COVID-19: Grading the Year in Review

We have crossed the one-year mark from when the US had its first case of coronavirus 2019 (COVID-19). In my first column addressing the pandemic, I wrote that we needed to take notes on how we do as it progresses. Now seems like an opportunity to time-stamp those notes and grade our response.

Messaging: Poor messages abounded at the beginning of the pandemic. Statements came from officials about the relative lack of importance of COVID-19 compared to influenza. The understandable need to preserve masks for healthcare professionals led to confusing messages against masks for the public, before changing to recommending cloth masks. The willingness to correct this misstep when science dictated is commendable, but some damage already had been done and that became weaponized by politicians. The use of COVID-19 as a political issue has now had effects that will be felt for years. Grade: F

Testing: The US started behind in testing for SARS-CoV-2 with self-inflicted wounds when a CDC-developed test was found to be error-prone. The initial issues with viral assay delays may have influenced FDA to swing in the other direction when it came to serology, as an “EUA Wild West” for antibody assays developed with predictable issues occurring. Testing capacity expanded over the course of the pandemic but in some places has still not attained the kind of widespread, easy access, rapid turnaround that is necessary for containment. Cheap, rapid antigen assays that could be used in schools and other in-person group settings have not been prioritized, and a national testing strategy is only starting to materialize. Grade: F

Therapeutics: Examinations of the repurposing of older drugs were worthy efforts when conducted rigorously. Despite the negative verdict on hydroxychloroquine, it was worth investigating, and I feel the same for studies of ivermectin, colchicine, fluvoxamine, lopinavir/ritonavir, and others. The early positive results with remdesivir were tempered after SOLIDARITY results were published, though shorter durations of illness are still important outcomes. RECOVERY identified dexamethasone as our first life-saving therapy for COVID-19 patients. IL-6 inhibitors and convalescent plasma have been studied with equivocal overall results, though they may have roles in the right patients.

Most recently, monoclonal antibody therapies have shown promise. Phase 2 studies of bamlanivimab and casirivimab with imdevimab both showed decreased medically-attended visits compared to placebo, and post-hoc analyses of high-risk patients suggested a greater effect. Recent press releases on the bamlanivimab and etesevimab combination look impressive if they bear out in peer review; an EUA for this combination is likely. The fact that these therapies were derived from patients who recovered from COVID-19 to being synthesized and given to patients with COVID-19 in under a year is impressive.

No miraculous breakthroughs have yet been found, but both finding useful therapeutics and vetting failed therapies warrants merit. An effective, oral medication to prevent progression of mild-moderate cases in outpatients is still badly needed. Grade: B-

Vaccines: First and foremost, the availability of multiple vaccines in about a year from the discovery of a new pathogen is a truly amazing feat. No matter what else becomes of COVID-19, this point needs emphasis. We are very fortunate that these vaccine platforms had already been developed prior to the emergence of SARS-CoV-2 and that the sequence of the virus was shared early. The acceleration of vaccine development has also been an enormous success and, after initially harboring concerns about political interference, I feel FDA’s review process has remained sound and trustworthy. Operation Warp Speed sought to increase dose availability through guaranteed purchases, and it is unclear to me how successful this was.

Vaccination plans have been disappointing. Some organizations and governments have had detailed plans created well in advance of vaccine availability, while others seem to have wasted that planning time. Vaccinators are still being recruited and have not yet been maximized, though recent signals from the new administration are promising. Grade: B

Finally, thank you for all that you have done over the past year. The efforts of healthcare practitioners in the face of personal danger, limited support, shortages, and exhausting schedules have been remarkable. Grade: A+