How COVID-19 Will Change the World

Perhaps the primary lesson gleaned from the US experience with the COVID-19 pandemic is that “we must be humble and willing to accept the fact that there is a lot we don’t know yet,” said Michael Osterholm, PhD, MPH, during his keynote address at the Interdisciplinary Autoimmune Summit on April 21.

Dr Osterholm is an epidemiologist, Regents Professor, and director of the Center for Infectious Disease Research and Policy at the University of Minnesota.

In November 2020 he was appointed to then-President-Elect Joseph Biden’s advisory board on COVID-19. Members of that board developed a ‘roadmap’ of what needed to be done to respond to the pandemic, where the national response had fallen short, and how the future of this—and other—pandemics might look, Dr Osterholm explained.

The work of the advisory board and the roadmap effort showed that “we must sustain our research and development; we must sustain support for local and state public health; and we must sustain our medical care area,” not only to deal with COVID-19 but also to be prepared for all respiratory pathogens.

“I wish I could say the pandemic is over. It’s not. We don’t know what the next shoe might be that will drop. We have to prepare for the possibilities,” Dr Osterholm said.

Those possibilities are wide-ranging, he explained. COVID-19 “could slide into endemicity, with seasonal variations as cases increase, then come down. We already have several seasonal viruses in the coronavirus family—cold-causing viruses. We recover, no one gets severely ill.”

But there are more ominous possibilities, as well, involving altered disease and symptoms. Dr Osterholm explained that a 1984 transmissible gastroenteritis virus in pigs mutated into porcine respiratory virus and changed its cell receptor sites. “It’s a coronavirus; they do that,” he said.

Over the past several months, he explained, “I’ve heard people say time and again that if COVID-19 were going to become a recombinant virus, like the flu, it would have done so by now. Well, now we have compelling evidence of a recombinant SARS-CoV-2 virus, a cross between delta and omicron.” Although there is no evidence this variant is more contagious or causes more severe disease, “it’s a proof of concept that recombination can occur.”

We must also be prepared for COVID-19 to take the course of “exploitation of antibodies, very similar to what we see with dengue hemorrhagic fever,” Dr Osterholm explained. “If you have a lot of antibody or almost no antibody, then your clinical course is that of plain dengue. But if you have a very low but present level of antibody, it can set off an entire immune cascade resulting in severe hemorrhagic disease. As you well know, this is often a life-threatening illness.”

Testing and surveillance capabilities must be supported, he said. “As we sit here in April of 2022, we are seeing challenges already, where government entities all around the world—not just in the US—are shuttering their testing programs.” This has happened before, when the first outbreaks began to diminish and testing facilities shut down. Then came the delta variant. “We had to scramble, we were far too late in responding with adequate testing for our communities and in understanding what was happening with the virus,” Dr Osterholm said. “Then we responded to delta, and then we shut things down again as that waned, and omicron showed up.”

The lesson, he said, is that “you don’t order the fire truck and have it delivered the moment the 911 call comes in, and you don’t sell it immediately after it goes back to the fire station because you might not need it tomorrow.”

The Biden Administration has put forward the concept of test and treat, Dr Osterholm stated. “We must have testing and surveillance program in place. We should have available to every person in this country adequate same-day testing so you get the information back immediately, and then you can be given any of the several drugs we now have to help avoid serious illness, hospitalization, and even death,” he said. “If it takes several days to find a place to get tested, and then several more days to get a prescription, it’s already too late.” However, he noted, “At this point, I don’t see any great plans coming down the pike. Right now, we’re challenged to get enough money out of this Congress to do any testing at all.”

Further, Dr Osterholm said, “if there was anything that was highlighted throughout this pandemic it was the inadequacy of our understanding and response to the quality of indoor air. Early on, it was clear to many of us that what was occurring was aerosol-based transmission—the very tiniest of particles. But we got waylaid around so many issues around ‘hygiene theatre,’ such as plexiglass barriers, that had no meaningful impact at all on viral transmission. We need to do so much more to improve air quality, but we have done so little to invest in this, especially in our schools.”

The importance of adequate personal protective equipment (PPE) was also thrown into sharp relief. “Think of aerosols like perfume or smoke,” Dr Osterholm said. “If you’re in a big room and someone is smoking you will smell it across the room. If you’re in a store and you’re several aisles away from the perfume counter, you can still smell the perfume. That’s because these are aerosols.”

The US Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) initially maintained that there was no evidence for aerosol-based transmission of COVID-19, but over time, Dr Osterholm said, study results showed “clear and compelling evidence that aerosols were the primary method of transmission, not respiratory droplets.”

For this reason, Dr Osterholm said, he has not been a supporter of mask mandates. “We basically gave people confidence that masking would protect them, but cloth coverings and surgical masks fail in blocking aerosols. However, N95 and KN95 are made from material that can let air in and out but trap viruses.” It’s important to not only have the correct protective equipment, but also to use it properly. Up to 25% of those wearing masks do not ensure they cover the nose, he said. “That’s like fixing 3 of the 5 screen doors in your submarine.  And we’ve done nothing to really educate the public.”

The history of the COVID-19 vaccines is “remarkable,” Dr Osterholm stated. “Few had heard of mRNA vaccines before COVID.” Early studies showed these vaccines conferred 90-95% protection with 2 doses. However, he explained, “we have learned that waning immunity is a critical aspect of these vaccines, and realized we had to recommend a third dose or a booster.” Recent results indicate that the adenovirus vaccine may offer stronger protection over time.

“What we have to guard against is undue pessimism,” Dr Osterholm said. “We’re going to learn a lot over the next several months and years about vaccines. But the vaccines we have are dramatically reducing serious illness, hospitalizations and death.”

Much more focus must be placed on the health data infrastructure in the US, he said. The pandemic highlighted that “we have a very, very broken health information system. We need instantaneous information, while some health departments are still reporting data via fax. Why do we have to rely on UK and Israel for timely population-based data? It’s time to understand that we need to bring health data infrastructure to the forefront.”

Local and state health departments can be powerful in their communities, but “they’ve been beaten down” recently, Dr Osterholm said. “I can’t count how many colleagues have left these departments in the past 2 years, victims of 'personal terrorism.' We have allowed public health to die on the vine, and mark my words, we will pay a price if we do not improve public health infrastructure.”

Health care is also suffering a major exodus of providers, he noted. “This has been the health care worker’s finest and most horrible hour; many individuals have been extremely brave and capable, at great personal cost, working on the front lines. But we have a problem; 500,000 health care workers have left in the last 2 years. They couldn’t take it anymore. People never got a break. We have to re-evaluate what we’ve done to support health care workers, not just staffing but the entire support system.”

The same is true for essential worker safety, Dr Osterholm said. “These people are absolutely critical for what we must do. Look at the toll COVID took on workers in grocery stores, delivery, sanitation, law enforcement—how were they protected? In many cases poorly. Worker safety has to become a high priority. This is not the last of this virus or the last of pandemic viruses in general.”

Finally, he said, “We have a lot to think about. I don’t know how long this pandemic will last. I do believe more variants will occur. What I can say for certain is that we don’t need more evidence to understand that we have to address all the issues that I just covered

“We can no longer accept planning for the average. We have to plan for the exception.”

—Rebecca Mashaw

Reference:
Osterholm, M. How COVID-19 will change the world. Presented at: Interdisciplinary Autoimmune Summit. April 21, 2022. Virtual.