大流行将结束,但Covid-19可能会继续存在

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尽管疫苗分发和任命过程很混乱,但美国的Covid-19疫苗接种情况比最初看起来要好。截至周五,疾病控制与预防中心的疫苗追踪器显示已分发了近5800万剂疫苗。上周二,总统拜登宣布他的政府可能早日达成其100天内提供1亿张枪击的目标。

预计我们将能够以预防流感的方式思考Covid-19可能能够帮助我们规划其持久性。这可能会使带有鼻烟盒的人正常佩戴口罩,就像Covid-19开始之前亚洲国家中一样。

尽管疫苗分发和任命过程很混乱,但美国的Covid-19疫苗接种情况比最初看起来要好。截至周五,疾病控制与预防中心的疫苗追踪器显示已分发了近5800万剂疫苗。上周二,总统拜登宣布他的政府可能早日达成其100天内提供1亿张枪击的目标。

然而:任何时候,美国将超过50万例冠状病毒死亡的可怕里程碑。上个月,接受调查的五分之一的美国人表示反对服用疫苗(13%的人表示他们不会服用;只有7%的人需要时才使用)。全球范围内,疫苗的推出速度要慢得多。经济学人智库12月曾预测,许多低收入国家将明年之前不接种疫苗,而上个月,世界卫生组织总干事特德罗斯·阿达诺姆·盖布雷耶苏斯(Tedros Adhanom Ghebreyesus)警告说,世界处于“濒临灭绝的边缘”。灾难性的道德失败”,因为他们没有与全球南方公平分享疫苗。

总结:这不会很快结束。全球疫苗接种步伐缓慢和病毒变种迅速出现之间(可能是由斑驳疫苗覆盖率加大了对病毒的选择压力所致),研究人员和政策制定者开始承认Covid-19永远这里。

这需要心理上的重置。大流行的第一年,我们表现得好像Covid出人意料地来了一样,没有我们的警告,如果我们足够努力的话,这些东西可能会打包收拾走了。现承认该病毒是不受欢迎的永久室友会更现实。我们不太可能强迫它离开。但是我们也许能够阻止它接管房子。

接受这种可能性意味着我们必须立即开始考虑两条行动路线。首先,我们需要尽一切可能减少当前紧急情况下发生的疾病和死亡人数。其次,我们需要承认这些行动不足以永远将Covid-19赶出世界,这就是公共卫生人员所说的根除之道,并考虑到它永久存或成为地方性疾病意味着什么。

肯特大学流行病学教授兼史密斯教授塔拉国立大学公共卫生学院。 “潜的动物保护区和如此频繁无症状的事实之间,我认为这将非常困难。”

根除是一项崇高的目标,因此公共卫生领域很难实现,因此只能针对一种人类疾病:天花进行管理。 (牛瘟,一种牛的疾病,也已被根除。)根除的普遍定义是,通过隔离,治疗或接种疫苗,使疾病的传播达到零,从而使病原体无处藏身和有效地生存。结束生命。除这两种疾病外,针对疾病的根除运动步履蹒跚,因为接种疫苗无法渗透到有机体世界上的庇护所:黄热病,猴子;疟疾,蚊子;用于破伤风,土壤中。 (脊髓灰质炎是一项为期32年的国际运动的目标,它可以悄无声息地隐藏无症状人群的胆量中。它已经接近灭绝,但是当大流行停止疫苗接种工作时,病例又反弹了。)

Covid-19病毒具有类似的避难所:它最初是从蝙蝠中跳下来的,某种可能是中间(但仍未被识别)的动物中跳出来,这种动物帮助它从蝙蝠适应了人类,并一些国家中被确认为藏有貂皮的貂皮中,而且无论人口数量的多少,都不受自然免疫或疫苗的保护。

因此,没有办法Covid-19周围撒网,并且将其收紧为零。它的动物宿主将始终为它提供逃生舱口。但是,疫苗已经保护了所有疾病的潜人类受害者之前,开始考虑替代宿主实际上并没有用。到目前为止,我们距离还很遥远。只要世界上某个地方的人们仍等待他们的第一张照片,Covid-19就会繁殖出人类宿主。而且,有可能发生变异,从而创造出如今全球范围内出现的变种。

这就增加了一种可能性,即随着病毒的变化,我们需要不断修补疫苗以跟上病毒的发展。强生公司首席执行官亚历克斯•戈尔斯基(Alex Gorsky)本月早些时候CNBC的一次活动上表示:“我认为大多数人都认为,未来几年里,我们很可能会获得Covid-19疫苗。”。“我想我们今天还不知道那一枪到底是由什么组成的。”

如果Covid不能成为一种疾病,我们将尝试快速遏制-例如,我们推出疫苗来对抗埃博拉疫情-它必须成为我们计划的疾病,例如麻疹和流感。有了麻疹,我们从小就开始接种疫苗。对于流感,我们会每年重新接种疫苗,同时调整疫苗的含量以跟上病毒的进化。我们为那些人接种疫苗,因为他们要付出如此高的代价。过去的10年中,流感每年美国造成12,000至61,000人死亡。全球范围内,麻疹每年造成140,000人死亡。

我们无法保证Covid-19流行后是否会像麻疹一样凶猛,或者变得温和。大流行开始之前,已知有六种冠状病毒可感染人类:2003年最初的SARS; 2009年爆发的SARS。 MERS,于2012年产生;还有四个会导致季节性疾病。最后四个,现被认为是地方性流行,约占我们每年冬天感染感冒的25%,它们表明某些冠状病毒可以成为我们不喜欢的东西,但不必担心。 (尽管它们并不总是那么温和。其中之一最近与1889年和1890年的呼吸道疾病和神经系统疾病世界范围内流行有关;历史上被称为“俄罗斯流感”,但这个名字是一个猜测。原因于,直到40年后才发现流感病毒。)

埃默里大学的博士后珍妮·拉文(Jennie Lavine)最近撰写了一篇模拟新型冠状病毒潜潜力的论文,试图根据四种流行的冠状病毒以及SARS和MERS收集的数据,预测Covid-19未来的行为。研究发现,Covid-19可能会达到目前占据这四种地方性流行病的状态,并定期导致大多数轻度疾病-但结局将取决于儿童初次感染时的循环疾病表现,因为这是首例感染使免疫系统迅速响应。

当然,这与疫苗执行的功能相同。我们的身体对病原体产生多种免疫力。 Lavine说,现还为时过早,无法收集我们需要的长期数据,以了解Covid-19疫苗接种和儿童期感染是否都能以任何后续感染仅产生轻度疾病的方式提供保护。

但是,现就假定该病毒不会像感冒那样变成轻度感染,而是仍然是一种无法预测的危险。这种前景使得迫切需要消除疫苗的民族主义,并尽快全球范围内分发疫苗,这不仅是为了保护人们免受疾病侵袭,而且是为了剥夺病毒可以其中变异的宿主。

尽管一些数据开始表明某些配方可能有效,但新疫苗是否能防止感染并阻止病毒传播给其他人仍是一个悬而未决的问题。射击是基于防止严重疾病,住院和死亡的授权。如果我们成功地预防了这些最坏的影响,我们有可能将Covid-19转化为流感或其他季节性呼吸道感染,例如呼吸道合胞病毒(称为RSV)或腺病毒,这一年中的特定时间段会带来风险,但是,大多数情况下,不会阻塞医院或关闭ICU。

约翰霍普金斯大学健康安全中心的医师,资深学者Amesh Adalja说:“如果消除死亡的风险,当有足够的人接受疫苗接种时,Covid就会成为您计划的目标。” “医院将适应这种风险。我们可以建立减少伤害的框架,以帮助人们更安全地开展活动。一旦我们能够照顾好严重的疾病,我认为我们将像我们现所希望的那样接近正常。”

预计我们将能够以预防流感的方式思考Covid-19(知道我们预期的疾病严重程度以及何时发生)可能能够帮助我们规划其持久性。这可能会使带有鼻烟盒的人正常佩戴口罩,就像Covid-19开始之前亚洲国家中一样。我们重返办公室的程度上,这可能会使人们更加重视病假。尽管如此,它甚至可以帮助我们想象一下,要建立一个能够与流行的Covid长期共存的社会,我们必须建立什么样的结构和程序。

我们被迫每年更换流感疫苗,因为该病毒会不断改变其抗原特性:当它进入由流感疫苗产生的免疫力,再加上人们从过去的感染中获得的任何免疫力时,它就会演变成超越这种保护措施。但是,我们知道流感正发生变化,因为全球范围内建立并由世卫组织监督的共享的国际参考实验室网络不断监控病毒样本以检测正出现的情况。而且,由于世界卫生组织,疾病预防控制中心和其他国家卫生机构之间的合作,我们知道如何应对这种疫苗,每年都要就如何更新疫苗成分达成协议。


英文译文:

For all the chaos of vaccine distribution and appointment-making, Covid-19 vaccination in the United States is going better than it initially seemed. As of Friday, the Centers for Disease Control and Prevention’s vaccine tracker showed almost 58 million doses had been given out. Last Tuesday, President Joe Biden announced that his administration may arrive early at its goal of giving 100 million shots in 100 days.

And yet: At any moment, the US will pass the terrible milestone of 500,000 coronavirus deaths. Last month, one in five Americans surveyed said they were opposed to taking the vaccine (13 percent said they’d never take it; 7 percent only would if required). And globally, the vaccine rollout is going much more slowly. In December, The Economist’s Intelligence Unit predicted that many low-income countries won't receive their vaccines before next year, and last month, the World Health Organization’s director-general, Tedros Adhanom Ghebreyesus, warned the world is “on the brink of a catastrophic moral failure” for not sharing vaccines equitably with the Global South.

Summing up: This won’t be over soon. Between the slow pace of global vaccination and the rapid emergence of virus variants—potentially driven by the selective pressure that patchy vaccine coverage is putting on the virus—researchers and policymakers are beginning to admit that Covid-19 is here for good.

This requires a psychological reset. In the first year of the pandemic, we acted as though Covid was an unexpected guest, something that arrived without warning and could be packed up and sent away if we worked hard enough. It would be more realistic now to admit that the virus is an unwelcome permanent roommate. We are unlikely to force it to leave. But we may be able to keep it from taking over the house.

Accepting this possibility means that we have to start considering two lines of action at once. First, we need to do everything possible to reduce the number of illnesses and deaths occurring in this current emergency. Second, we need to admit those actions won’t be enough to chase Covid-19 from the world forever—what public health people would call eradication—and consider what it will mean for it to be a permanently present, or endemic, disease.

SARS-CoV-2 “just doesn't have the characteristics that we look for when we're talking about a virus that is able to be eradicated from the human population,” says Tara C. Smith, an epidemiologist and professor at the Kent State University College of Public Health. “Between the potential for animal reservoirs and the fact that it is asymptomatic so frequently, I think it’s going to be very difficult.”

Eradication is a lofty goal, so hard to achieve in public health that it has been managed for only one human disease: smallpox. (Rinderpest, a disease of cattle, has also been eradicated.) The generally accepted definition of eradication is that the transmission of a disease is brought to zero—by isolation, treatment, or a vaccine—leaving the pathogen no place to hide and effectively ending its life. Eradication campaigns for diseases beyond those two have faltered because vaccinations can’t penetrate the places the organisms shelter in the world: for yellow fever, in monkeys; for malaria, in mosquitoes; for tetanus, in soil. (Polio, the target of a 32-year international campaign, can hide quiescently in the guts of asymptomatic people. It got very close to eradication, but when the pandemic halted vaccination efforts, cases rebounded again.)

The Covid-19 virus has similar shelters: in the bats it originally jumped from, in some probable intermediate (and still unidentified) animal that helped it adapt from bats to humans, in the minks that have been identified as harboring it in several countries—and in whatever percentage of the human population remains unprotected by natural immunity or vaccine.

So there is no way to cast a net around Covid-19 and tighten it to nothing; its animal hosts will always provide it an escape hatch. However, it’s not actually useful to start thinking about alternate hosts until all of a disease’s potential human victims have been protected by vaccination—and so far, we are not remotely close. As long as people somewhere in the world are still waiting for their first shots, Covid-19 will have human hosts to reproduce in. And also, potentially, to mutate in, creating the kind of variants that are now appearing across the globe.

That raises the possibility that, as the virus changes, we’ll need to keep tinkering with vaccines to keep up with it. “I think most people feel that this will be something where likely for the next several years we’ll be getting a Covid-19 shot,” Alex Gorsky, the CEO of Johnson & Johnson, said earlier this month at a CNBC event. “Exactly what that shot is going to be comprised of, I don’t think we know today.”

If Covid cannot be a disease we try to squelch quickly—the way, for instance, we roll out vaccines to counter Ebola outbreaks—it has to become a disease we plan for, such as measles and influenza. With measles, we begin vaccinating in childhood. With the flu, we revaccinate annually, while tuning the vaccine’s contents to keep up with viral evolution. We vaccinate against those because they take such a toll. In the past 10 years, influenza has killed anywhere from 12,000 to 61,000 people per year in the US; globally, measles kills 140,000 each year.

We have no guarantee whether Covid-19, if it becomes endemic, will be as ferocious as measles, or mellow into something mild. Before the pandemic began, there were six coronaviruses known to infect humans: the original SARS from 2003; MERS, which arose in 2012; and four that cause seasonal illnesses. Those last four, which are now considered endemic, are responsible for about 25 percent of the colds we contract every winter, and they demonstrate that some coronaviruses can become something that we dislike, but don’t need to fear. (They have not always been mild, though. One of them has recently been linked to a worldwide epidemic in 1889 and 1890 of respiratory illness and neurological problems; it came down in history as the “Russian flu”—but that name was a guess at its cause, since flu viruses weren’t identified til 40 years later.)

A recent paper modeling the potential future of the novel coronavirus, written by postdoc Jennie Lavine of Emory University, attempts to forecast the ways that Covid-19 might behave in the future, based on data gathered from the four endemic coronaviruses, plus SARS and MERS. It finds that Covid-19 could reach the state that the four endemic strains now occupy, of causing mostly mild disease on a regular basis—but that outcome will depend on how the circulating disease behaves in children during their first infections, since it’s those first infections that set the immune system up to respond down the road.

That is the same function that vaccines perform, of course. Our bodies create multiple types of immunity in response to pathogens; it’s too soon, Lavine says, to gather the long-term data we’ll need in order to know whether Covid-19 vaccination and childhood infection both protect in such a way that any subsequent infections produce only mild disease.

But assume, for the moment, that the virus doesn’t become a mild infection like a cold, but remains an unpredictably dangerous one. That prospect makes it more urgent to defuse vaccine nationalism and to distribute doses worldwide as fast as possible, not just to protect people from illness, but to deprive the virus of hosts in which it can mutate.

Whether the new vaccines protect against infection and block the ability to transmit the virus to others is still an open question, though some data is beginning to show that some formulas might. The shots were authorized on the basis that they prevent serious disease, hospitalization, and death. If we successfully prevent those worst effects, we potentially transform Covid-19 into something more like influenza or other seasonal respiratory infections such as respiratory syncytial virus (known as RSV) or adenovirus—something that poses a risk at particular times of year, but, most of the time, doesn’t clog hospitals or close down ICUs.

“If you take away the risk of death, when you get enough people vaccinated, then Covid can become something that you plan for,” says Amesh Adalja, a physician and senior scholar at the Johns Hopkins Center for Health Security. “Hospitals will be attuned to the risk. We can develop a harm reduction framework to help people go about their activities in a safer manner. Once we can get severe disease taken care of, I think we will be as close to normalcy as we can hope for now.”

Projecting that we’ll be able to think about Covid-19 the way we do the flu—knowing what severity of illness we expect, and when—might be able to help us plan for its persistence. It might make mask-wearing normal for people with a case of the sniffles, the way it was in Asian nations before Covid-19 began. To the degree we return to offices, it might make people take sick days more seriously. Even more, though, it might help us imagine what structures and procedures we’ll have to create to get to a society in which we can live alongside endemic Covid long-term.

We are forced to change the flu vaccine every year because the virus continually alters its antigenic profile: As it runs into the immunity created by the flu shot, plus any immunity the population possesses from past infections, it evolves to get past that protection. But we know how flu is changing because a shared international network of reference laboratories, set up around the globe and overseen by the WHO, continuously monitors virus samples to detect what is emerging. And we know how to alter the vaccine in response because of collaborations between the WHO, CDC, and other national health agencies, which each year come to agreements on how the vaccine composition should be updated.


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