The Body Scientific

By Richard Kessin

In an extraordinary 20 months, science has tackled the SARS-CoV-2 virus (the novel coronavirus that can lead to Covid-19) and made vaccines for adults and children. Scientists have developed monoclonal antibodies that help if given early, and we now have the first drugs that could stop infections or tilt the immunological fight in favor of the patient. The number of Covid cases in the U.S. is going down, although in some areas like the Mountain West the disease is still raging. The virus is an opportunist— 750,000 people in the U.S. and millions around the world have died. 

People go without vaccines for various reasons, but some who refuse vaccines may not understand that “Fortune favors the prepared immune system,” to paraphrase Louis Pasteur’s saying, “Fortune favors the prepared mind.” A 50-microgram injection induces antibodies that neutralize the SARS-CoV-2 coronavirus or T cells that kill the human cells that contain multiplying virus. As the vaccines’ protection wanes over six months, some elderly people in their 80s or older have died of Covid infections. The late waning can be corrected by boosters, as evidence from Israel suggests. 

The grizzly experiment to test the SARS-CoV-2 vaccines has been done in Texas, Florida, Louisiana and other places where the level of vaccination is low. As the virus, or more recently the Delta variant, raced through the population, hospital wards filled with Covid patients. A year and a half after disaster hit New York hospitals, those in the West, South, Alaska and elsewhere are now converting space to treat Covid-19 patients. More than 90 percent of their patients in intensive care were not vaccinated. 

Predicting the end of the pandemic is a tricky business. We thought we had seen the end in June and July. Then, with the Delta variant, the trend reversed among unvaccinated people and cases went up. Could there be more variants? Yes, but so far the vaccines have worked against all variants. Antibodies and T cells react with all parts of a virus protein, not just the sections that have changed in the variants. 

What does medicine have to throw into this battle? Monoclonal antibodies work if applied early in the disease. These antibodies are produced in fermenters and must be infused intravenously, which makes them expensive and tricky to use. Fighting an epidemic, especially in poor areas of the world and the U.S., demands simplicity. 

There is a drug, molnupiravir, that if given early in an infection often controls it. It was developed at Emory University in Atlanta and has been licensed to Merck for production. Molnupiravir is a cleverly designed molecule that gets incorporated into new viruses and mutates them out of existence. It has been approved for use in the U.K. Whether it can block infection in people who have been exposed to the virus will be known soon. Merck has said that it will not enforce patent restrictions. 

Pfizer also has a promising drug that works by a different mechanism from that of molnupiravir. The difference is important because viruses often mutate to become resistant to one drug. In the case of HIV, for example, several drugs were required to stop infection. Pfizer’s drug is well along in phase 3 clinical trials and may soon receive an emergency use authorization.

Excited journalists are writing about these drugs as game changers, but that is premature; on a population basis, that remains to be seen, and a little caution is in order. Still, drugs like these have worked for the HIV, hepatitis C and dengue viruses. Producing and distributing these drugs for the whole world will take time. 

My prediction is that Covid-19 will recede in areas of high vaccination and then linger at low levels where vaccination is low. All treatments will have a role, but vaccination will play the primary one. In areas where vaccination rates are low, say 40 percent, there will be serious problems with high levels of infection and overwhelmed medical facilities for extended periods. That patient load affects a hospital’s ability to treat other diseases. The poor and medically underserved will get even less attention. Schools, industry and the economy will weaken. Society could become very cranky, even violent.

The vaccines and perhaps the drugs offer an off-ramp from this disaster. 

Richard Kessin is Emeritus Professor of Pathology and Cell Biology at the Columbia University Irving Medical Center.