![Passengers wear face masks on a Dublin Bus. ‘Although our healthcare system is struggling now, we are far from [a] doomsday scenario.’ Photograph: Dara Mac Dónaill](https://www.irishtimes.com/resizer/v2/OYCYG7VWZW4TBBJAILMPO6WB3A.jpg?auth=0f3dfe00c1ed59fa3d9d7851643bba79213facaec58a32d08ae891d7f3fd3924&smart=true&width=1024&height=576)
Despite all our efforts, we find ourselves with the Delta variant of Sars-CoV-2 swirling across the country and throughout the world. Should we despair? No. Instead let’s do a little thought experiment and imagine where we might be if we had the Delta variant but didn’t have effective vaccines or any understanding of preventative behaviour.
Infection rates would be so much higher than they are now, many more people would be dying and countless more would be sick – a high proportion of whom would require hospitalisation. This would mean that hospitals would be struggling to cope, not only with the floods of infected patients, but also the awareness that numerous people with non-Covid conditions may being too frightened to attend hospital for the care they need. Huge numbers of healthcare workers would likely be off work, sick, chronically exhausted and depleted; regular patient care would be impossible.
Although our healthcare system is struggling now, we are far from this doomsday scenario. It is hard to imagine that it was a real possibility in early 2020, when many immunologists anticipated that it could take one to two years to develop and deliver an effective vaccine against Covid-19. Instead, we have several vaccines approved and distributed to millions across the globe (albeit unevenly), and many more in the pipeline. New anti-viral drugs are being discovered and trialled. People are still becoming infected, but far fewer than if we had no vaccine; relatively few infected people require hospitalisation and fewer still die of the infection, especially in the developed world. In countries with high vaccination rates and access to the new therapies, such as Ireland, the virus is being brought to heel – it is becoming endemic.
The word “endemic” comes from the Greek “demos” (people), meaning “belonging to a particular people or country”. Covid-19 is a global issue so Sars-CoV-2 now belongs to the human race and it looks like it is only a matter of time until we each come to know it personally. It seems that the virus is being successfully domesticated in several jurisdictions, including our own, so we need to learn to live peacefully with it – and to make sure that it is tamed elsewhere, so aggressive variants do not emerge and thrive.
We need to know more about the variability of the human immune system and what controls it. Even in those who make a good response – how long does it last?
What will it be like living with this “tamed” coronavirus? It will probably be a bit like how we are living with the flu virus now. We will have to accept a certain infection rate, we will have to accept some deaths and some severe illness. We will have to accept loss of working days and extra pressure on our health services. There will be a need for regular vaccination to keep the infection, illness, hospitalisation and death rates more or less under control.
In order to maintain control, we need to know more about breakthrough infections. Why do some people become infected even if they are vaccinated? Is it because of the virus or their immune systems? We know already that there is enormous variation in how people respond to infection and to vaccination. Some people generate a wonderful comprehensive immune response, which is protective against infection and illness. Others don’t respond quite so well, and some don’t respond at all.
Why is this? What is it in our genes that determines how well our immune system reacts? We need to know more about the variability of the human immune system and what controls it. Even in those who make a good response (most of us, luckily) – how long does it last? Does anti-Sars-CoV-2 immunity wane with time? Does it wane quicker in some people than others? Even if antibody levels wane, do we have strong memory cells capable of producing antibodies quickly? Are older people as well protected as younger people? What about people with co-morbidities?
We need to be better prepared for the next pandemic. For there will inevitably be more pandemics, almost definitely within decades, not centuries
It seems inevitable that most of us will need booster vaccines. If so, who precisely? When should they be given? How often? Is one vaccine better as a booster than another? Will boosters perform similarly in all populations? It is clear that the virus will be able to throw up new versions of itself for as long as it is circulating, so we’ll probably need a constant supply of new vaccines. All these questions could be addressed systematically. We have the technological, scientific, immunological and clinical expertise in this country to collaborate with international initiatives in addressing each of these immediate issues.
Also, we need to be better prepared for the next pandemic. For there will inevitably be more pandemics, almost definitely within decades, not centuries. Why the certainty? There are multiple reservoirs of viruses in many diverse animal species. We have seen how quickly they mutate, we have seen how quickly they can jump species, we have seen how vulnerable humans are, we know how interconnected human populations are. With the current technologies and approaches, it seems virtually impossible to completely protect a population from a virus as infectious as Sars-CoV-2. Even New Zealand, the most isolated of developed countries, was not able to keep it out.
We need to drive a worldwide attempt to make sure that every country in the world has access to these capabilities, technologies, skillsets and expertise
Therefore, we need to develop our testing and tracing skills. We need to move away from expensive molecular testing technologies, such as PCR. We need to transform our healthcare delivery system by introducing personal identifiers at birth so we can test, diagnose, treat and vaccinate more efficiently, while maintaining personal privacy. For that, our health service needs an integrated, sophisticated, safe, protected IT system. We need to develop better vaccines – ideally vaccines that can be delivered orally or nasally without injection, and which can be transported and delivered without special conditions.
We need more innovative anti-viral drugs. Several research labs in Ireland are making significant advances in these fields. Irish initiatives should be supported and international collaboration promoted, so that we can identify valuable breakthroughs as soon as they are made, and incorporate them into a coherent, integrated, health service. More targeted and productive interactions between Irish researchers, Irish clinicians and the world’s leading pharmaceutical, medical device and IT companies based in Ireland, could place Ireland at the forefront of these fields and help give it the health service it aspires to have.
Perhaps most importantly of all, we need to drive a worldwide attempt to make sure that every country in the world has access to these capabilities, technologies, skillsets and expertise, so that the next global pathogen can be tackled at source and contained, before it becomes endemic. Our political and diplomatic experience and skills are as important in achieving this aim, as our clinical, scientific, technical and innovative skills.
Cliona O'Farrelly is professor of comparative immunology at Trinity College, Dublin