Much of the response to Covid-19 to date has been reactionary. Travel restrictions were implemented after a new variant had already breached the country. The use of higher-quality masks was recommended months after the emergence of increasingly more infectious variants — Alpha, Delta, then Omicron — and well after shortages had subsided. The need to ramp up the availability of rapid antigen tests was recognized during the sixth wave of Covid and amid the winter holidays.
To reach a state of normalcy, leaders must look beyond the latest crisis and proactively prepare for an unknowable future, instituting policies and building programs that will guard against all respiratory viruses that pose threats to public health, society, and the economy.
The nation must first agree on the goals of a new strategy. Many people had hoped that SARS-CoV-2, the virus that causes Covid-19, could be “defeated,” but it’s become increasingly clear, even to the most ardent supporters of a “zero Covid” strategy, that this goal is now biologically impossible. By setting an impossibly high bar for success, public health leaders run real risks: They don’t make optimal use of the highest-yield interventions, they don’t target strategies to protect the most high-risk and vulnerable people, and the nation loses trust in public health because our leaders fail to reach unattainable goals.
Because the measures to control SARS-CoV-2 — such as vaccination, masking, improved indoor air ventilation and air filtration, testing, and treatment — overlap with those to control other viral respiratory infections, we and our colleagues Luciana Borio, David Michaels, and Michael Osterholm recently proposed in three Viewpoints in JAMA setting new goals for controlling all viral respiratory illnesses.
We use history as our guide for where to set these new goals. During the century between 1919 and 2020, neither society nor the economy were shut down to control a virus. Yet, though illnesses caused by respiratory viruses are under-recognized and under-appreciated, they are the cause of significant disease and death every year. In recent years, the U.S. has accepted as many as 35,000 hospitalizations and 3,000 deaths per week from influenza and respiratory syncytial virus (RSV) alone.
We believe that hospitalizations and deaths are the appropriate metric for assessing control measures for respiratory viruses. Health systems can use projections to plan for year-round and seasonal hospital bed and workforce needs. Forecasts of hospitalizations and deaths linked to respiratory viruses could help public health officials and the general public plan for when to wear high-quality masks, switch to remote work or school, or avoid certain indoor activities, much as weather forecasts nudge people to carry umbrellas.
The U.S. is currently averaging almost 150,000 hospitalizations and 12,500 deaths per week just from Covid-19. That’s four times as many hospitalizations and deaths as from influenza and RSV in a bad year. Some think that suppressing hospitalizations and deaths to levels seen in bad pre-pandemic years is too ambitious. Some will be horrified the country didn’t do more to suppress illnesses and deaths from viral respiratory infections in years past. But these numbers provide a place to start debating goals.
Once the goals have been agreed upon — both national and local — the U.S. needs to build a comprehensive, representative testing and real-time reporting system for all illnesses caused by respiratory viruses. Every person in the country should have access to free testing and paid sick and family leave, empowering them to isolate when contagious and to seek prompt treatment. Rapid antigen tests, which exist not only for SARS-CoV-2 but also for influenza and RSV, and could be combined into one test strip for use at home. Labs, too, should routinely test for a panel of the most common respiratory infections in all patients presenting with relevant symptoms.
Positive results from either home- or lab-based tests should automatically link to treatment ranging from monoclonal antibodies and Paxlovid (nirmatrelvir and ritonavir) for Covid to Tamiflu (oseltamivir) or Xofluza (baloxavir marboxil) for influenza, as well as access to enroll in clinical trials. The U.S. government should accelerate the development and production of such therapies, making them widely available at low or no cost. Better measuring the burden of viral respiratory illness may lead to better understanding of what new antiviral therapeutics are most urgently needed and more closely link point of care diagnostics to appropriate treatments. An extra benefit of this approach would be reducing the overuse of antibiotics, which are effective only against bacterial infections, not viral ones.
The country also needs to ramp up and target national genomic surveillance systems and reporting to better understand how viruses are changing over time — how they spread and cause disease and how they evade immune and pharmaceutical defenses. Specifically, genetic sequencing should be conducted on a larger and more geographically representative proportion of respiratory infections as well as breakthrough infections among vaccinated individuals regardless of the severity of these infections. Results of all genomic sequencing should be uploaded into global databases in real time, facilitating a more global understanding of the emergence and spread of novel variants.
Earlier recognition and characterization of new variants of respiratory viruses would allow state and local health departments and systems to mobilize resources proactively ahead of a surge and inform research and development on new vaccines and therapeutics.
The most proactive way to stay ahead of future variants would be to develop a universal coronavirus vaccine that protects against known coronaviruses as well as oral, intranasal, and transdermal administered vaccines that improve both access and immune responses.
Finally, the United States must strengthen its national, state, and community public health workforce to respond and serve effectively and visibly and to address both persistent problems and evolving emergencies.
The Covid-19 crisis has created a unique opportunity for the U.S. to build a stronger, more proactive, and more prepared public health system. While vaccines will continue to be a crucial tool to control illness and death from viral respiratory infections, they must be complemented by a strong public health infrastructure, real-time data, testing, treatment, air ventilation and filtration standards, and clearly guided non-pharmaceutical interventions. By investing in a broad public health response that is both strategic and coordinated, the U.S. has an opportunity to build a foundation for establishing and returning to a “new normal” with Covid-19 and stemming future health emergencies altogether.
Céline R. Gounder is an internist, infectious disease specialist, and epidemiologist at the NYU Grossman School of Medicine and Bellevue Hospital and host of the “Epidemic” podcast. Rick A. Bright is an immunologist and virologist, CEO of the Pandemic Prevention Institute at The Rockefeller Foundation, and former director of the Biomedical Advanced Research and Development Authority. Ezekiel J. Emanuel is a physician, vice provost for global initiatives, and co-director of the Healthcare Transformation Institute at the University of Pennsylvania. All three served on the Biden-Harris transition team’s Covid-19 advisory board.
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