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When the pandemic began, the medical tool box was empty. There were no coronavirus vaccines, no treatments, not even tests to tell who was infected and who was not.
For the past two years, scientists and doctors have been building and expanding an arsenal. None of these tools are silver bullets. They can’t eliminate the coronavirus. But together, they can help turn the virus into a manageable risk, allowing people to hug relatives, go to the movies and travel without fear.
Deaths from covid-19 still have a long way to drop before the crisis of the pandemic recedes. But most experts believe that as immunity is broadened through vaccination and waves of infection, covid-19 will eventually blend into the other illnesses that are part of the daily background of respiratory disease.
That doesn’t mean the virus becomes harmless. Every year, respiratory diseases cause tens of thousands of hospitalizations and deaths. Precisely how much covid-19 contributes to that suffering remains to be seen.
What is certain is that the world needs to prepare the tools now to help control future waves and iterations of the virus and reduce their harm: vaccinations, antiviral pills, and other treatments and preventive measures.
“We’re looking forward, as I think everyone feels is appropriate, that ultimately … we’re going to have to ‘live’ with something that will not be eradicated and very likely would not be eliminated,” Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases, said at a coronavirus task force briefing.
One model for how to move forward comes from HIV. There isn’t a vaccine, but a slew of treatments and prevention strategies means infected people with access to health care can live nearly normal life spans with the right support and access to medicine. In the case of the coronavirus, scientists hope to build a medical tool kit stacked with vaccines, boosters, pills, monoclonal antibodies and other countermeasures that will provide layers of protection and defense, helping tame the pandemic.
“For HIV, we have a plethora of stuff, because we haven’t been able to have a vaccine,” said Larry Corey, a virologist at the Fred Hutchinson Cancer Research Center in Seattle. “Here, we may have a vaccine, but we still may need a plethora of stuff.”
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- Vaccines
- Self-testing
- Antivirals
- Antibodies
Vaccines are the first line of defense, protecting people from the worst outcomes
Vaccines were once seen as the “finish line” in the pandemic, the switch that would flip things back to normal by turning people who are susceptible into people who are immune.
The shots are powerful because they teach the body’s multifaceted immune system to recognize and rout the coronavirus. If a person is exposed, virus-blocking antibodies can impede the virus from infecting cells. Other immune cells, called T cells, can kill infected cells. Memory B cells can recall the virus and churn out virus-fighting antibodies.
Vaccines against the original strain of the coronavirus have shown remarkable versatility, protecting people against the variants that have emerged so far — particularly with a booster.
Even so, their limitations have come into focus. Immunity wanes over time. New variants can find vulnerabilities in the shield of protection, infecting people despite vaccination. Those problems are tractable with boosters or revised vaccine shots, but the realization that vaccination can’t vanquish the virus with a once-and-done public health campaign has been a major disappointment.
That has motivated scientists to stay hard at work, building vaccines that trigger even better immune protection for the long run. Vaccines delivered as nasal sprays might be better than current shots at preventing people from getting infected and spreading the virus. Existing vaccines protect best against hospitalization and death. Universal vaccines that protect against variants and even stop future coronaviruses from sparking pandemics are being developed.
Treatments work best when started early, so tests will be critical
Fast, accessible testing will be a key strategy in a world in which the coronavirus never goes away.
Before the pandemic, people with cold symptoms didn’t routinely get tested to find out which of the wintry mix of respiratory viruses was causing their sniffles and sore throat. The pandemic normalized nasal swabs and testing, and many experts think those aren’t temporary changes.
Tests that can be self-administered at home could be a powerful and simple way to detect active infections — allowing people to alert contacts of their diagnosis and seek treatments.
Antiviral drugs, including one from Pfizer and another developed by Merck and Ridgeback Biotherapeutics, work best when initiated early — ideally within three to five days of the first symptoms. There’s experience with that approach for another a respiratory ailment: Tamiflu can shorten the duration of flu symptoms but is often given too late.
“If it takes you two to three days before you get tested, another one to two days before you get results — you are pretty close to that five-day time period,” said Rajesh Gandhi, an infectious-disease physician at Massachusetts General Hospital. “Testing and treatment have to go hand in glove.”
Testing can have ripple effects: People who test positive can seek out treatments, and can alert the friends they just had dinner with or the colleagues they were in close contact with at a meeting. Those people might be eligible to take medications that can prevent infection after exposure, helping extinguish chains of transmission before they begin.
The tool kit to manage the coronavirus depends on people getting tested quickly, finding out their results right away and getting connected to treatment options. Delays or barriers to any of those steps could lead to people not getting treated in time.
Antibodies block the virus from entering cells and can be used as a treatment — or a prevention option
Antibodies are virus-fighters generated by the immune system after it has been exposed to a virus or vaccine.
Monoclonal antibodies are laboratory-brewed versions of those Y-shaped proteins that serve as immune system warriors. These drugs are typically given by intravenous infusion or injection.
They can be used to treat an infected patient and can also be enlisted to protect a person who has been exposed. Some are engineered to stick around in the body for a long time — providing protection for people who do not respond to vaccines, including some cancer patients or people on medication that suppresses the immune system.
As the virus evolves, it can develop resistance to monoclonal antibodies. The omicron variant, for example, can dodge two of the key drugs that have been workhorses of treatment for the last year.
No silver bullets
Experts debate what the world will look like post-omicron. Everyone has an opinion, but no one has a crystal ball. One thing seems clear. The post-covid world will not look like the pre-covid world in at least one key way: We will be armed with medicines, treatments and testing.
The tool kit is not finished. Vaccines will need to be updated and boosters given to maintain immunity, particularly in those most at risk. Treatments may need to be combined and honed to combat new variants. People with compromised immune systems will need different treatment and prevention strategies — and protecting them will become a bigger priority as it has become clear that long-term infections can allow variants to arise.
Scientists and physicians will be busy for years to come. But if they are successful, the coronavirus will join the panoply of viruses that people prepare for, but mostly ignore, each winter.
“Overall, we’re in this position where we have tools, and as we go forward, we’re going to have to figure out how to use those tools in the most efficient way,” said Barney Graham, a former National Institutes of Health scientist whose work laid the foundation for coronavirus vaccines. “It’s probably going to require data, but it’s in part going to be judgment: how to best prepare this person for protection against this virus.”
Jake Crump contributed to this report.