When are mandates necessary? Many will say never, as freedom is paramount. But, in reality, there is a tradeoff between liberty and security. Our society has always prioritized freedom. With COVID-19, this question has become more complicated and, unfortunately, confrontational. How we incorporate public health strategies into our society is not a theoretical discussion but an urgently needed one, necessitated by the evolving and threatening pathogens looming on the horizon. These include H5N1 (avian flu), Dengue Fever, mpox, human metapneumovirus (HMPV), and other evolving infectious agents.
In the case of SARS-CoV-2, freedom advocates question the need for security by downplaying the severity of the disease. This is still occurring, and many are trying to rewrite history, forgetting the refrigeration trucks that once served as morgues in New York City or the over 1 million US citizens lost to the acute infection and the over 5% of all adults who are currently experiencing long-term sequelae of COVID-19.
Freedom advocates have also downplayed the effectiveness of masks and vaccines by not analyzing all of the evidence and touting negative ‘controlled’ trials that are unblinded and biased.
First Emergence of a Pathogen
During the initial emergence of a novel respiratory pathogen, only non-pharmaceutical interventions (NPIs) are available. Non-pharmaceutical interventions such as masking, closures, and lockdowns are effective but take away freedoms. Initially, the goal is to eliminate the pathogen by blocking spread (driving the R0 less than one). This strategy was successful with MERS in the Republic of Korea and stopped the SARS-1 outbreak in Toronto. However, as a pathogen, such as SARS-CoV-2, evolves to become more infectious, this goal becomes more challenging to achieve. And when animal hosts emerge, as also occurred with SARS-CoV-2, it becomes nearly impossible.
Unfortunately, herd immunity is not possible with highly infectious, mutating pathogens that do not elicit durable immunity.
Lockdowns
Many view lockdowns and isolation as draconian interventions akin to imprisonment. However, these interventions benefit societal safety, especially during the initial phases of an outbreak, and are highly effective in protecting those isolated. However, frontline workers are still at risk of exposure. The longer the lockdown, the larger the number of frontline workers who are required to keep society functioning at a minimal level. Thus, the effectiveness of lockdowns in eradicating pathogens decreases.
Proposed Advisements
- Lockdowns may be indicated during the initial phases of the emergence of a dangerous pathogen and if the health care system is at risk of collapsing.
- Longer lockdowns increase the number of needed frontline workers, which may decrease their effectiveness.
- Mandatory NPIs may also be indicated to “flatten the curve” in order to delay cases until vaccines and pharmaceuticals become available.
- N95 masks need to be used for respiratory pathogens. Surgical masks are not designed for this purpose.
- Increasing ventilation and improving air quality is an important NPI.
- Mandatory 2-way masking and high-quality ventilation should be required in venues (such as health care facilities) with high concentrations of respiratory pathogens and in venues frequented by immunocompromised individuals.
- Mandatory vaccinations should be primarily reserved for highly effective, safe vaccines that provide durable immunity.
- mRNA vaccines can be rapidly deployed at the start of a pandemic, but SARS-CoV-2 vaccines should serve as a bridge to second-generation vaccines.
If a second lockdown is required, eradicating the pathogen will not be possible since public compliance decreases dramatically, and the pathogen may have had time to adapt to various animal hosts. However, lockdowns and other NPIs may still be necessary as a stopgap measure if the health care system is on the verge of collapsing.
Masking
Masking is one of the first strategies implemented. This intervention has been shown to be effective in community and school settings. However, due to the high exposure dosage, masking alone may not be effective in health care settings. In these settings, additional NPIs should be implemented.
Two-way masking is much more effective than one-way masking since source control is paramount. Unfortunately, with one-way masking, one can still be infected through the eyes. Surgical masks are not designed for respiratory pathogens. Therefore, N95 masks or respirators should be used whenever possible.
Mandatory NPIs such as masking, closures, and upgrading ventilation need to be implemented immediately at the onset of the pandemic for frontline worker protection and pathogen eradication. If, despite these efforts, the pandemic worsens, NPIs should also “flatten the curve,” thereby delaying the development of cases until pharmaceutical treatments (antiviral drugs and monoclonal antibodies) or vaccines become available. Improving ventilation may be viewed as costly. Initially, installing a new HVAC system may not be feasible, but a Corsi-Rosenthal air filter can easily be made, and windows can often be opened.
Vaccinations
Mandatory vaccinations have become the v most controversial intervention. This intervention should primarily be considered for highly effective, safe vaccines that provide durable immunity. Measles, polio, and mumps vaccines fall into this category. Effective and durable vaccines can drive the R0 below 1 and eradicate a disease. However, this is a societal effort. For measles, 95% of the population must be vaccinated to prevent transmission effectively. If the protection level falls below this, the virus will spread. Spread increases the chance of mutation; with mutations, the virus could someday evade the vaccine. In Italy, a strain of measles is already starting to evade tests. Thus, for vaccines to be effective in the long term, they must be able to stop the spread of the virus. This requires a high-quality product and widespread acceptance and use by the public.
Mandatory vaccination may also be considered to preserve critical infrastructure until a crisis has passed. This would apply to armed forces who may be faced with biological weapons and certain frontline workers who cannot be easily replaced.
In early 2020, the mRNA COVID-19 vaccines were highly effective at stopping the spread of disease and preventing infections, but the duration of their protection was unknown. During the acute crisis, mandatory vaccination strategies were employed to maintain a workforce for critical infrastructure. However, as the crisis passed, the protection from vaccinations waned, and the high mutation rate of viruses further reduced vaccine effectiveness. Currently, the reduction in the COVID-19 vaccine’s durability and effectiveness diminishes the rationale and need for implementing mandates.
Long-Term Strategies and Effects of Pathogens
Our society will be dealing with the long-term damage from COVID-19 and its propensity to cause reinfections for decades to come.We are already seeing a rise in infectious diseases, which are now being linked to immunological damage from the virus. In addition, reports of Kaposi Sarcoma are starting to appear. I suspect these occurrences will be in a minority of patients because, unlike AIDs, most patients clear the virus, although reinfections are becoming all too common. In addition, in some patients, elements of the virus, such as the spike protein, may persist for years, causing protracted symptoms and can have prion-like characteristics, causing neurodegenerative diseases.
We cannot assume the human body will naturally ward off an infection with its immune system. We are part of the natural order, and civilizations, along with entire species, can be eliminated by infectious diseases. What sets us apart is our intelligence and understanding of science. This gives us an advantage in our survival, but it is an advantage that will only be effective if utilized.
