Herd Immunity Won't Save Us-But We Can Still Beat Covid-19: Share Your Thoughts
Herd Immunity Won't Save Us-But We Can Still Beat Covid-19: Share Your Thoughts
The idea of “herd immunity” against Covid-19 has achieved almost magical
status in the popular imagination. Once we reach that threshold, many
Americans believe, we’ll be in the clear, and the pandemic will finally fade
into history.
But we are unlikely ever to reach herd immunity with Covid-19—it’s not how
this nightmare will end. Although case counts are now declining from their
winter peak, we fear another spike from potential super-spreader events
following spring break, Easter weekend, Memorial Day and the Fourth of
July, or even again after the end-of-year holidays. The time to double down
on our efforts to stamp out transmission is now. We must develop what
amounts to a national immune system to quickly detect and repel the new
outbreaks ahead, not just for this pandemic but for future ones as well.
About 43% of the U.S. population has at least some immunity against
Covid-19—very far from the 80% needed for herd immunity.
As of this writing, 130 million doses of vaccine have been given in the U.S.,
leaving 46.4 million Americans fully immunized and 33 million partially
immunized as they await a second dose. In addition, there have been
about 30 million reported cases of Covid. Epidemiologists at the CDC and
NIH estimate that perhaps an equal number of cases, some 30 million,
have gone unreported.
Leaving aside the question of how much these two populations overlap and
the extent and durability of protection provided by previous infection, this
amounts to about 140 million Americans, in a population of 330 million, with
at least some immunity. That is just under 43% of the population—very far
from the 80% needed for herd immunity.
Worse, such math misses a crucial point: The virus is changing so rapidly
that immunity to the Covid strain of yesterday may not protect against
today’s or tomorrow’s strain. We now face the challenge of new variants
that may elude immunity created by natural infection and possibly by
vaccines as well.
More than 200 people have already been infected with a new variant
named “Cluster 5,” emerging from farmed minks in Denmark. Covid-19 has
also been reported in more than a dozen other species, including great
apes, tigers, lions and snow leopards in zoos, monkeys, cats, dogs, pigs
and some deer. There is no evidence yet of continual spillover from
established animal reservoirs of the virus. But epidemiologists fear a worst-
case scenario in which new variants continue to ping-pong among humans,
domestic animals and wildlife.
There is also the issue of vaccination rates. Many Americans cannot get
vaccinated for medical reasons. Others have been left out of vaccination
outreach or distrust the medical system. Children count as part of the
“herd” but are not yet being vaccinated. Each year there will also be new
births and in-migration of unvaccinated people. But the biggest challenge is
the 30% of Americans who, in the most recent Pew poll, say that they will
either definitely not or probably not get vaccinated.
If herd immunity is out of reach, does that mean we’re doomed? Not at all.
But we must immediately begin to supplement the impressive recent rollout
of vaccines with a comprehensive rapid-response system, modeled on the
“surveillance and containment” strategy that William Foege, former head of
the CDC, developed to fight smallpox in the early 1970s. Smallpox was
eradicated from the globe in 1980—the first disease to meet this fate.
Today, time is of the essence in finding new Covid-19 cases. The disease
travels at exponential speed, whether it is traveling between states,
imported from other countries or spreading as new variants from animal
populations. “Speed to detect” is one of the most important metrics in public
health. Finding the first cases within days, when an outbreak still amounts
to just a handful of cases, is essential. When an outbreak goes undetected
for weeks, it can generate hundreds or tens of thousands of cases, and
contact tracing and containment become much more difficult.
Nor is just finding new generic Covid-19 cases enough. We need to know
what variant of the virus is involved. Enhanced testing will be critical and
should include faster and cheaper molecular and antigen tests, serology to
detect immunity created by both infection and vaccination, and viral
sequencing to inform vaccine and drug design. We will need to match new
variants of Covid-19 with the vaccines most effective against them.
The global program in the 1970s took place in a different era, against a
different virus, and used a very different vaccine. In some places it built
upon and supplemented mass vaccination. In others, eradication was
accomplished with less than a quarter of the population vaccinated. The
program that brought Ebola under control by 2016, after a two-year
outbreak, adopted some of these strategies as well. For both diseases, the
paramount goal was finding and isolating cases early and giving just-in-
time vaccinations to those most likely to get the disease next. The
approach recalls what hockey legend Wayne Gretzky once said: “I skate to
where the puck is going, not to where it has been.”
Until recently, the lack of faster immunizing vaccines was a stumbling block
to adopting just-in-time vaccination for Covid-19. But recent news suggests
that the vaccines now authorized for use might work. Despite the rapid
onset of viral infection (an average of 6 days after exposure, with a range of
2-14 days), Johnson & Johnson has reported success in preventing
moderate to severe disease as early as 7 days after the administration of
its single-dose vaccine. In a real-world study in Israel, the Pfizer vaccine
also prevented severe disease soon after a single dose.
It is not too late to find, isolate and vaccinate those who do not yet have
Covid-19 but are most likely to get it. It is not too late to use just-in-time
vaccination to stop outbreaks in midcourse and prevent the spread of
infection.
How do we find exposed people “just in time” to vaccinate them? The same
way that we find people just in time to isolate them. We build exposure
notification and tracing systems that find contacts and contacts of contacts
most at risk of getting the disease.
Moviegoers in Singapore check in on a contact tracing app, October 2020.
PHOTO: SINGAPORE PRESS/ASSOCIATED PRESS
Contact tracing has been difficult in the U.S. in part because most
Americans no longer pick up the phone from unknown callers. Adding more
sensitive, community-based tracers helps, as do new “low friction” tools to
supplement manual tracing. One intriguing possibility is to piggyback just-
in-time vaccination onto digital exposure notification systems that tell
people when they (really, their phones) have been in close proximity to
someone who is infected, offering them testing, support for isolation and
vaccination appointments at the same time they are notified. Data from
Ireland and the UK suggest that such digital systems find more contacts
and find them sooner than other methods.
How to achieve these ambitious goals? The $1.9 trillion stimulus bill
recently signed into law by President Biden provides vital resources for the
effort, including $47.8 billion for testing, hiring contact tracers and creating
safer settings for isolation. There is also $1.75 billion for surveillance,
genomic sequencing, and “effective response” based on this data, and
another $7.5 billion for vaccination, which could eventually include just-in-
time vaccination targeted at new variants. Though a clear strategy doesn’t
yet exist for creating a national immune system, many of the key elements
are at least now partly in place.
But more needs to be done. The states should work together to establish a
national outbreak alert and response network, connecting data scientists,
public health experts and technologists, and each state needs to establish
a core group of first responders to complement the CDC’s state
epidemiologists—trained local specialists ready to deploy to current and
future outbreaks.
Americans should not expect some kind of “all clear” signal on Covid-19 in
the months ahead. But if we have substantial numbers of vaccinated
Americans, robust rapid detection and successful outbreak containment,
we can accelerate the journey to “normal-ish.”
Every year, up to five novel viral pathogens like Zika, swine flu or West Nile
“spill over” from animals to humans. We have been unlucky with Covid-19,
but perhaps it will focus our attention on how lucky we have been that the
genomic roulette wheel has not given us more lethal bird flus or other
coronavirus pandemics. A robust national immune system will help us to
control Covid-19 and leave us better prepared for the pandemics yet to
come.
—Dr. Brilliant is the founder and CEO of the firm Pandefense Advisory and
was a WHO medical officer from 1973-81 working on the eradication of
smallpox. Dr. Lipkin is the director of the Center for Infection and Immunity
at Columbia University. Dr. Danzig is the former chief medical officer at
PaxVax. Ms Oppenheimer is principal at Pandefense Advisory. The authors
would like to thank Dr. William Foege (former director of the CDC), Dr.
Baruch Fischhoff (Carnegie Mellon University) and Dr. Ira Longini
(University of Florida) for their help with this essay.