Three pillars of pandemic preparedness to end this one while preparing for the next
With more than 50 new mutations that increase infectivity and help the virus evade immunity, Omicron is the first COVID-19 variant uniquely capable of prolonging the pandemic. In order to achieve high infectivity, Omicron adapted to the upper airway, forfeiting the ability to cause deep lung infection, thereby reducing mortality. This tradeoff reduces symptoms, keeping people active but increasing transmission in a community.
Some experts argue that Omicron’s low virulence foreshadows the end of the pandemic. Unfortunately, the opposite is more likely — that Omicron’s balance of high infectivity and milder illness is evidence of adaptation towards a more potent pathogen.
Viruses also can evolve to become more lethal. During the Spanish Flu pandemic of 1917 and 1918, it was the virus in the second wave that proved more deadly.
Lessons from history and from Omicron’s worrisome adaptations that help it prolong the pandemic are an urgent warning that our government needs to stop fighting the last virus and develop a new strategy to counter new waves of Omicron-like variants now evolving globally.
There are three interdependent pillars needed to achieve this goal.
The first pillar requires that the federal government — and not vaccine manufacturers — dictate the capabilities of all future pandemic vaccines. This is the normal process for government procurement. When the Air Force needs a new jet fighter, the Air Force — and not Boeing or Lockheed — dictate the type and functionalities of the aircraft to be delivered. In drug and vaccine development, these characteristics are called the “target product profile” (TPP). However, in the early weeks of this pandemic, vaccine companies — not the U.S. government — defined the TPP for the U.S.’s first COVID vaccines. In the spring of 2020, the Department of Health and Human Services (HHS) did not demand that the new vaccines prevent person-to-person transmission. This requirement, known as transmission termination, is fundamental to eliminating the vaccinated as a source of continued transmission. Besides safety and efficacy, including the demonstrable action of the first generation vaccines in reducing disease severity, the TPP also determines manufacturing location, storage and delivery requirements, and ease of administration. The TPPs for pandemic vaccines go further: simple refrigeration, long shelf life, higher safety for vulnerable populations, and protection against variants that could prolong the pandemic.
Pillar two requires the nation to restore international virus intelligence-gathering. This early warning system allows the U.S. time to prepare for inbound threats using layered public health strategies and domestic testing, and to get a running start on new drug and vaccine development, if necessary. Current U.S. surveillance systems lack coordination and are politically unacceptable to many countries. As the early days in Wuhan demonstrated, U.S. surveillance was outperformed by U.S. hospitals and corporations which had physicians embedded in Chinese hospitals and pharmaceutical companies. Redesigning mutually beneficial data-sharing on outbreaks with countries, both friendly and adversarial, is in our best public health and economic interests. We neglect this warning system at our peril.
The third pillar requires recognition that COVID-19 is a continuing global disaster that has killed more than 830,000 nationally and more than 7 million globally, and therefore requires disaster-level prioritization on par with the response to the 9/11 terrorist attacks, which killed 2,977 people. Yet, only 9/11 prompted bipartisan support for a new Department of Homeland Security (DHS) to coordinate a wide range of security and intelligence operations. The absence of a foreign terrorist attack on U.S. soil over the past 20 years is testimony that DHS has been successful against a persistent threat. In contrast, the U.S. government’s latest attempt to improve pandemic response — the third in 16 years, and outlined in the draft Senate Health, Education, Labor and Pensions Committee’s Prevent Pandemics Bill — omits basic features of integrated disaster response, unified command and metrics for success, and it is naïve to the requirements for both industry and foreign collaborators. From a disaster management perspective, it will fail like the previous two.
A more plausible plan would be a new agency with the clarity of mission of DHS — perhaps a Department of Pandemic Response whose singular purpose is the prevention and response to infections from natural and human origins. The leadership would be appointed by nonpartisan experts from disaster response, science, medicine, manufacturing, regulatory, vulnerable populations, and global health. Partisan infighting would be reduced by terms that span elections. The metrics for success would be the number of American lives saved and the number of outbreaks detected and prevented.
Events over the last 22 months provide little doubt that the product of this tripartite plan will be needed for the remainder of this pandemic — and the ones to follow.
Michael V. Callahan, M.D., DTM&H, MSPH, is former COVID special adviser to the Assistant Secretary for Public Health Preparedness at the Department of Health and Human Services. He has led seven disease outbreak deployments for Ebola, Bird flu and SARS, directed DARPA Biodefense Program and is director for Clinical Translation, Vaccine and Immunotherapy Center at Massachusetts General Hospital.
Mark C. Poznansky, M.D., PhD., FIDSA, is director of the Vaccine and Immunotherapy Center, Infectious Diseases Division, of Massachusetts General Hospital and professor of medicine at Harvard Medical School.