A Rational Roadmap to Future COVID Management

Photo by Yoav Aziz | Unsplash


On March 2nd, President Biden announced his new National COVID-19 Preparedness Plan stating, “The path forward in the fight against COVID-19 is clear: we must maintain and continually enhance the tools we have to protect against and treat COVID-19.” We applaud this fresh start and put forth a ten-point plan to help guide the transition to endemic COVID management in the United States. Of import is that the US will need ongoing funding allocated to continue to advance vaccines, testing, and surveillance.


First, we must replace resource-intensive asymptomatic testing, contact tracing, and quarantines for efficient and sustainable monitoring through wastewater surveillance. When wastewater surveillance demonstrates a spike in caseloads, testing should be reinitiated in a time-limited fashion to protect high-risk populations. Surveillance testing will not be needed in schools where the majority of persons under age 18 in the U.S. now have evidence of prior COVID infection and are now considered a low risk-population even pre-vaccination. With additional protection from vaccination-induced immunity down to the age of 5 years old, our nation’s youth have an ever greater level of protection.

Second, we must continue with the five-day isolation period for COVID, but also enact a “stay home when sick” model historically used for other infections – as was adopted in the UK’s Living with COVID plan. This model allows the protection of the population from other respiratory pathogens as well.


Third, we should invest heavily in President Biden’s test-to-treat initiative to ensure that vulnerable adults have rapid access to effective therapies through community-based pharmacies and health centers. These locations can test and dispense anti-viral pills on the spot, such as Paxlovid, Pfizer’s groundbreaking COVID anti-viral pill. This access will be especially important in vaccine-hesitant communities that have suffered higher rates of COVID-related illness and death over the past ten months. New monoclonal antibody therapies could also be added to this initiative for Omicron, as was possible with pre-Omicron monoclonal antibody formulations.


Fourth, to identify and support our most vulnerable communities, we must accurately quantify and track immunity in terms of both vaccination and natural infection in terms of protection against future infection and hospitalization. For the unvaccinated with prior infection, a single vaccine dose should be recommended to achieve highly protective hybrid immunity. This hybrid immunity can be achieved without insistence on completion of a two-dose series. Hopefully, the concept of hybrid immunity will be viewed as a welcome compromise among many vaccine hesitant individuals with prior infection while providing protection that is equivalent, if not superior to, a three dose vaccination series without natural immunity. The need for future booster shot will be likely determined by the age and comorbidities of the host, as well as the emergence of additional variants.


Since vaccines are now most protective against severe disease, vaccine passports should now be avoided. The last year has shown that top-down mandates and passports are both socially divisive and out of step with the primary purpose of vaccination: the prevention of serious illness. Vaccination should not be marketed as preventing an infection entirely.


Fifth, we can further enhance the safety of our vaccines by spacing the doses of the primary series eight weeks apart for young men – ages 12 to 39 – thereby significantly lowering the risk of myocarditis (i.e., the inflammation of the heart that has shown up in rare cases). While the CDC has embraced this concept, it needs to become the default option.


The only group that should sit outside this stratagem among younger individuals is the immunocompromised, who should instead undergo a three-week spacing of doses, with four shots recommended at this time.


Sixth, we need a more targeted approach to boosters. This requires more precise reporting from the CDC, which involves categorizing severe breakthrough infections by the specific comorbidities and vaccination status of those hospitalized. Compared to many European countries such as the United Kingdom, the U.S. at large has failed to provide more detailed data on severe COVID-19 breakthroughs. More refined data will allow for more efficient targeting of further booster shots, prioritizing those most likely to benefit from regular boosting by age and health status.


In addition, prior infection with Omicron should be counted as a booster dose since a breakthrough infection with Omicron after vaccination led to broad neutralizing antibodies and T cells against essentially all prior COVID variants.


Seventh, we should continue to increase our population’s immunity to COVID by expanding vaccine options including Novavax and Covaxin which are different from mRNA-based vaccines like Pzifer and Moderna. Novavax is a more “traditional” vaccine of the spike protein linked to an adjuvant. Covaxin is a whole inactivated virion vaccine, linked to an effective adjuvant funded by the NIH, which has a potential advantage as a booster against future variants by representing the whole virus, rather than a limited portion such as a spike protein.


Eighth, we should reassure the public that long-haul COVID can be prevented through vaccination. Studies suggest that vaccination reduces the risk of long COVID back to baseline, meaning that vaccinated individuals are no more likely to suffer from long COVID symptoms than persons never infected with COVID at all.


Ninth (as recently announced by the White House), we should continue to upgrade and improve our ventilation systems in public spaces, including schools, which will accrue long-term benefits from the reduced transmission of all respiratory pathogens to improved air quality in areas plagued by wildfires or other environmental pollutants.


And tenth, we should retire mask mandates (but not recommendations) for good, including those currently in place for public transportation. Evidence is lacking that broad mask use (including in schools) had a significant impact on slowing COVID transmission or hospitalizations over the past two years – whether due to inconsistent use or variability in mask quality or both.


Moreover, blanket mandates are not appropriate when individuals have highly variable risks for both exposure to and outcomes from COVID infection. Instead of mask mandates, the CDC should recommend specific fit and filtered masks (e.g. N95, KN95, FFP2, KF94, double masks) that can be worn by individuals who desire a higher level of protection against respiratory pathogens on a seasonal basis or for specific settings such as large gatherings or when traveling in higher prevalence areas.


With this roadmap, we hope to reframe the discussion away from returning to normal to a new paradigm in which we have the vaccines, therapeutics, and surveillance to combat COVID-19 to provide confidence in our scientific progress. With these scientific advances, infectious disease control becomes the responsibility of the medical system, not the public. By relying on these powerful strategies for endemic management of COVID, we can more readily return to the “new normal” of public life where we live with the virus in the most rational way possible.


Dr. Jeanne Ann Noble

Dr. Noble is the Associate Professor of Emergency Medicine and Director of COVID Response for the UCSF Emergency Department. Noble has a special interest in global health, particularly the use of ultrasound in emergency medicine, and frequently volunteers as an attending physician and ultrasound instructor in Central American and South American countries. Her research on global health and the use of emergency ultrasound has been widely published.


Dr. Monica Gandhi

Monica Gandhi MD, MPH is Professor of Medicine and Associate Division Chief (Clinical Operations/ Education) of the Division of HIV, Infectious Diseases, and Global Medicine at UCSF/ San Francisco General Hospital. She also serves as the Director of the UCSF Center for AIDS Research (CFAR) and the Medical director of the HIV Clinic at SFGH (“Ward 86”).


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