February 22, 2022

This is the second of a three-part series

The best news about the Omicron variant has been that our vaccine booster doses were effective against it. The booster doses took efficacy against hospitalization from 70% to close to 90% and from infection from 40% to 70%.

But there are still more breakthrough cases with three doses than there were with the ancestral strain to two doses. That’s what’s hard to accept. Why can’t we get back to December 2020? Well, we can, in some very real ways. Importantly, we’ve created several new treatments to complement the astounding development of our vaccines. But production issues are presently limiting widespread implementation of those medications. Controlling an epidemic takes combination therapy, which my colleague Mike Cohen and I wrote about at the beginning of our battle with SARS-CoV-2, before we had medical countermeasures. Today we have a combination of effective measures to protect us from the worst outcomes of SARS-CoV-2: behavioral measures and reducing risk of exposure, masks, and the three biomedical interventions of vaccines, some monoclonal antibodies, and antivirals. Vaccines and monoclonals came earliest and were hugely effective. Monoclonals have emerged as effective treatments for early outpatient therapy and as prevention for people with high exposure or at greater risk (e.g., household exposure or immune compromised). When available, some monoclonals provide the backup coverage for breakthrough infections — they are more expensive than vaccines but also highly effective in preventing hospitalizations, deaths, and, more recently, reducing the risk of getting COVID-19 for unvaccinated people. Their disadvantages are the requirement for more frequent administration and higher cost than vaccines. A more recent tool are antiviral medicines. Antiviral research in coronaviruses was an orphan field before SARS-CoV-2. We knew it would take considerable time to figure out what to target in the complicated SARS-CoV-2 virus and what compounds would selectively inhibit the viral genes and not inhibit important proteins in our cells and cause problems. Remdesivir was one potential solution. An off-the-shelf drug initially tested for Ebola that had efficacy against other coronaviruses such as MERS, remdesivir has been useful in hospitalized people and has been available since early in the pandemic. But we couldn’t build on this knowledge and needed a better drug against the viral protein that remdesivir inhibited. So, different targets of the SARS-CoV-2's viral life cycle needed to be evaluated. Enter Paxlovid, an inhibitor of the viral protease enzyme. One of the very few studies of the drug showed that the pill prevented hospitalization in nearly 90% of people when it was taken early after infection by COVID-19. This is a great outcome. Importantly, it appears additional drugs against the viral protease enzyme are also emerging. Antiviral therapies will be a major part of the medical response tool kit because it’s critical for people to know there is an oral pill that can prevent severe disease progression if they get sick with SARS-CoV-2. One can ask why is this reassurance needed? While it’s obviously needed for unvaccinated people, such reassurance is also important for vaccinated individuals. We have seen that Omicron can severely sicken some vaccinated people, especially the elderly and those who have several other risk factors. Waning immunity increases this chance and knowing there is a backup medicine has enormous implications medically and psychologically. If the public knew there were therapies available at any pharmacy, whether a monoclonal injection or an oral antiviral pill to avert severe illness, society’s ability to cope with COVID-19 would markedly change. Healthy people could start going to restaurants and feel closer to a sense of normalcy. For the less healthy, the availability of these therapies as well as rapid testing could make them feel more comfortable attending family gatherings or going to movie theaters. Flying on an airplane wouldn’t feel like a risky activity, nor would one feel like they might get trapped in another city or country in quarantine or worse, hospitalized. Our options would expand, our economy would fully open, and our social well-being would improve. When will this happen? These additional tools to ward off Omicron are expected to become widely available in April or May this year. They are, in some cases, more available than currently known and educating physicians, pharmacists, and the public about them is crucial.