As we enter the third calendar year of the COVID pandemic, most of us are hoping that 2022 might bring the end of at least the acute pandemic stage of our relationship with the virus. The news that the globally dominant variant Omicron causes milder disease gave some hope for a reprieve, yet health experts are warning that the pandemic is not over and Omicron may not the last variant we see. AFP (France) reports WHO’s Tedros reiterated in a press conference, “’This pandemic is nowhere near over’. Tedros warned against dismissing as mild the coronavirus variant Omicron, which has spread like wildfire around the globe since it was first detected in southern Africa in November…. But Tedros stressed it remained vital to ensure broader, more equitable access to the jabs. ‘Vaccines may be less effective at preventing infection and transmission of Omicron than they were for previous variants, but they still are exceptionally good at preventing serious disease and death,’ he said.”
 
Speaking on a panel at the World Economic Forum WHO’s Dr. Michael Ryan said the worst of the pandemic could be over this year if the huge inequities in access to vaccines and medicines is addressed quickly. He said, “What we need to do is get to low levels of disease incidence with maximum vaccination of our populations, so nobody has to die. The issue is: It’s the death. It’s the hospitalizations. It’s the disruption of our social, economic, political systems that’s caused the tragedy—not the virus." Ryan also addressed what endemicity might actually mean. “Endemic malaria kills hundreds of thousands of people; endemic HIV; endemic violence in our inner cities. Endemic in itself does not mean good. Endemic just means it’s here forever.”

If You Are in a Hurry

• Read an essay by a Tennessee nurse in Scientific American (US) lays out the realities of the impact of the Omicron wave and its impact on nurses.
• Read Vox on what long term immunity to the virus might look like. The long piece includes a great explanation of how T cells and B cells work.
• Read Apoorva Mandavilli in The New York Times on the US CDC and “imperfect science.”
• Watch a Medscape conversation with ethicist Art Caplan on ethical responses to people who are unvaccinated.
• Read NPR’s Goats and Soda Blog on issues beyond vaccine supply that are keeping vaccination rates low in some countries.
• Read a NEJM perspective that argues for adolescents having the right to consent to getting a COVID vaccine.

 

What Comes After Omicron?

 
We don’t know what comes after Omicron and how new variants might interact with current and future vaccines, monoclonal antibodies or treatments. Bloomberg (US) reports that US NIH’s Tony Fauci told a panel at Davos, “’It’s an open question as to whether or not omicron is going to be the live virus vaccination everyone is hoping for.’ Fauci also noted, ‘We have such a degree of push-back against regular, normal, easy-to-understand public health measures,’ he said. ‘A reluctance to wear masks, to promote vaccination, to the kinds of measures we know if we all pull together as a society we’d be much, much better off.’” Reporting on the same panel discussion, STAT (US) quotes Annelies Wilder-Smith, a professor of emerging infectious diseases at the London School of Hygiene and Tropical Medicine: “Omicron will not be the last variant. There’s a high probability we will have another variant coming up. The question is when and will it be less dangerous?”
 

Vaccine Access

 
Reuters (UK) reports, “The COVAX global vaccine-sharing programme has delivered 1 billion COVID-19 vaccine doses…. Supplies to poorer nations have long been very limited because of lack of vaccines, as wealthier states secured most of the doses initially available from December 2020. But in the last quarter shipments have exponentially increased, allowing COVAX to reach the milestone of 1 billion doses shipped to 144 countries, said GAVI, which co-leads the programme alongside [WHO].”
 
Al Jazeera (Qatar) reports on a new report from Oxfam, Inequality Kills: “In this deeply unequal world, structural and systemic policy and political choices are skewed in favour of the richest and most powerful, resulting in harm to the majority of ordinary people around the world, said the report, which highlighted the COVID-19 vaccine divide as a prime example. ‘Millions of people would still be alive today if they had had a vaccine — but they are dead, denied a chance while big pharmaceutical corporations continue to hold monopoly control of these technologies,’ said Oxfam.”
 
The Zimbabwe Mail (Zimbabwe) reports, “Zimbabwe’s President Emmerson Mnangagwa said on Wednesday that China would be donating another 10 million doses of its COVID-19 vaccine over the course of 2022…. The country has so far fully vaccinated just over a fifth of its population of 15 million people, mostly using vaccines either purchased from or donated by China. Nearly a third of Zimbabweans have received at least a single dose of the Chinese vaccine.”
 
CNBC (US) reports, “Cuba has vaccinated a greater percentage of its population against COVID-19 than almost all of the world’s largest and richest nations.” Cuba has vaccinated children as young as two. “The country’s health authorities are rolling out booster shots to the entire population….” Cuba has developed five vaccines “all of which Cuba says provide upwards of 90 percent protection against symptomatic COVID when three doses are administered. Cuba’s vaccine clinical trial data has yet to undergo international scientific peer review, although the country has engaged in two virtual exchanges of information with the World Health Organization to initiate the Emergency Use Listing process for its vaccines.” Some experts say, WHO approval of Cuba’s COVID vaccines would have “enormous significance” for poor countries. “Cuba, unlike other countries or pharmaceutical companies, had offered to engage in the transfer of technology to share its vaccine production expertise with low-income countries.”
 
NPR’s Goats and Soda Blog (US) reports on issues beyond vaccine supply that are keeping vaccination rates low in some countries. African Alliance’s Maza Seyoum explains one aspect of low vaccination rates in many African countries: “Recently vaccine deliveries to Africa have increased. But now there are new problems: the shipments are haphazard and sometimes consist of less popular brands that are about to expired. ‘Now we're seeing the sort of drip, drip, drip of vaccines,’ she says. ‘People are waiting for vaccines to come. They come, then they stop.’ This unpredictable supply chain, she says, makes it nearly impossible for African countries to plan nationwide vaccination drives. And in some of these places where hardly anyone has gotten the jab, rumors about the mysterious vaccine have flourished and augmented vaccine hesitancy. ‘The truth is, there is vaccine hesitancy everywhere,’ Maaza says. ‘But as people are waiting, it leaves kind of a fertile ground for these rumors to circulate.’"

Hillary Omala and Eddah Ogogo write in STAT (US) about developing a vaccination program for Kibera, one of Africa’s largest informal settlements in Nairobi. “Most Kibera residents wanted to get vaccinated against COVID-19 as soon as possible. They began showing up at the clinic as word got around that we were offering it. Some, however, were hesitant, wanting to wait and see how it went for their friends and neighbors—much as happened in the US and other countries. The same myths and misconceptions concerning the vaccine exist in Kenya as in the US and other countries. But we have the connections and the time to discuss the effectiveness and the safety of the vaccines with each patient and answer their questions. We have a team of staff members and community health volunteers dedicated exclusively to the vaccine drive, providing them with the quality time that some patients need for reassurance. We also have a long-standing history in Kibera—20 years, to be exact—that has enabled us to build up a sufficient level of trust that would successfully drive the COVID-19 vaccine initiative among the highly dynamic and hard-to-reach populations.”
 

About that Fourth Shot

 
AP (US) reports “An Israeli hospital on Monday said preliminary research indicates a fourth dose of the coronavirus vaccine provides only limited defense against the omicron variant that is raging around the world.” AP reports among who had received three shots of the Pfizer vaccine and received either Pfizer or Moderna, all had “slightly higher” antibodies, but “the increased antibodies did not prevent the spread of omicron.”
 
Fortune (US) reports, “EMA vaccine strategy chief Marco Cavaleri said there was still no data supporting the need for a fourth COVID vaccine dose. And even if multiple boosters do prove to be necessary, they would need to be spaced out in the style of annual flu jabs, rather than delivered every several months. He also warned that overly frequent booster doses could potentially lead to ‘problems with immune response.’"
 

Let’s Hear It for the T Cells

 
Nature (UK) reports that while attention has remained on antibodies elicited by vaccines, we should also be paying attention to T cells. “When it comes to coronavirus immunity, antibodies have stolen the limelight. Researchers are monitoring people’s levels of antibodies—particularly ‘neutralizing antibodies’ that directly prevent the virus from replicating—with bated breath…. But the rise of coronavirus variants has shown how fragile antibody-based immunity can be in the face of a changing virus…. T cells, however, are more resilient. These cells perform a variety of immune functions, including acting as ‘killer’ cells that destroy virus-infected cells. By killing infected cells, T cells can limit the spread of infection—and potentially reduce the chance of serious illness…. ‘The picture that’s emerging is that [new] variants remain highly susceptible to T-cell responses,’ says Dan Barouch, director of the Center for Virology and Vaccine Research at Harvard Medical School in Boston, Massachusetts. ‘That includes Omicron.’”
 
Vox (US) reports on what long-term immunity to the virus might look like, noting that antibodies are only part of the story, calling B cells and T cells “your enduring pandemic protectors…. After an infection or a vaccination, some B cells and T cells stick around, becoming memory B cells and T cells. They sit idle, sometimes for decades, waiting to see if a pathogen returns. If it does, they can quickly reactivate. This is why we a decline in neutralizing antibody counts isn’t always a disaster. Even if concentrations of neutralizing antibodies dip so low that they can no longer prevent an infection, other parts of the immune system can spool up to make sure the virus doesn’t do too much damage.”
 
Reuters (UK) reports “High levels of T-cells from common cold coronaviruses can provide protection against COVID-19, an Imperial College London study published on Monday has found, which could inform approaches for second-generation vaccines.”
 

Adolescents and COVID Vaccines

 
A NEJM (US) perspective looks at the question of who should decide about adolescent vaccination—the child or a parent. Vaccination rates remain relatively low among adolescents in the US and many adults have indicated no plans to vaccinate their adolescent children. The authors argue, “Allowing adolescents to independently consent to COVID-19 vaccination could substantially increase vaccine uptake in this population. The process of obtaining consent from adolescents doesn’t have to mirror the consent process for adults. Since adolescents may be more susceptible to peer pressure and emotional influences than adults, conversations about consent could occur only in private encounters with medical professionals delivering vaccines (whether in private offices, clinics, pharmacies, or schools). We believe that allowing adolescents to independently consent to COVID-19 vaccination is on par with allowing independent consent to any intervention that is in adolescents’ best interest and supports an important public health goal.”
 
Medscape (US) reports, “Nearly all teenagers admitted to intensive care units because of COVID-19 were unvaccinated, according to a new study published in the New England Journal of Medicine…. The Pfizer vaccine prevented 94 percent of hospitalizations and was 98 percent effective in keeping the young patients out of the intensive care unit, the study said.
 
A NEJM (US) editorial notes, “as of December 1, 2021, only 60 percent of US adolescents had received a single dose of a COVID-19 vaccine, and only 50 percent had been fully vaccinated…. These immunization rates are in sharp contrast to rates of more than 95 percent for routine pediatric vaccinations…. In the United States, as of December 23, 2021, more than 7.5 million children had been infected during the pandemic and 721 had died. The widespread use of vaccines would markedly reduce this toll.”
 

Children and COVID

 
CIDRAP (US) reports, “A 10-country study of more than 3,000 children who tested positive for COVID-19 in emergency departments (EDs) finds that 3percent went on to develop severe disease within 2 weeks, with risk factors being older age, having chronic conditions, and experiencing symptoms longer…. The study authors wrote, ‘Although asthma has been suggested as a risk factor for severe illness in youths with COVID-19, our study, as well as a registry-based study in the United States, did not confirm this association.’” Read the study in JAMA Network Open.
 

COVID and Schools

 
One of the most devastating global impacts of COVID has been the impact on education and children. The Daily Maverick (South Africa) reports, “Several online schools have noted a significant increase in enrolments during the pandemic, as pupils appear to be abandoning traditional schools in favour of online classes, and concerns persist around rotational learning and COVID-19 disruptions.” One person affiliated with an online school is quoted: “as a result of schools being forced to incorporate online teaching during remote periods, parents have realised that [online schooling] is a possibility where they would never have been exposed to it before…Parents are scared of sending their children to school as a result of COVID-19….”
 

Public Health Guidance and Imperfect Science

 
Apoorva Mandavilli writes in The New York Times (US) about the US CDC’s issues with developing guidance for the pandemic. Early in the pandemic, “Testing and surveillance lagged as the agency tried to implement dated approaches with creaky infrastructure. Officials were late to recommend masking, in part because federal scientists took too long to recognize that the virus was airborne…. Now the contagious Omicron variant is pushing the CDC into uncharted territory. Because decisions must be made at a breakneck pace, the agency has issued recommendations based on what once would have been considered insufficient evidence, amid growing public concern about how these guidelines affect the economy and education.”
 

Access to COVID Treatments

 
Bloomberg (US) reports African health officials are looking to secure HIV treatments to help the continent fight the virus. Africa CDC’s John Nkengasong is quoted: “If you have such drugs, people can test and treat themselves at home and not overwhelm the health system. That is why treatments are very important.” Negotiations are ongoing with Pfizer and Merck has said “it will supply the global relief organization UNICEF with up to 3 million courses of molnupiravir…. Pfizer and Merck have each agreed to allow generic manufacturers to make inexpensive versions of their pills for low- and middle-income countries. But demand for antiviral drugs is set to outpace supply, with poorer countries potentially waiting until early 2023 for generic-drug makers to produce large quantities, an analysis from London-based Airfinity Ltd. found.”
 
Elizabeth Merab writes in The Nation (Kenya), “Given an estimated time of six to eight months to ramp up production and with Pfizer expecting to make 120 million courses of the treatment in 2022, it might once again take longer for low-and middle-income countries to acquire the pills. And just like the vaccines, the availability of the drugs comes with some significant caveats, including the fact that supplies of the Pfizer treatment are very limited, while the Merck treatment is less effective than hoped.”
 
Health Policy Watch (Switzerland) reports, “The first generic version of Paxlovid, the Pfizer pill that has proven highly effective in treating COVID-19, is already available in Bangladesh…. Bangladesh’s generic company Beximco started distributing its version of Paxlovid—called Bexlovid—last week after Bangladesh’s Directorate General of Drug Administration issued an Emergency Use Authorisation (EUA) for its production on 30 December…. Last November, Pfizer signed a voluntary license agreement with the Medicines Patent Pool (MPP), enabling the MPP to grant sub-licenses to qualified generic medicine manufacturers, to produce and supply Paxlovid to 95 countries, covering up to approximately 53 percent of the world’s population.”
 
AP (US) reports that even in the US supplies of the Pfizer and Merck treatments are in short supply. “The US didn’t make the kind of mass purchases in advance that it did with vaccines. Pfizer’s pill, Paxlovid, is considered far superior to Merck’s, but because of the six to eight months it takes to manufacture, the company says it can supply only about 250,000 courses of the treatment by the end of this month. The US has ordered enough Paxlovid to treat 20 million people, but the first 10 million orders won’t be delivered until June.”
 
Reuters (UK) reports WHO, “recommended use of two drugs by Eli Lilly, and GlaxoSmithKline and Vir Biotechnology for COVID-19 patients, adding treatment options as the fast-spreading Omicron variant renders many ineffective…. The panel on Thursday strongly recommended Lilly's baricitinib, sold under brand name Olumiant, for patients with severe COVID-19 in combination with corticosteroids, while conditionally endorsed GSK-Vir's antibody therapy for non-severe patients at the highest risk of hospitalization.”
 

Ethics and the Unvaccinated

 
In a Medscape (US) conversation with ethicist Art Caplan, he outlines his thoughts on ethical responses to people who remain willfully unvaccinated. He argues against “gloating” when an unvaccinated person dies of COVID, but notes that doesn’t mean you shouldn’t be angry. “part of the response we have when someone dies is to, if you will, try to change the behavior so that others don't succumb to the same unnecessary death. I don't think gloating gets us there. If somebody dies because they didn't vaccinate, and they got COVID, and they didn't mask, and they engaged in a lot of risky behavior, to me, I don't want their family to wind up dead. I don't want their friends to wind up dead. I don't think I'm going to reach them by gloating.”
 

From the Frontlines of Pandemic Care

 
An essay by a Tennessee nurse in Scientific American (US) lays out the realities of the impact of the Omicron wave and its impact on nurses. “There is always light, even in this unrelenting dark. The human condition has always been dogged by misery, genocide, colonialism, pandemics and petty wars; yet there is always beauty in small things. I remind myself of this when I feel overwhelmed by all the terrible things in the world, by the amount of death that I’ve seen since I became a nurse in July of 2020. I feel that dark tugging at me like a riptide, a constant crush of all the love that has nowhere to go and the grief that could swallow the world, and I feel the bravery and goodness of the people staring back into the abyss with me. After two years the death and darkness threaten to swallow us whole, and yet I look to my co-workers standing battered but steadfast against each wave of death, and I find courage to face it myself. This is what it is to be a nurse: facing that darkness and telling it that you are not afraid.”