely monitoring the new variants. If vaccines need to be updated in the future, Anderson says that it could be done quickly—in roughly six weeks for currently authorized mRNA vaccines, such as those made by Pfizer-BioNTech and Moderna. That timetable, though, doesn’t account for the regulatory approvals that updated vaccines would need to go through.

Anderson adds that depending on how the evolution of the virus progresses, lineages of SARS-CoV-2 may arise that are distinct enough that vaccines will need to be tailored to specific regions akin to vaccines for pneumococcus. To successfully guard against SARS-CoV-2 going forward, we will need a global monitoring network similar to the worldwide reference laboratories used to collect, sequence, and study variants of influenza.

“We’re going to have to live with it, we’re going to have to have constant vaccination, and we’re constantly going to have to have a very sophisticated molecular surveillance program to keep track of how the virus is evolving,” Anderson says.

The promise and challenge of widespread vaccination

Experts agree that transitioning beyond a pandemic depends on the prevalence of immunity, especially among older and more vulnerable populations. Younger people, especially children, will build up immunity to SARS-CoV-2 over a lifetime of exposure to the virus. Today’s adults have had no such luxury, leaving their immune systems naive and exposed.

The exact threshold for achieving population-wide immunity that slows down the virus’s spread will depend on how contagious future variants become. But so far, research of early variants of SARS-CoV-2 suggests at least 60 to 70 percent of the human population will need to become immune to end the pandemic phase.

This immunity can be achieved in one of two ways: large-scale vaccination, or recovery from natural infections. But achieving widespread immunity through uncontrolled spread comes at a terrible cost: hundreds of thousands more deaths and hospitalizations around the world. “If we don’t want to push forward vaccines and champion vaccines, we have to decide collectively how many old people we want to die—and I don’t want to be the one making that decision,” Duplex says.

Jeffrey Shaman, an infectious diseases expert at Columbia University, points out that the global push for vaccines also exposes existing inequities in global health. In a widely shared map from December, The Economist Intelligence Unit estimated that rich countries such as the U.S. will have widely accessible vaccines by early 2022, which may not happen for poorer countries in Africa and Asia until as late as 2023.

Efforts to vaccinate the developing world hinge, in part, on vaccines that can be stored with standard refrigeration, such as the vaccines under development by Oxford/AstraZeneca and Johnson & Johnson. (See the latest on COVID-19 vaccine development around the world.)

As of the week of January 18, according to a World Health Organization estimate, some 40 million COVID-19 vaccine doses have been administered around the world, mostly in high-income countries. In Africa, only two countries, Seychelles and Guinea, have started providing vaccines. And in Guinea, a low-income country, only 25 people have received doses.

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