The pace of emerging SARS CoV2 variants makes clear there is urgency to fully vaccine the U.S. population as quickly as possible. We must prevent a COVID-19 surge across the Southern States this summer, similar to the one we saw in 2020, while recognizing that ongoing virus transmission could promote variants in the states lagging behind in immunization rates.
To combat this troubling possibility, we should also get ready for boosters either because of homegrown mutations or because of ongoing virus variant entry from abroad.
The latest news from Israel confirms that two doses of the Pfizer-BioNTech mRNA vaccine offers high levels of vaccine protection against both the original lineages of the SARS CoV2 and the more contagious variant that arose out of the United Kingdom, known as B.1.1.7. This is welcomed news for the United States as B.1.1.7 is now our dominant variant and will be in the foreseeable future.
Currently, U.S. levels of vaccination in the Northeast (New England and Mid-Atlantic states), as well as California and New Mexico are rapidly approaching 60 percent single-dose vaccination coverage and 40 percent full vaccination with two doses. Based on what just happened in Israel with the world’s highest vaccination coverage — 50 percent fully immunized population — if vaccinations continue at their current trajectory, the Northeast, California and New Mexico could become the first areas in the U.S. to dramatically slow or even halt virus transmission.
Unfortunately, the Southern states, as well as Idaho and Wyoming, rank at the bottom of vaccination coverage rates. Only about one-third of the populations in these states has received even a single COVID-19 vaccination, while only one-quarter are fully immunized. Based on the high levels of vaccine hesitancy and refusal among conservative groups documented by multiple polls and news sources, it is increasingly likely that virus transmission with B.1.1.7 will continue in these deep red states.
Especially worrisome is the potential for a new wave or peak of COVID-19 during the summer months in the South. This happened last year with devastating consequences in terms of overrun hospitals and deaths. In this case, we should expect that the low-vaccination Gulf Coast states of Texas, Louisiana, Mississippi and Alabama, in addition to Tennessee and Georgia could become new epicenters for COVID-19 in America. Because the populations there are partially vaccinated, things may not be as dire as they were in 2020.
However, a new issue might also arise.
If we allow B.1.1.7 to circulate aggressively in the American South this summer, the virus could acquire an additional mutation known as E484K in its spike protein. This was shown to happen in the United Kingdom. That second mutation would lessen the effectiveness of COVID-19 vaccinations. In fact, an E484K mutation on the UK’s B.1.1.7 background closely resembles the variant of concern from South Africa, B.1.351 — which we now know can partially escape the vaccine protection that results from even two doses of the Pfizer-BioNTech vaccine. A new study published in the New England Journal of Medicine found that Pfizer-BioNTech vaccine provides only 51 percent protection against B.1.351 of South Africa.
Even if the UK’s B.1.1.7 variant does not pick up a second mutation such as E484K, we should anticipate the entry of additional variants of concern from abroad, whether it is B.1.351 or its closely related P.1 variant from Brazil. We are also closely monitoring the B.1.617 variant from Maharasthra state in India.
But there is good news: Managing the arrival and emergence such variants is achievable through booster immunizations. If you received two doses of the Pfizer-BioNTech or Moderna vaccine you can expect to need a third immunization, possibly later this fall or in 2022. Similarly, you might expect another dose following your single-shot Johnson & Johnson vaccine.
In all three cases, an additional immunization will augment your existing immunity in terms of the amount of virus neutralizing antibody and durability of protection. In addition, the boost may be tailored to specifically increase protection against the new variants arising either indigenously or from abroad.
What happens after that is still unknown. I believe that we might not need additional annual boosters but there is not yet a scientific consensus. In fact, Pfizer-BioNTech just reported that it is exploring co-formulations of mRNA COVID-19 vaccines with seasonal influenza vaccines in case this is necessary.
But the growing list of variants around the world highlight the urgency to fully vaccine the U.S. population — now. This not only helps to get ahead of the B.1.1.7 variant but also to minimize future mutations.
Peter Hotez, MD, Ph.D., is professor of Pediatrics and Molecular Virology, and dean of the National School of Tropical Medicine at Baylor College of Medicine where he is also Texas Children’s Hospital chair in Tropical Pediatrics and co-director of the Texas Children’s Center for Vaccine Development. Follow him on Twitter: @PeterHotez.