COVID-19 Pandemic Year 3: 2022 Lessons Learnt

Authored by: Venkat Rao

As 2022 draws to a close, it is a good time to take stock of the two years of COVID-19 pandemic: what went well and what went wrong? What lessons have we learned?

A little over a 100-years ago, in 1918 a mysterious and deadly disease spread around the world in three consecutive waves from spring 1918 to Winter 1918-19 that infected over an estimated 500 million people, a third of the world’s population, and killed an estimated 50 million people, and by some death estimates as high as 100 million people. Clinical manifestations were very severe in previously healthy adults and the pathogen spreading the havoc remained unknown and could not be identified as the pandemic spread like wild fire.

US National Archives narrates the influenza epidemic of 1918 as, “hard as it is to believe, the answer is true that the influenza epidemic of 1918 killed more people than died in World War I”.

The Archives narrates the exploding pandemic as follows, “The plague emerged in two phases. In late spring of 1918, the first phase, known as the "three-day fever," appeared without warning. Few deaths were reported. Victims recovered after a few days. When the disease surfaced again that fall, it was far more severe. Scientists, doctors, and health officials could not identify this disease, which was striking so fast and so viciously, eluding treatment and defying control. Some victims died within hours of their first symptoms. Others succumbed after a few days; their lungs filled with fluid and they suffocated to death.” 1918-1919 influenza pandemic consumed by death a third of humanity. Immunological studies indicate that the genetic descendants of the 1918 virus still persists in pigs and in circulation in humans as well, but in 1977 the human H1N1 virus suddenly reemerged from a laboratory freezer and remains in circulation. Fortunately, the genetic descendants were not as dangerously pathogenic like the original 1918 pandemic virus. Nonetheless, H1N1 descendants from the 1918 strain and other related genetic variants have been circulating worldwide and are expected to persist without extinction.

Why am I going about narrating a century-old pandemic as we begin taking stock on the lessons learnt from the ongoing COVID-19 pandemic?

Past century provides us with a rich history of disease dynamics, persistence, and circulation of the virus in natural environment and its recurring appearance in different genetic forms, each with its own capacity to cause harm and remain in circulation. Why would coronavirus episodes we witnessed, starting from SARS in 2003-2004 and now, SARS-CoV-2 and COVID-19 pandemic, be any different?

There are striking similarities and notable differences between the 1918-1919 influenza pandemic and the ongoing COVID-19 pandemic. What lessons are we to learn from the two global pandemics so we are better prepared to respond to the next one?

Two years ago, and since the World Health Organization declared a global pandemic after an outbreak of a novel coronavirus, over 620 million people have been infected worldwide with SARS-CoV-2 virus and 6.5 million people have died of the disease as of October 2022. Some lessons learnt during this period were striking highlights of human innovation, ingenuity, adaptability, and comradery, whereas many others portrayed abject failure at every level in public health agency response to the pandemic, and policy measures enacted during this period that are likely to have devastating, long-term consequences for decades into the future.

A century ago, scientists, doctors and health professionals could not identify the cause for the disease which struck fast and severe, eluding treatment and defying prevention and control. Government agencies and public health officials could not even grasp the scope and size of the influenza pandemic, except to watch and report the horror of disease, death, and destruction. Compare that to the COVID-19 pandemic, where a global community of scientists collaboratively were able to rapidly identify, sequence, and characterize genomics of the SARS-CoV-2 virus, share crucial information on disease diagnosis and detection, and multiple types of generally safe and effective vaccines made available within a short 10-month period for global distribution. The stark differences between the two-centuries in pandemic response are attributable to current advancements in science and technology, and laudable aspirational goals of solidarity and equity among global commons in combating a pandemic, which sees no national boundaries.

If rapid detection of the viral pathogen and impressive medical countermeasures development are the success stories of COVID-19 pandemic, the results were not as impressive and actually was quite the opposite. Not only COVID-19 vaccines remain underutilized in the United States, but the routine immunization rates have also declined across all groups and state immunization laws are in jeopardy. Differences in pandemic response implementation policies at the state-level has forced the state vaccine mandate controversy before the Supreme Court of the United States, where some states have sought the Court’s force of hand to stop the vaccine mandate.

COVID-19 vaccination rates have dropped in the US. According to the CDC, as of December 7, 80% of the people in the US had received their first COVID-19 shot and only 68.9% are considered fully vaccinated. Data tracker for vaccination rates at county level show large swaths of United States with less than 40% vaccination rates.

A recent cross-sectional analysis of 3,142 counties reports poor vaccination rates in the United States is attributed to vaccine hesitancy as the principal barrier to achieve optimal population-level immunization to achieve herd immunity. Vaccine hesitancy was significantly and negatively correlated with vaccine uptake rates with communities with highest vaccine hesitancy having the lowest vaccination rates. A striking observation was that 55% of the study population attributed lack of trust in COVID-19 vaccines as the reason for vaccine hesitancy, which was the number one reason for low levels of vaccine uptake rates. The second most common reason was concern around side effects of the vaccine among 48% of the respondents.

According to the Commonwealth Fund’s International Health Policy Survey, US is the last among high-income countries to fully vaccinate at least 60% of its population falling behind dozens of other countries with limited resources. United States started out in 2021 as the leader among high-income nations in COVID-19 vaccine uptake rates only to find it overtaken by all ten peer nations. Countries like Australia and New Zealand were late comers to the vaccination program, but quickly overtook US in terms of vaccine uptake rates. According to the Commonwealth Survey, access to COVID-19 vaccines, despite abundant supply of the vaccine is an anomaly in the case of US. Unlike other peer-nations, COVID-19 vaccinations are not centered around primary healthcare facilities, but instead offered at locations where qualified healthcare providers are not available to educate the public on the benefits and risks of vaccination.

The situation is not very different in other parts of the world for a different set of reasons. The World Health Organization reported a 50% decline in COVID vaccination rates in Africa, one of the worst affected regions of the world. Only 24% of the population have completed primary series of COVID-19 vaccination compared to 64% globally. Lower vaccine update rates in African countries are generally attributed to limited budgets on public health and fewer resources for short-term emergency response, although some countries in the region have made superb efforts on COVID-19 disease prevention, treatment, and vaccine uptake rates, large swaths of Africa remain way below the optimal levels to achieve herd immunity.

A baffling development in the past two years is how a strictly public health crisis has devolved into unrelated domains, eroded public trust and confidence in highly respected institutions that serve and advance scientific research, provide public health services, and government agencies formulating policies in the best interest of the citizens at large. These developments have dramatically altered public’s confidence on the safety and efficacy of the COVID-19 vaccine, greatly reducing vaccination rates, and contributing an added burden on public health systems to a generally preventable infectious disease.

Health experts have identified the damaging impact of these developments in the past two years that are likely to persists for decades into the future. An example is the precipitous decline in public’s trust on science and public health experts and government at large on matters relating to disease outbreak response.

Many missteps from the national scientific leadership team entrusted with the task of developing and implementing a national pandemic response, and frame communication on the pandemic to a wary public, waded beyond the confines of science, proclaiming contradictory guidelines on prevention and infection control measures, role and the need of vaccines as medical countermeasures, and shutdown and closure of economic activities in major US metropolitan centers. What was lost during this difficult and challenging phase of the pandemic was the loss of trust without which the public is unlikely to follow future public health guidance as we saw through much of 2022. Unless there is a foundation of trust, public would not willingly and voluntarily comply with future health guidelines. It goes without saying these developments have serious health and national security implications.

During the 1918-1919 influenza pandemic there was a dearth of information and it took months, years and even decades to discern more details on the causative viral pathogen and the scope and size of the pandemic. In the case of COVID-19 pandemic, by contrast, a flood of information began to flow through a wide array of mass communication and social media networks almost immediately at the onset of the early reports on the coronavirus disease. However, the flood of information on the virus and the pandemic were not always reliable and helpful. As more data from studies from around the world became available, some of the early reporting on the mode of transmission, environmental viability of SARS-CoV-2 virus, mode of transmission, disease prevention and infection control turned out to be less accurate.

There is nothing unusual or sinister about public health officials sometimes changing recommendation on masking, social distancing, disinfection, and infection control measures. For example, at the onset of the COVID-19 pandemic the WHO issued a guideline that SARS-CoV-2 is not airborne and was not transmitted through the air, which turned out be a huge error. It took a while through a prolonged process to rectify this error, which by then had sowed confusion on changing guidelines, raising questions on what might happen with the next pandemic.

Nonetheless, this is what is expected in a normal course on new and emerging infectious diseases as more data become available and scientific conclusions require course corrections on science-driven policies, which gets reflected in guidelines and recommendations from public health agencies. New data should guide development of a better approach towards infection prevention and disease management strategies. But what we saw in the past two years was more refined information on the pandemic actually backfired with a skeptical public with adverse outcomes on vaccine uptake rates, infection control measures and other sensible preventive measures. Consequently, more information did not necessarily produce a better outcome. It was quite the contrary in this case as false information polarized debates and oversimplified complex scientific issues.

Public health officials attempt to convey a nuanced understanding of the scientific approaches seldom worked, as public wanted answers in simple, binary, straightforward terms.

Mass media and social networks makes very little effort educating public on how science works, how scientific investigations are carried out, how vaccines work and how they are researched and developed, and the reasons we continuously update our understanding of a problem based on new data and findings using objective scientific methods. Public in general are not afforded the opportunity to learn the basics to understand of how physical and biological worlds operate. Just imagine how a more scientifically attuned public might have reacted to the deluge of information and misinformation that was dished out in the past two years?

Compared to 1918-1919 when modern biological sciences were in infancy, we in a better position in 2022 when biotechnology and information technology are at the zenith of advancement. However, studies have shown more data does not necessarily lead to better decisions and how people interpret new information to make choices on health and wellbeing.

No prior pandemic response plan existed before 1918 Influenza pandemic hit the United States. A key lesson was prior pandemic response planning could have made a significant difference in the number of cases and deaths. Response measures were rapidly implemented in 1918 in the form of use of mask, increased sanitation, limiting crowing and coordination with hospital staff to maximize resources. Disagreements between agencies could have been discussed in advance as part of pandemic planning, but that was not the case. So was lack of medical supplies and the need to stockpile critical medical resources as part of pandemic planning. Controversial patient quarantine and containment policies were not worked out in advance as part of pandemic planning. During 1918 pandemic, public health officials were not given clear orders, so public in turn were not provided clear consistent advice and information. The public had to decide for itself, as much of the messages provided to the public contradicted each other.

The sequence of events and list of lessons learnt from 1918 are eerily similar to those we just witnessed during the past two years of COVID-19 pandemic. So, taking stock of the situation should include a century of collective experience into consideration.