GRANT: Vaccines will never eliminate COVID, so it's time to pivot our response

When COVID started, I was convinced that we wouldn’t have a vaccine.

This wasn’t simply pessimism, I based my opinion on our experience with other Coronaviruses. Specific attempts to create vaccines for SARS-CoV (the original) and MERS-CoV had been complicated by what’s known as “antibody dependent immune enhancement” — a fancy way of saying some people had worse disease after vaccination.

I had a good helping of humble pie when we developed not only 1, but 155 vaccine candidates, and 24 licenced vaccines in less than 2 years. Even more amazing, the available COVID vaccines, especially the mRNA versions, were developed and deployed in record time, and were more than 90% effective in reducing symptomatic disease. As we began to vaccinate through the spring of 2021, cases fell precipitously. We had won.

This is when we got greedy. The initial promise of a vaccine with sterilizing immunity (ability to stop infections and transmission), brought the prospect of disease elimination tantalizing close. Now, in the late fall of 2021, it is becoming obvious that while vaccines are still incredibly effective at stopping severe disease, they are less so at stoppingtransmission.

So where does that leave us?

The obvious, and generally accepted, conclusion is that current vaccine technologies will not stop viral circulation. This means that SARS-CoV-2 is destined to become the 5^th circulating coronavirus, with which everybody is eventually infected. Canada’s unspoken strategy has been that of COVID Zero, including strict border quarantines, widespread masking mandates, school closures and more. This is the same strategy that is being abandoned by Australia and New Zealand. The only option is to change to an endemic approach, which changes the emphasis on vaccination and prevention efforts.

This means that for people at risk of severe disease, vaccine is now more important. However, the incessant drive to an arbitrary percent of the population being vaccinated has ceased to make sense: It is not how many are vaccinated, but whom that matters.

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For example, vaccinating 100 people over the age of 65 is likely to prevent 3 hospitalizations, while vaccinating a 2000 member high school or university class is unlikely to avoid any. Time and effort need to go to identifying communities of high-risk unvaccinated people, understanding their reasons for hesitancy and working with them towards acceptance of vaccines.

The next pivotal change is to stop counting cases and concentrate instead on outcomes with personal and social impact. Testing everybody with a cold is expensive and ultimately futile if we all eventually end up infected. Hospitalizations and deaths become the only metric that matters.

Politicians need to abandon the quixotic quest for COVID zero, making many of the interventions intended to stop virus circulation irrelevant. Public mask-wearing, social distancing etc. were only going to defer, not eliminate, transmission.

Canada is in 10^th place in the world with almost 80% of the population vaccinated; The highest risk ages (above 60) are 90% or higher. Much like the UK, Norway and much of the rest of Europe, we need to return to normal.

Society also needs to shift how it sees the unvaccinated. The prevailing opinion, including among many of my colleagues, is that the unvaccinated pose a threat to others. Since the vaccinated are still likely to be infected and transmit disease, with similar viral loads as those who are unvaccinated, this is not entirely true.

We want high risk, non-immune, people to be vaccinated for their own protection and to reduce the impact on hospitals and health care systems. However, the unvaccinated are not a threat to patrons at a supermarket or ski hill. In fact, it is the unvaccinated who are at risk in crowded situations. This means, at the very least, that the use of vaccine passports beyond the very limited recommendations of public health read more as moral panic, or vigilante justice, than a public health intervention.

Finally, we need to think very carefully about how we approach vaccination in the very low risk parts of the population, particularly children. The FDA deliberations included significant concern about applying the same criteria to this very low-risk population as is applied to older groups. If we assume that everybody gets infected, and that young people almost never end up in hospital, the need to limit youth activities with mandates or exclusion becomes less defensible.

We need to stop penalizing the young for being young, even in those who are unvaccinated. Youth need to socialize, engage with their peers and develop their physical and mental abilities.

It would have been great if we could have had a vaccine that would allow us to eliminate COVID. But, even if we don’t, vaccines for COVID have been a miracle, saving millions of lives. Rather than resent our inability to produce the vaccine that we wanted, let’s celebrate the vaccine that we have, and use them to get life back to normal.

— Dr. Jennifer Grant is an infectious diseases physician and a Clinical Associate Professor at the University of British Columbia’s Faculty of Medicine.

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