Intended for healthcare professionals


Covid-19: Former advisers urge Biden to adopt new pandemic strategy and learn to live with virus

BMJ 2022; 376 doi: (Published 10 January 2022) Cite this as: BMJ 2022;376:o56
  1. Janice Hopkins Tanne
  1. New York, USA

Six of President Joe Biden’s former covid-19 advisers have urged the president to take a different approach to the US’s covid strategy and learn to live with the virus. They published three opinion papers online in JAMA on 6 January 2022 and suggested ways to achieve “a new normal” that would mean major changes to the US public health structure.123

In one paper, Ezekiel Emanuel, a health policy expert at the University of Pennsylvania, who coordinated the proposals, argued that the “new normal” with covid-19 does not include eradication or elimination.1 “Neither covid-19 vaccination nor infection appear to confer lifelong immunity,” he wrote. “Covid-19 infections are asymptomatic or mildly symptomatic, and the SARS-CoV-2 incubation period is short, preventing the use of targeted strategies like ‘ring vaccination.’ Even fully vaccinated individuals are at risk for breakthrough SARS-CoV-2 infection. Consequently, a ‘new normal with covid’ in January 2022 is not living without covid-19.”

Instead, Emanuel called for all respiratory viral illnesses to be considered together, noting that people have lived “normally” with influenza, respiratory syncytial virus (RSV), and other viruses.

In future, he proposes a risk threshold that reflects peak weekly hospital admissions and deaths based on 2017-2018, a high severity rate for influenza, and annual cases of RSV. “This would translate into a risk threshold of approximately 35 000 hospital admissions and 3000 deaths (<1 death per 100 000 population) in the worst week,” he wrote. If this threshold were crossed, mitigation and other measures would be put into effect. The threshold could also be used for healthcare planning.

Emanuel called for three changes to the US health system. First would be “a modern data infrastructure that includes real time electronic collection of comprehensive information on respiratory viral infections, hospital admissions, deaths, disease specific outcomes, and immunisations merged with sociodemographic and other relevant variables.”

Second would be setting up “a permanent public health implementation workforce that has the flexibility and surge capacity to manage persistent problems while simultaneously responding to emergencies.” It would include a community health worker system and an expanded school nurse system.

Third would be allowing healthcare workers to practise across state lines to help severely affected areas. At present US medical workers are licensed by individual states.

The cost of these changes would be substantial, but so would be the benefits, Emanuel argued, noting that the US has had more 800 000 deaths from covid-19 and a projected loss of $8 trillion in gross domestic product through to 2030.

In a second paper2 on testing, surveillance, and mitigation, the authors said the US government’s response to covid-19 was “seriously flawed.” The US “needs a comprehensive testing and reporting system for all viral respiratory illnesses” that links medical and testing facilities, emergency departments, hospital admissions, intensive care admission, and deaths with information reported to the Centers for Disease Control and Prevention (CDC) and connected to anonymised sociodemographic, vaccination, and clinical outcomes, it said.

The paper also called for testing to be available free or at low cost to everyone in the US. When the CDC learns of a positive test result, “the system should automatically provide clear guidance on self-isolation and treatment options.”

The emergence of the omicron variant has shown the need for “a comprehensive, nationwide environmental surveillance system that includes wastewater and air sampling to monitor for potential outbreaks of viral and bacterial illnesses.” They call for a comprehensive genomic surveillance system to detect new variants, noting that the US is still heavily reliant on data from Israel and the UK for assessing the effectiveness and durability of covid-19 vaccines and rate of vaccine breakthrough infections.

To reduce aerosol transmission of respiratory diseases including covid-19, all US workers need access to testing and paid medical leave if infected—including those on low wages and temporary and freelance workers. Better quality masks should be made available to all, free or at low cost, it added.

Clear communication from trusted public health officials to local governments and the public is needed to “help reduce confusion and guesswork.”

The third paper3 covers the role of vaccines and therapeutics in achieving the “new normal.” It noted that nine out of 10 countries in the Organization for Economic Cooperation and Development have full vaccination rates above 75% and have reached a target of less than one covid-19 death per 100 000. Only about 60% of the US population has been vaccinated. Vaccine efficacy seems to decline over time and regular, perhaps annual, vaccinations will be needed.

The authors argue that in the US, achieving 90% vaccine coverage will require mandates, and suggest vaccination may be required for public transportation and attendance at indoor events.

“The government should accelerate efforts to develop a universal coronavirus vaccine to protect against known coronaviruses, including SARS-CoV-2,” they added. “A more broadly protective vaccine would allow the world to limit the effects of emerging viruses and nimbly react to novel coronaviruses.” They added, “There needs to be an electronic vaccine certification platform. Relying on forgeable paper cards is unacceptable in the 21st century.” Admitting that this would be controversial, they point to other state and national databases for driver’s licenses, voter registration, and organ donation.

They also urge the government to speed up the development of oral antiviral treatments that are easy to manufacture and administer. Outpatient treatments should be made available completely free and offered proactively to anyone who tests positive. “The short window for administration of drugs requires a much closer linkage between covid-19 testing and treatment,” the authors wrote.

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