Viewpoint: CDC Might Help COVID-19 Make a Comeback in U.S.

The Centers for Disease Control and Prevention’s abrupt reversal regarding public masking on May 13, caught all by surprise. Not only was it entirely unexpected but it seemed to contradict information generated by the CDC just a few days earlier. On May 7, the CDC affirmed that the SARS-CoV-2 virus is airborne, a finding which should have been known over a year ago from numerous case reports involving, cruise ships, restaurants and choirs. As early as July 2020, hundreds of scientists published a letter in Clinical Infectious Diseases to raise awareness of SARS-CoV-2 aerosolization and to encourage strategies to interrupt transmission.

Aerosolized spread makes the wearing of masks an imperative in the control of community spread. In an informal survey of 723 epidemiologists that was conducted between April 28 and May 10, 2021, 80% felt that masks would need to be worn indoors for another year. On May 14,

Kevin Kavanagh, MD

2021, a modeling study was published in the CDC’s Morbidity and Mortality Weekly Report that concluded that “an accelerated decline in NPI (public health policies, such as physical distancing and masking) adherence (which encapsulates NPI mandates and population behavior) was shown to undermine vaccination-related gains over the subsequent 2–3 months and, in combination with increased transmissibility of new variants, could lead to surges in cases, hospitalizations, and deaths.”

The day before the publication of the modeling study’s dire warning, the CDC abruptly removed mask and physical distancing requirements for those who are vaccinated. Unfortunately, this will probably also result in many unvaccinated individuals unmasking.

There are two major concerns. First is too few of the United States’ population have become fully vaccinated. In the United States, only 37% are fully vaccinated, with 48% receiving at least one dose. And the rates vary widely between communities, creating pockets that are literally sitting ducks for a major viral outbreak. For example, Kentucky has 36% of its population fully vaccinated but the rates vary widely from a high of 57% in Woodford County to a low of 21% in McCreary and Lewis Counties.

Second, there are major variants abroad which are more infectious and may at least partially evade immunity. For example, in Southern India, the N440K immune escape variant is reported to be 10 times more infectious and produces 10 times the viral load than the D614G variant (the dominate 2020 variant in the United States). N440K also has the ability to avoid several monoclonal antibody treatments (C135 and REGN10987) and cause reinfections.

Another problematic variant is expected to replace the N44K variant, the Indian (B.1.617) “double mutation” variant. The double mutation variant is named after two of its major mutations (L452R and E484Q) being a combination of those found in the Californian variant and a similar mutation found in the South African variant. The double mutation Variant is also an immune escape variant. It can cause reinfections, along with evading vaccine induced antibodies with “moderate efficiency.” It has a strong foothold in England and is predicted to become the dominate strain. Initial reports are that the double mutation variant is more infectious than the UK variant (B117) and the UK Variant is 70% more infectious and more lethal than the wild type of virus.

Because of the dangers the Indian double mutation variant poses, the World Health Organizatoin has classified it as a variant of concern. The CDC defines a variant of concern as having the attributes of a variant of interest plus:

• Evidence of impact on diagnostics, treatments, or vaccines.
1. Widespread interference with diagnostic test targets.
2. Evidence of substantially decreased susceptibility to one or more class of therapies.
3. Evidence of significant decreased neutralization by antibodies generated during previous infection or vaccination.
4. Evidence of reduced vaccine-induced protection from severe disease.
• Evidence of increased transmissibility.
• Evidence of increased disease severity.

In view of the above, a more cautious approach would be to wait before unmasking and throwing social distancing to the wind for solid data to be generated in the UK. If just over a third of our population is fully vaccinated and the US is invaded by a variant which has twice the infectivity and is more lethal than the last year’s virus (G614D), then the U.S. could be facing an even greater surge in cases, hospitalizations and deaths. To make matters worse, the U.S. has only a rudimentary genomic surveillance detection system for variants. Similar to what happened in the beginning of the pandemic, immune escape variants may spread in the community undetected until it is too late to prevent a major outbreak.

For those vaccinated, laboratory data indicates that there will be some protection with severe cases and deaths being less likely to occur. However, there is little data on the risks of long COVID-19 which can afflict 10% to 30% of individuals with mild to moderate infections. And if a vaccinated individual can develop asymptomatic, mild to moderate infection from an immune escape variant, it is intuitive that they might also spread the virus. And, if the virus spreads, it can also mutate.

An April 30 Washington Post op-ed written by Madhukar Pai, an Indian doctor and epidemiologist, and Manu Prakash, summed up the causative factors of India’s current crisis, but may also be a stark warning for the U.S.: “The devastating second wave in India is the result of a perfect storm: a failure to plan for a second wave; premature relaxation of public health measures; large gatherings; insufficient vaccination coverage; and newer variants such as B.1.1.7 and B.1.617 that are highly transmissible and potentially more severe.”

Those of you who advocate reopening at the peril of those who are vaccine hesitant—letting nature decide the fate of the ill-informed—need to remember that survival is not the same as recovery. Many will develop debilitating long COVID, enacting a societal legacy of disregard for humanity, which will impair our health care system for decades to come.

Let’s not be cavalier in our approach to a return to a new normal. Let’s be smart and cautious. Continued masking and social distancing for a few months, possibly just a few weeks, is a small price to pay to assure the safety of our nation.