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Remain Strapped In: This Roller Coaster is Still Going

But you should be able to get off the ride pretty soon. Let’s take a look at how high the next hill might be, and some of the twists and turns we can expect after that.


We’re going to start and end this story with vaccines. Despite delays and confusion, the big story is that we now have three vaccines available to prevent COVID hospitalization and death. It feels hard to convey how spectacular this is: some bugs just aren’t susceptible to vaccination (e.g. HIV), others can get worse with vaccination (e.g. dengue), and some mutate so rapidly they’re hard to pin down for more than a few months at a time (e.g. influenza). There was no guarantee that we would have this tool available to fight COVID, even with the years of underlying research, recent massive investments, and extraordinary dedication of scientists and health workers that got us to this point. Regarding just this very narrow sliver of the pandemic: we got lucky that SARS-CoV-2 can be prevented by vaccination, and our biomedical teams were ready to take advantage of the opportunity.


This big vaccine story is now converging with the other big story: takeover by the B.1.1.7 variant, which is continuing unabated. This variant now accounts for about 10% and perhaps even 20% of new cases, consistent with projections that it is expected to become the dominant strain in the U.S. in coming weeks. At the nexus of vaccination rollout and B.1.1.7 emergence, we have the question of what’s going to happen with COVID case counts and deaths. It looks like cases are destined to rise again before vaccination can really bend the curve more permanently, especially as states roll back COVID precautionary measures prematurely. The most likely scenario is another uphill, repeating the pattern we’ve shown before: increases followed by decline that leaves us at a higher baseline than before. It’s still not clear if the B.1.1.7 takeover is going to be a relatively bloodless coup, with the most vulnerable adequately immunized, or a surge that results in overwhelmed health systems and avoidable deaths.


Once we’re over that hill, we expect that we’ll be in a relatively flat run out of the pandemic going into the summer months, with widespread vaccination and immunity (both through vaccination and resulting from infection) approaching levels needed for community protection -- although as transmissibility goes up with B.1.1.7, we’ll need higher levels to achieve community immunity. By summer we expect we’ll have less focus on COVID (with the exception of variant threats), and more visibility on some of the time bombs planted during the pandemic:

  • Post-Acute Sequelae of COVID-19 (PASC): this refers to the constellation of symptoms and illness that people experience months after COVID infection. We were talking about this back in November, and since then several more studies have come out and PASC is now being used by NIH in place of long-haul COVID and other references to post-acute COVID illness. It looks like about one-third of people with mild and moderate COVID may experience PASC, and perhaps more than half among patients with more severe disease who were hospitalized. NIH has now launched a new PASC study initiative, and this issue promises to be with us for some time to come.

  • Within the broader realm of mental health and the challenges of isolation and despair driven by the pandemic, the opioid crisis is among the most concerning elements. The pressures that a pandemic places on a society reveals the weak spots and fault lines: long standing inequity gets a brighter spotlight, underfunding of public health systems comes back to haunt us, and the fragile gains we had made in battling the opioid crisis have been reversed.

  • The clinical and public health systems we’ll need to cope with these and other issues may come out of the pandemic weakened, due to the burn out, drop out, and moral injury that front line staff have suffered throughout the response. Attacks on public health workers have become an issue significant enough to warrant legislation, although it’s unclear whether there are effective measures lined up, nor whether the damage has already been done and the fields where we most need seasoned experts and additional staff are being depleted.


We also need to keep in mind that there’s a lot we still don’t know about COVID and the impacts of the pandemic, whether direct or indirect. Humility remains the key to keeping our eyes open and trying to stay in front of whatever COVID might throw at us next. Keeping this in mind, all signs point towards excellent COVID vaccine efficacy and safety, which is where we started out with this post and where we’re going to end: our hope is that at least one silver lining of this pandemic will be a new era of vaccine technology, which will be better and safer than ever before -- and with new capability of rapidly developing and deploying booster doses that fend off variants as they arise. We didn’t want to be on this ride, but hopefully we’ll be getting off soon and finding that at least some good can come out in the aftermath.

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