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How will the COVID pandemic end?

The Body Scientific

In an extraordinary 20 months, science has tackled the SARS-CoV-2 virus and made vaccines for adults and children. Scientists have developed monoclonal antibodies that help if given early; we now have the first drugs that could stop infections or tilt the immunological fight in favor of the patient. The number of COVID cases is going down, although in some areas like the mountain West the disease is still raging. The virus is an opportunist. Remember the 750,000 people in the United States and the millions around the world who have died.

People go without vaccines for various reasons that we know by now. People who refuse vaccines may not understand that “Fortune favors the prepared immune system,” to paraphrase Louis Pasteur’s “Fortune favors the prepared mind.” A 50-microgram injection induces antibodies that neutralize the SARS-CoV-2 coronavirus or T-cells that kill the human cells, which contain multiplying virus.  As the vaccines’ protection wanes over six months, a few elderly people in their 80s or older have died of COVID infections. The late waning can be corrected by boosters, or at least I hope so.

The grizzly experiment to test the SARS-CoV-2 vaccines has been done in Texas, Florida, Louisiana and other places where the level of vaccination is low. The virus, or more recently the delta variant, raced through the population, filling wards with COVID patients. A year-and-a-half after this disaster hit New York hospitals, other hospitals in the West and South, Alaska and other places are converting space to treating COVID-19 patients. More than 90% of their patients in intensive care were not vaccinated. Anti-vaxxers do not usually plan clinical trials, but in this case, inadvertently, they did. The vaccine protects people.

Predicting the end of the pandemic is a tricky business. We thought we had seen the end in June and July. Then, with the delta variants, the trend reversed among unvaccinated people and cases went up. Could there be more variants? Yes, but so far, the vaccines have worked against all variants. Antibodies and T-cells react with all parts of a virus protein, not just the sections that have changed in the variants.

What does medicine have to throw into this battle?  Monoclonal antibodies are being used and they work if applied early in the disease. These antibodies are produced in fermenters and must be infused intravenously. They are expensive and tricky to use. Fighting an epidemic, especially in poor areas of the world and of the United States, demands simplicity.

There is a drug, malnupiravir, that if given early in an infection often controls it. It was developed at Emory University in Atlanta and licensed to Merck for production. Malnupiravir is a cleverly designed molecule that gets incorporated into new viruses and mutates them out of existence.  It has been approved for use in the United Kingdom. It may block infection in people who have been exposed to the virus. That will be known soon. Merck will not enforce patent restrictions.

Pfizer also has a promising drug that works by a mechanism that is different from that of malnupiravir. The difference is important because viruses often mutate to become resistant to one oral drug. In the case of HIV, several drugs were required to stop infection. Pfizer’s drug is also well along in phase 3 clinical trials and may soon receive an Emergency Use Authorization.

Excited journalists are writing about these drugs as game changers, but that is premature. A drug or combinations of drugs must have changed the game to be called a game changer. On a population basis, that remains to be seen. I am hopeful, but a little caution is in order. On a more hopeful note, drugs like these have worked for HIV, Hepatis C virus, and Dengue virus. Producing and distributing these drugs for the whole world will take time.

My prediction is that COVID-19 will recede in areas of high vaccination. All treatments will have a role, but vaccination will play the primary one. In areas where vaccination rates are low, say 40%, there will be serious problems with high levels of infection and overwhelmed medical facilities for extended periods. That patient load affects a hospital’s ability to treat other diseases. The poor and medically underserved will get even less attention. Schools, industry, and the economy are weakened. Society becomes very cranky, even violent. The vaccines, and perhaps the drugs, offer an off ramp from this disaster.

Richard Kessin lives in Norfolk and is Emeritus Professor of Pathology and Cell Biology at the Columbia University Irving Medical Center. See other essays at RichardKessin.com or at The Lakeville Journal. www.tricornernews.com/category/opinion-author/body-scientific. E-mail: Richard.Kessin@gmail.com.

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