Everyone is desperate to understand how the pandemic ends, what will be the silver bullet that saves us all. The answer is not that simple nor is it a comfortable easily digestible narrative. Everyone has a different definition of what an “end” looks like. As the virus changes and evolves, the answer will also change.               

The first issue we must grapple with is time. Over time the I believe that the efficacy of all the Covid vaccines will wane with respect to protection from infection, transmission, illness, and even death. With the Biden Administration’s announcement of boosters for all Americans 8 months after their initial vaccination, it is clear that I am not alone in this opinion. Receiving booster shots to protect us from new variants is not unlike how we receive an influenza vaccine each year to protect us from new strains.   

The second issue is virus evolution. Delta has changed the equation. Having observed the first increase in transmissibility by the B clade that appeared in Europe in February 2020 (not even dignified by a Greek letter) followed by Alpha, Delta, and a host of others, I think it highly likely that a variant more transmissible and deadly will appear that once again changes our calculus. Particularly, as the US once again reaches a daily caseload of over 250,000. Such an astronomical case number gives the virus ample opportunity to mutate as it moves from host to host. Such a variant may be either still more transmissible, more deadly, more capable of evading vaccines, and possibly all three.

Covid-19 has also become endemic in domestic species from cats and dogs, to field mice and farmed mink. Antibodies to SARS-CoV-2 have been detected in 40% of wild white-tailed deer in four U.S. states. An animal reservoir of the virus means that the virus may possibly mutate and transmit back and forth between animals and humans, becoming deadlier with each mutation.  

However, there are some things that are certain, no one modality will end the pandemic, not vaccines, not rigid public health enforcement, anti-viral drugs nor international cooperation. We need all four modalities working together in what I call Multimodal Covid Control. In addition to these modalities, we need wastewater surveillance, genomic sequencing, and a paradigm shift to prioritize pathogen free-air in our buildings.           

Our vaccines can and must be improved. I believe we can and will develop vaccines that are more potent and broadly protective against multiple variants. Recent research published in the journal Advanced Science demonstrates that the use of biomaterials and oxygen to improve the delivery of a vaccine can boost the immune response. Research is also underway on a universal conronavirus vaccination that protects against all variants. Such vaccines and the research needed to develop them are deserving of “Warp Speed” subsidies by multiple governments. 

We are missing a critical arm of medical control, namely inexpensive, injectable, or orally available, long-acting prophylactic drugs. By attacking the virus before it has a chance to replicate we have the opportunity to prevent the spread of infections and mutation of future variants. These drugs would need a strong safety profile so they are suitable for administration to all who are exposed to the virus. Similar to how Xofluza, an antiviral used for Influenza reduces transmission by 80% in a close-quarter family context. I am confident such drugs can be developed based on the success of similar drugs for the prevention of HIV protection, and my knowledge of SARS-CoV-2. They do not exist today save for cumbersome to administer and expensive cocktails of monoclonal antibodies. Here too we need multinational ‘Warp Speed” drug development programs. 

The combination of potent broadly effective vaccines and powerful prophylactic drugs will give us the medical capability to end the pandemic and eliminate Covid-19. Resistance to the vaccines and be countered by combinations of effective prophylactic drugs and vice versa.

Having the medical capability to eliminate a disease does not guarantee it’s eradication as we have learned from bitter experience. Each country must do its part to ensure that appropriate public health mitigation measures are effective. Central to Covid control is the identification of the infected in the form of truly effective contract tracing or hyperlocalized wastewater surveillance, and prevention of onward transmission from those exposed and infected. Today that means isolation of the exposed. Tomorrow, hopefully, with the advent of prophylactic treatments, it will mean treatment of the exposed in lieu of isolation. 

Only a handful of countries today, alas the US and European nations not included, have effective contact tracing programs. While wastewater surveillance has grown in prominence during the pandemic, most programs are still in pilot stages. There is an urgent unmet need to develop and implement such programs in all countries if we ever wish to control the pandemic.

Finally, many nations still fail to place the health of their people at the top of their agenda. Many spend less than 2% of their GDP on health with predictable results. Wealthy nations cannot make up for the deficit in the intention and will of governments to ensure a healthy present and future for their people. We have learned in times of plague that the health of one is the health all. However challenging it may be, we must prioritize working toward a future in which all people no matter where they are have access to high-quality affordable healthcare.