COVID 2023: Despite life-saving victories, the future remains uncertain

It’s that time of year when scientists, clinicians and public health experts are asked to become oracles forecasting what awaits us in the new year. Many of us feel like Cassandra, the Trojan princess in Greek mythology whose prophecies, often of gloom, are ignored. 

As respiratory viruses such as influenza, Respiratory Syncytial Virus (RSV) and SARS-COV-2 rage through communities, resulting in increasing infections, hospitalizations and over 300 deaths per day just due to COVID-19, questions arise to what awaits us in 2023. 

I wish that I could be more hopeful, but I’m not, just yet. 

It appears that we are living in a Greek tragedy with well over 1 million deaths since the start of the pandemic, more than 235,000 people dying in 2022 and millions now suffering from Long COVID in the United States alone. Mitigation efforts largely disappeared in 2022, when mask and vaccine mandates were deemed illegal and the public was encouraged to resume their pre-pandemic lives. 

CHINA’S AT THE FOREFRONT – AGAIN

COVID-19 first appeared in China, which was at the eye of the hurricane coming, into 2020. In 2023, China is again front and center in this torrential storm. 

After maintaining a draconian “zero COVID” policy for three years, a public uproar in late November led to their reversal by early December. The infection rate soared to over 250 million cases in just 3 weeks and an estimated 9,000 deaths per day by the end of 2022. 

Experts predict that China’s basic reproduction number for how many people are infected by one person is on the same level as measles — one of the most contagious viruses on the planet. Additionally, as the virus replicates, it mutates. What happens in China has a profound impact on global health and the economy.

Because China is not transparent with its data and has stopped official testing, several nations, including the United States, have implemented testing requirements for flights arriving from China in 2023. There are questions on how useful this approach may be; however, it can be a more effective surveillance tool if followed up with additional testing, including genomic sequencing to detect new mutations.

OMICRON’S IMPACT

By early 2022, the omicron variant was starting to ravage the United States and its health care workforce. During the year, clinicians continued to leave practices resulting in staff shortages. This year, it is imperative that support services be provided to all clinicians and front-line employees, and programs such as physician and nursing reentry are implemented to ensure that health systems can be sustained to handle pandemic-related issues as well as other health concerns.

In response to the surge, in January 2022, the Centers for Disease Control and Prevention (CDC) updated its mask guidelines to recommend N95 respirators, leading to a nationwide effort to distribute 400 million free respirators from the National Stockpile. Unfortunately, N95s only successfully fit 85 percent of women. 

In 2022, the National Institute for Occupational Safety and Health in conjunction with the Biomedical Advanced Research and Development Authority announced the winners of its Mask Innovation Challenge and said during a November workshop it has plans for future challenges this year. It’s an important step toward ensuring that everyone can live and work well and safely in any environment. 

To stave off omicron, updated vaccines were authorized in 2022, but by December, only 15.1 percent of eligible individuals had received the newest bivalent vaccine booster. Last year, it became apparent that vaccines did not prevent COVID transmission or infection, but could still prevent serious illness and hospitalization for those at high risk. However, there is concern that the omicron subvariants such as XBB.1.5 could be even more immune evasive and these vaccines may be less effective. 

Additionally, in 2022, enhanced concern over the development of rare side effects of myocarditis with mRNA vaccines, especially in young men, and blood clots in premenopausal women with the Janssen vaccine, elevated the urgency to examine the impact of subpopulation demographics and the role of precision medicine in order to tailor the dose and type of vaccine to the population being treated. 

Seeking solutions, the White House hosted conferences to address the need for new types of vaccines, including mucosal and intradermal, which may provide greater protection. One challenge is that the duration and durability of immunity due to natural infection and vaccinations are still unknown and constantly changing as the virus evolves. Furthermore, there is an increased need for the use of therapeutics beyond monoclonal antibodies because some of the current crops are no longer effective against new subvariants. 

LONG-TERM IMPACTS

COVID-19 is a diabolical virus. Long COVID or post-acute syndrome of COVID-19 (PASC) is a complication from even asymptomatic or mild infection. Though the exact incidence is unknown, it became apparent in 2022 that millions are afflicted and many had to leave the workforce. It has also been associated with increased mortality. 

Paxlovid, an antiviral agent, was authorized in late 2021 for the treatment of mild to moderate COVID-19 in high-risk adults and pediatric patients. It is also being studied to see if it can prevent Long COVID. Unfortunately, some patients have experienced “rebound” infections after completing a five-day course. The duration, dosage and timing need to be further studied in 2023 to know how to best use this drug.

Last year, the National Institutes of Health launched a multi-site study to understand Long COVID’s etiology, prevention and treatment and the Department of Health and Human Services released comprehensive reports on its clinical, research and community care implications. In 2023, it should be required that all clinicians ask about Long COVID symptoms and more clinics are established to treat this debilitating condition. 

In 2022, the term “immunity debt” was coined, but it may actually be an “immunity deficit,” in that the immune and inflammatory systems are impaired after COVID-19 infection. Studies are showing that repeat COVID-19 infections are associated with more long-term complications. A recent study published in Nature revealed that there is even a 66 percent increased risk of diabetes post-infection and children are also at risk for this development.  

Given all of those factors, in 2023, communication is key. Throughout the pandemic, messages need to be clear, consistent with the facts as we know them and coordinated among all messengers. Otherwise, the public will ignore what is stated. 

In a piece I wrote for this publication last January, I said that “this new year will bring better tests, therapeutics and vaccines. Spring is coming.” Whether 2023 will be hopeful will depend on what we say and do today and in the coming months. Only time will tell.

Saralyn Mark, MD is the founder of SolaMed Solutions, LLC, host of the “Always Searching” podcast and founder of iGIANT (Impact of Gender/Sex on Innovation and Novel Technologies). She is the American Medical Women’s Association’s COVID-19 lead and a former senior medical and policy advisor to the White House, the Department of Health and Human Services and NASA.