COVID-19: Almost two years later, and now?

Almost two years have passed since the first detection of the new coronavirus. At a time when the vaccine is already a reality and some drugs to treat the infection have been approved, it is important to summarize what is known and understand what is next.

Since its detection in the Chinese city of Wuhan in December 2019, the new coronavirus has affected about 250 million people worldwide, causing more than 5 million deaths, according to data from the World Health Organization (WHO).  In terms of the distribution of the pandemic, the United States of America (USA) remains the most affected country in terms of both deaths and infections, with more than 780,000 deaths and more than 47 million cases. After the USA, the most affected countries are Brazil with over 610,000 deaths and over 183,000 active cases, followed by India with over 46,000 deaths and over 138,000 active cases.

Given the large number of diagnosed cases and the length of time Covid-19 has been studied worldwide, a fairly solid body of knowledge about this infection has already been achieved. Yet, despite the vaccines that are already being administered and the drugs that are approved or awaiting approval to treat the infection, there is still much to be discovered, particularly with regard to the long-term effects of the disease. At the same time, there is also a doubt that the world shares: how do we know the pandemic is over? Here we have gathered the latest information on these topics, to answer the doubts that are haunting most people at the moment.

Vaccines – a process like we have never seen before

Early in the pandemic, when isolation was imposed as a means of containing the spread of the coronavirus, the world placed high hopes on the development of a vaccine. The response from scientists, academics and the pharmaceutical industry was short-lived, and after about nine months, the first Covid-19 vaccines were known. Currently, according to WHO, a total of 24 vaccines are in use or under development. As for the European Unionare currently four vaccines against covid-19 authorized by the European Medicines Agency (EMA), namely: Comirnaty (BioNTech/Pfizer), Spikevax (Modern), Vaxzevria (AstraZeneca/Oxford) and Janssen Covid-19 Vaccine (Janssen/J&J).

One of the main doubts that arose, when vaccines began to be administered, was the speed of their development, but the answer to this question is very simple, as explained in a video aimed at enlightening the public on the subject, scientist Bruno Silva Santos, immunologist at the Institute of Molecular Immunology (IMM):”[A rapidez] is due, firstly, to the technological advances that have made it possible to adapt to this virus a technology previously developed, tested and validated in humans. Second, the commitment of the scientific community and pharmaceutical companies, who attacked this problem on multiple fronts and essentially with unlimited resources. And third, to the immediate and real-time evaluation of clinical trial results by regulatory agencies, maintaining their degree of exigency, but with an extraordinary degree of urgency, which allowed them to validate the efficacy of these vaccines, without ever compromising their safety.”

A hope that does not solve everything

Another issue that has worried many people around the world – and continues to worry, despite the increase in information on the subject – is related to the safety of Covid-19 vaccines. As Miguel Prudêncio, a parasitologist at IMM, also points out in a science broadcast video, “the vaccine is absolutely safe,” stressing that “the vaccines developed against Covid-19 have gone through, like any other vaccine, a rigorous process of safety and efficacy evaluation.” According to him, “the data collected throughout these trials have been carefully reviewed by the scientific community and by regulatory agencies, composed of independent experts”, adding that “only a vaccine that proves to be safe and effective is licensed”. In addition, the researcher emphasizes that “no serious side effects have been observed in the approximately one hundred thousand participants in the clinical trials of the approved vaccines and those in the process of approval”.

Despite the proven effectiveness of vaccines, several studies have shown that it may not be as long-lasting as one would like. For example, in August of this year, the journal Nature published a study that found that BioNTech/Pfizer and AstraZeneca/Oxford vaccines are effective against the highly transmissible delta variant, but their protection decreases over time.

Data from another study, this one published in October 2021 in the scientific journal The Lancetindicate that vaccination reduces the risk of infection with the delta variant; however, fully vaccinated infected individuals have a similar viral load to unvaccinated individuals and can transmit the infection, particularly in household settings and to fully vaccinated individuals. According to the researchers, their results “help explain why the delta variant was transmitted so efficiently in populations with high vaccine coverage.” Thus, while noting that existing vaccines are effective in preventing disease severity and covid-19 mortality, they conclude that “vaccination alone is not sufficient,” emphasizing the need for nonpharmacologic measures for individual protection of persons in at-risk groups.

Third dose

In the same study, funded by the National Institute of Health Research – The researchers emphasize the importance of vaccinating not only those in at-risk groups, but also recognize the need to increase herd immunity through booster programs and vaccination of adolescents to address the currently limited effectiveness of vaccination in transmission.

The booster program is already underway, with the process of administering the third dose to people over 65 years of age and nursing home residents beginning in October 2021, and 2.3 million people expected to be inoculated by the end of December. Similarly, immunocompromised patients and those over 16 years of age are already receiving a third dose, as recommended by the DGS.

Regarding vaccination of children, in several countries, the covid-19 vaccine is recommended from the age of 12 years, there is some expectation of inoculation below this age, but the WHO continues to refer only to vaccination from 12 years of age, recommending for this purpose the Pfizer/BioNTech vaccine .

Drugsfighting on another front

To fight the pandemic, in addition to non-pharmacological personal protection and vaccines, it is also necessary to develop effective treatments to combat the infection caused by SARS-CoV-2. Recently, and after the green light given by the EMA , the European Commission approved two monoclonal antibody treatments for Covid-19, Ronapreve (casirivimab/imdevimab) and Regkirona (regdanvimab) on November 12, 2021. Monoclonal antibodies are laboratory-produced proteins that bind to specific parts of the virus to help the immune system recognize them and fight the disease, mimicking the mechanisms the immune system uses to defend against SARS-CoV-2.

These are the first drugs against this disease to be approved in Europe since the approval of the antiviral Veklury (remdesivir), but whose efficacy remains questionable. It should be noted that the WHO does not recommend their use, but the FDA has approved their use in hospitalized patients.

Meanwhile, several other Covid-19 drugs are in development and testing. For example, MSD and Pfizer have announced encouraging results for their first Covid-19 treatments, molnupiravir and paxlovid, respectively. Both are antivirals that reduce the ability of the virus to replicate, thereby helping to slow the disease. Both pharmaceutical companies report a significant reduction in hospitalizations among treated patients (a reduction of half for molnupiravir, and nearly 90% with paxlovid), but it is not possible to make direct comparisons on the efficacy of the two, due to the different study protocols used.

How an old drug saved lives

But Covid-19 treatment is not just about innovative drugs. The one that has been used most successfully in hospitals around the world is dexamethasone.It is an affordable steroid that has been used for decades and has saved a million lives since it was realized last year that it could be used effectively to treat Covid-19. According to an NHS study, the drug has saved 22,000 lives in the United Kingdom and about a million lives worldwide, with dexamethasone reducing the risk of death by about one-third in Covid-19 patients who need to be placed on a ventilator and by about one-fifth in patients who need oxygen.

More recently, a new study confirmed the effectiveness of this drug in treating hospitalized patients with Covid-19: in a sample of more than 2,000 people in the United Kingdom, it was shown to reduce the risk of ICU admission and death (including in patients with diabetes) by 56%. It should be noted that this drug was already available on the market in generic form, used for years in the treatment of autoimmune diseases, severe forms of allergies, motion sickness, eye inflammation and also as an anti-inflammatory. It is recalled that the EMA authorization for the use of dexamethasone in the treatment of covid-19 dates from September 2020.

Other older drugs are also being tested to treat the infection caused by the new coronavirus, such as the antidepressant fluvoxamine (also sold as a generic), which has shown encouraging results in preventing severe forms of covid-19, according to a study published in October 2021 in The Lancet .

When the The Covid persists

They call it Covid long, and the WHO even created a definition to help physicians diagnose it: Covid long is a condition that presupposes the existence of at least one symptom of Covid-19, which usually begins to manifest three months after the onset of infection, persists for at least two months, and cannot be explained by another diagnosis.

The most common persistent symptoms are fatigue, dyspnea (shortness of breath), and cognitive dysfunction. Regarding the latter, it should be noted that it is commonly called brain fog and that the set of neurological symptoms attributed to the sequelae of the infection is already called neurocovid or neurological Covid, so much it has impact among the complaints reported by patients suffering from this manifestation of the disease.

Other symptoms of Covid longa, numbering about 200, include chest, throat and/or head pain, anosmia (loss of smell) and/or dysgeusia (loss of taste), muscle weakness, heart palpitations or even alopecia (hair loss). Most often, these symptoms last about three months, but there are reports of longer durations, and symptomatology can develop early in the infection or after recovery from an acute episode of covid-19.

According to a study by researchers at Penn State College of Medicine, USA, it is estimated that more than half of the people infected with covid-19 will develop a long. Another survey, this time conducted at Oxford University and involving more than 270,000 people who had covid-19, detected at least one symptom about three to six months after infection in 37% of participants, with symptoms being more common in patients who required hospitalization . In addition, according to research conducted by Harvard University, people of different ages can have long-lasting symptoms of covid-19, but it appears that the condition more often affects people under the age of 65. The researchers therefore emphasize the importance of vaccination in reducing the risk of covid-19 sequelae in young adults.

What’s next?

It is not known how or when the pandemic will cease to exist, or if covid-19 will be considered another infectious disease that we will have to learn to deal with on a daily basis.

But it is known that to reach that point, it is essential that the entire world progress at a similar pace. This has been the message from various officials, and WHO Director General Tedros Ghebreyesus emphasized it again recently while participating in a roundtable discussion at the Paris Peace Forum, stating that “Africa, in particular, is the continent most affected by the uneven distribution” of covid-19 vaccines, with only 5% of its population covered. The contrast with the rate of vaccination in developed countries is great, given that G20 countries, for example, have administered more than 80% of the covid-19 vaccines made available worldwide. For the official, this inequality is “condemnable”, not only from a moral point of view, but also considering the consequences that this has in terms of health and economy. Tedros Ghebreyesus explained that if the current trend continues, about 80 countries in the world will not reach 40% coverage by the end of 2021, making it difficult to prevent future epidemics. Indeed, after several months in which the pandemic appeared to be waning, there is an increase in the number of daily cases and deaths. Thus, the head of the WHO stressed that “no country will be able to stop this pandemic on its own”.

In addition to vaccines, another dimension to consider in order to talk about the end of the pandemic is the virus, its ability to evolve, transform and become stronger. Arnold Monto, a professor of epidemiology at the University of Michigan and a member of the committee that evaluates vaccines at the FDA, tells CNN that there is a “parade of variants,” with transmission patterns changing as new variants appear. “We are now seeing much more widespread transmission and much more uniform spread around the world. This makes it more difficult to declare the end of the pandemic.” said the expert.

Other factors to be considered include the gradual decrease in natural or vaccine-induced immunity, as well as the approach of winter, as pointed out in an opinion piece published in the Diário de Notícias, Filipe Froes, pulmonologist and coordinator of the crisis office of the Covid-19 Physicians Association, and lawyer Patrícia Akester. According to them, “the decrease in sun exposure, cold, rain and the circulation of other respiratory viruses, namely respiratory syncytial virus and influenza virus, are allies of SARS-CoV-2 and its survival, transmissibility and severity“. In addition, there is also the need to consider, as they state, the greater pressure that will be placed on the National Health Service that will be felt not only from the covid-19 cases, but also from the long covid and “non-covid patients that have accumulated throughout the pandemic and the usual assistance activity in this period.”

Back to telecommuting?

However, the increase in the number of diagnosed cases may again lead to more restrictive measures.
Among us, the possibility of a return to telecommuting is admitted, knowing that since the end of September, the country has moved closer and closer to the so-called red zone of the risk matrix presented by the government in March.
In Germany, for example, this is a solution that is already being prepared at the time of writing. In the Netherlands, the option could be partial containment, with bars, restaurants and non-essential stores closed at 7 p.m. for three weeks and a strong incentive to telework.
In Austria, the option is to impose confinement on unvaccinated people. Austria has one of the lowest vaccination rates in Western Europe, about 65%.

So the future is unknown, but we all have one certainty that cannot be ignored: we now know much more about the virus and the disease than was known when the pandemic was declared, and the world’s attention is still focused on finding ways to stop it, or at least to move forward.