Position Statement No. 12: The new normal – There will be no quick return to the pre-pandemic world

The threat of the virus spiraling out of control is real. Fortunately, we already have vaccines and also a fair amount of knowledge at our disposal. However, the implementation of the vaccination program is lengthy and varies enormously on a global scale. All of this means that a complete return to the situation that existed before COVID-19 cannot be expected within the next few years. And so, instead of waiting for the pandemic to end, we must all seek ways to live with the virus. This should involve not cyclically imposing unpredictable restrictions that damage the economy, education and social life, but rather creating new social norms that curb the possibility of the infection spreading.

What is a pandemic?

According to the classical definition, a pandemic is understood to mean to a situation when, in at least several regions of the world, the transmission of a certain pathogen is much more intense than in previous seasons, and the disease affects a large part of the global population. The use of the word is intended to serve as a worldwide mobilization to combat the disease. The World Health Organization (WHO) decides to declare the outbreak of a pandemic, or the end thereof, based on the recommendation of an expert committee. In the case of the previous pandemic – involving the new influenza A(H1N1) (known as “swine flu|) – which lasted from 2009 to 2010, its end was declared when the total number of influenza cases dropped to pre-pandemic levels and outbreaks were no longer observed during the summer season. But although the end of the pandemic was declared, influenza A(H1N1) did not disappear, but rather took on the character of ordinary influenza. Likewise, in the case of COVID-19, we do not expect to completely eradicate the disease. Rather, the objective is to reduce its incidence so as to be able to return to functioning as normally as possible in various branches of social life, the economy and education, whilst not disrupting the operation of the healthcare system. Already now it is clear that an essential condition for this “return” is the success of the vaccination program against COVID-19, at the local, national, and global levels.

Variability of SARS-CoV-2 virus forms

One of the key aspects that will shape the course of the pandemic is the emergence of new virus variants. Mutations of the SARS-CoV-2 virus are nothing surprising or unprecedented. They could, for example, mean new forms of the virus that spread easier or show lesser or greater virulence. As a rule, pathogens evolve to become better adapted to their main host. If that host is humans, strains that spread more easily among humans will begin to dominate. Also, although there is no rule here, adaptation may also involve decreased virulence, that is, new variants may cause a lighter course of the disease.

In the case of SARS-CoV-2, variants have already emerged that can spread faster than the original variant. This has already been shown with a high degree of likelihood for the so-called British variant (B.1.1.7, VOC 202012/01 or 20I/501Y.V1) as well as the so-called South African variant (20H/501Y.V2 or B.1.351). In the case of the UK variant, data suggest that the disease may have an even more severe course than the previously dominant variant. The easier spreading of the virus, and possibly its greater virulence, is bad news. It means that with the same restrictions, there will be more disease, greater need for hospital care, and higher mortality. It also means that the threshold for collective immunity increases. Instead of the previously estimated 60%–70%, it is above 80% for the new variants. Only by immunizing such a percentage of the population can it be guaranteed that, even if the virus does appear in such a population, the outbreak will die out naturally. Achieving such a high percentage of immunization with currently available vaccines is extremely difficult.

The timing of vaccination

Past experience with coronaviruses indicates that immunity achieved naturally or through vaccination declines over time. We already know that antibody levels decline, but we do not yet know the extent to which memory cells protect us. We also know that some people contract the disease again a few months after the first illness. In the case of seasonal coronaviruses, re-infection is common. If post-vaccination immunity really only lasts one or two years, then vaccinations will have to be repeated. To interrupt the circulation of the virus, we should also all get vaccinated before those who were the first to get vaccinated start to lose immunity. The timing of the vaccination campaign is therefore important. It is also worth remembering that the greater the number of people vaccinated, the lower the risk of new variants of the virus emerging.

Data from clinical trials indicate reduced vaccine efficacy for the South African variant. This is consistent with laboratory experiments that suggest that strains showing increased resistance to current vaccines are selected for under antibody pressure. Circulation of the virus in a partially immunized population may therefore result in a more rapid dominance of strains resistant to available vaccines. Hence, monitoring of circulating strains and vaccine efficacy worldwide, as well as research on the mechanisms of emergence of new virus variants, are extremely important. Already, despite many uncertainties, vaccine manufacturers are investigating the possible need to develop new versions of vaccines and are preparing for their development. Should this prove necessary, we will quickly have new versions of vaccines available. In addition, there is much evidence that reinfections are milder than first infections. Perhaps, therefore, even partial immunity will protect us from a severe course of the disease in the future, even as new dangerous variants emerge. For the time being, however, the majority of the population is not immune, and the prospect of full implementation of the vaccination program is still quite remote. The British and South African variants have already appeared in Poland. The experience of other countries indicates that the British variant is rapidly displacing the previous variants, so within a few weeks it is also likely to become dominant in our country.

The challenges of vaccine production and the vaccination program on the global scale…

Manufacturing vaccines on the scale currently needed poses huge logistical problems in itself – in view of not just production line capacity, but the availability of materials necessary for a mass vaccination program, such as syringes, and stabilizing substances necessary for vaccine manufacturing. Sufficient production of dry ice necessary for transporting mRNA vaccines, for example, is also important. Moreover, the companies that have developed the vaccines do not have the capacity to meet worldwide demand. Therefore, appropriate partnerships and technology transfers to potential manufacturers in different parts of the world are needed. The WHO has already authorized vaccines produced under license by Astra Zeneca/Oxford in Korea and India. The company’s agreements with manufacturers in Brazil, Argentina and Thailand have been made public. Johnson&Johnson has signed an agreement with manufacturers in South Africa, and Novavax has signed a contract with manufacturers in India. The companies whose vaccines have already been approved for use by the WHO (Astra Zeneca/Oxford, BioNTech/Pfizer, Moderna, Gamaleya, Sinopharm/Beijing Institute) state they can manufacture 8 billion doses by 2021, enough to vaccinate about 4 billion people. This is effectively the number of adults who currently say they want to be vaccinated against COVID-19.

However, the financial and logistical feasibility of organizing global-scale vaccination is in question. Vaccine prices currently vary quite significantly depending on the manufacturer and how the vaccine is obtained, ranging from less than a dollar to over twenty dollars per dose. This span of prices stems from technological differences, manufacturing costs, intellectual property costs, and company policies. Most of the companies have benefited from public grants on condition that prices are held down, at least until the pandemic is declared over. It is estimated that manufacturers have received more than $10 billion in public funding for COVID-19 vaccine development mainly from governments in countries such as the US, China and Russia and from the CEPI (Coalition for Epidemic Preparedness Innovations), in which European Union countries also participated.

CEPI, WHO, Gavi and UNICEF have launched the COVAX initiative back in April 2020, aiming to develop a vaccine as soon as possible, but also to create a mechanism for allocating available vaccine doses between countries according to established criteria. According to the COVAX distribution model, the global vaccination program should proceed in phases. In the first phase, all countries would initially receive enough doses to vaccinate 20% of their population (mainly senior citizens, as a group particularly vulnerable to severe COVID-19). In this model, vaccine prices were also made dependent on national income. Thus, high-income countries would pay an average of $11 per dose, while middle- and low-income countries would pay between $1.5 and $2. However, this is dependent on subsidies from wealthy countries, and it is estimated that in order to deliver 2 billion doses by the end of the year, between $10 billion and $12 billion would need to be allocated by the end of 2021.

An additional threat to global vaccine distribution is posed by the fact that many wealthy countries and the European Union are breaking away from the COVAX initiative – holding their own negotiations and entering into separate agreements with manufacturers. Currently, the most developed countries, home to about 16% of the world’s population, have secured 70% of the five major manufacturers’ vaccine doses for their populations, which they say will be available in 2021. Most of the doses secured by COVAX for the remaining countries are doses of potential vaccines still currently in clinical trials, meaning they will be available in the latter half of 2021 at the soonest. Globally, the lack of resources to put in place the infrastructure necessary to carry out vaccination programs could also be a major problem, especially given the deepening pandemic crisis. The continued presence of the virus in low- and middle-income countries is not only a matter of a deepening crisis and existing inequalities, but also means augmented migratory pressures and a greater risk of seeing further variants of the virus emerge.

…and on the national scale

At the national level, the organization and delivery of vaccines should be tailored to the real needs of the population, including geographical distribution. A lack of optimization in this regard causes long queues to form at some vaccination points, while there are vacancies at others – as has also been the case in our country. Having to wait for a long time or to travel to a distant vaccination center leads some individuals to forego getting vaccinated. In turn, reluctance to get vaccinated elsewhere increases the risk that some doses will be wasted. Given the limited supply of vaccines, this is a particularly acute problem. The vaccination distribution system should take into account both the number of residents per vaccination site and their geographic concentration. In more densely populated urban centers with relatively easy and fast access, distribution points need not be densely located but should be capable of handling large numbers of patients.

The most important link in the whole vaccination system is, and will continue to be, the doctors and nurses. Their skills and time are at a premium and should be put to best use. Wherever possible, vaccination logistics should benefit from economies of scale – the size and number of vaccination points should be organized to minimize the burden of administrative and other duties on medical staff, while ensuring the smoothest possible servicing of vaccinated persons. A well-organized vaccination system is one that will be able to rapidly increase its distribution capacity as soon as the availability of vaccines increases. However, bottlenecks are already evident while the number of doses is still very low. Many vaccination centers receive vaccines with long delays. Eliminating these bottlenecks in the vaccination system should be a priority – otherwise the problems will pile up and we will face even greater difficulty in matching more and more doses with more and more people willing to be vaccinated.

Privileges for the vaccinated?

The group of people already vaccinated is growing by the day, and with it the expectation that certain restrictions will no longer apply to them. However, it is important to look at the bigger picture. Most of us do not yet have the opportunity to become vaccinated, and will not have such an opportunity for a few months, or even more than a year. Hence, establishing special privileges for those already vaccinated before the completion of the vaccination program would exacerbate social inequities and thus could generate resistance to the vaccination order being followed and undermine confidence in the entire program.

In addition, doubts remain regarding the durability of the post-vaccination response, as well as the efficacy of vaccination against newly emerging variants. We must not succumb to a false sense of security. At this point, the main purpose of vaccination is to protect the groups most vulnerable to a severe course of the disease, as well as to increase the job security of key personnel who cannot shift over to remote work and whose illnesses would disrupt the functioning of society. Therefore, medical personnel have been vaccinated at Phase 0, in order to be able to do their jobs in relative safety. However, the situation may change when the availability of the vaccine increases and the outbreak is under better control. In our country, this will probably occur in Phase III of the National Vaccine Program. In this situation, it will probably be possible to introduce certain facilitations for vaccinated persons or, conversely, a requirement to be vaccinated in certain situations. This could provide an element of reward and encourage more people to get vaccinated. Given that some are still hesitant to accept the vaccine, this could be an important condition for a successful vaccination program. It will then be important to clearly stipulate what benefits vaccinated individuals can safely receive.

When is the risk of infection acceptable

The longer the pandemic lasts, the longer the associated restrictions to combat it remain in force, the wearier we become of them and the more willing we are to push the boundary of accepting more and more risk of infection. However, this is only to some extent a personal choice. The risk must not only be acceptable to someone who assumes that, since he has not fallen ill so far, then his or her risk of becoming ill is low. Above all, the level of acceptable risk must be determined by the decision-makers responsible for the proper functioning of healthcare and the economy. With a high percentage of the population vaccinated and a low incidence of disease, it will be easier to prevent the further spread of the epidemic. Right now, when we do not know to what extent having previously contracted the disease or getting vaccinated protect against asymptomatic infections, it seems reasonable to keep in place rules that hamper transmission. For this reason, even vaccinated individuals should adhere to DDM principle (distance, disinfection, masks), especially when dealing with people in groups at risk.

Seeking innovations

The threat of the virus spiraling out of control is real. Fortunately, we already have vaccines and also a fair amount of knowledge at our disposal. However, the implementation of the vaccination program is lengthy and varies enormously on a global scale. All of this means that a complete return to the situation that existed before COVID-19 cannot be expected within the next few years. And so, instead of waiting for the pandemic to end, we must all seek ways to live with the virus. This should involve not cyclically imposing unpredictable restrictions that damage the economy, education and social life, but rather creating new social norms that curb the possibility of the infection spreading.

Given that the rules of social distancing will remain with us for the long term, we need to come up with forms of them that meet counter-epidemic requirements but at the same time allow us to function in a reasonably normal way. This is where there is room for innovative thinking on the part of the designers of, for example, means of public transport, public-use spaces, and ventilation systems. For a long time to come, we will have to practice isolation in the case of even mild symptoms of infection, and undergo testing or quarantine if it proves advisable. There also needs to be a change in approach on the part of those in government – from crisis management to systemic management of the new reality, with expanded services able to continuously monitor the epidemic and improved systems of information and public communication. This involves moving away from public health as the only priority, and increasingly factoring in social and economic priorities. Consequently, broader interdisciplinary advisory groups are needed.

The public became mobilized in the face of the threat last spring. Now, however, we are increasingly facing the need for a long-term perspective. Returning to the pre-pandemic “normality” in the wake of SARS-CoV-2 may take longer than expected, and the coming years may bring new threats posed by other infectious diseases. We should prepare for this new normal that we be living in for a long time to come.

About the team

The Interdisciplinary COVID-19 Advisory Team to the President of the Polish Academy of Sciences was set up on 30 June 2020. The team is chaired by Prof. Jerzy Duszyński, President of the PAS, with Prof. Krzysztof Pyrć (Jagiellonian University) as deputy chair and Dr. Anna Plater-Zyberk (Polish Academy of Sciences) as its secretary.

Other members of the team are:
Dr. Aneta Afelt (University of Warsaw)
Prof. Małgorzata Kossowska (Jagiellonian University)
Prof. Radosław Owczuk, MD (Medical University of Gdańsk)
Dr. Anna Ochab-Marcinek (PAS Institute of Physical Chemistry)
Dr. Wojciech Paczos (PAS Institute of Economics, Cardiff University)
Dr. Magdalena Rosińska, MD (National Institute for Public Health – National Hygiene Institute, Warsaw)
Prof. Andrzej Rychard (PAS Institute of Philosophy and Sociology)
Dr. Tomasz Smiatacz, MD (Medical University of Gdańsk)