Potential Endgame Scenarios for COVID-19

John Whyte, MD; Eli Adashi, MD


August 11, 2021

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JOHN WHYTE: Welcome, everyone. You're watching "Coronavirus in Context." How does this pandemic end? Well, I think I have someone to talk to today who has the answers. Dr. Eli Adashi is professor of medical science at Brown University and the author of a commentary recently in JAMA: “Potential COVID-19 Endgame Scenarios, Eradication, Elimination, Cohabitation, or Conflagration?” Dr. Adashi, thanks for joining me today.

ELI ADASHI: My distinct pleasure. Good to meet you, John.

JOHN WHYTE: You know, it's what's on everyone's mind: “How does this end?” And I think the Delta variant has changed some of our thinking about it. So let's walk through it, if we can, each of these scenarios.

ELI ADASHI: Well, eradication is, of course, the ideal option, shall we say, that all of us would embrace wholeheartedly, and it refers to the outright elimination of the virus from the face of the Earth. And we have done this before, as you probably know, for smallpox for example.

JOHN WHYTE: Took a long time to do that, though.

ELI ADASHI: Took a long time, yes. And we might be near, but not quite there, with polio, which, of course, has also been with us now well over 50 years. There are a few pockets in Asia that have yet to be eradicated. But there has been a persistent and consistent effort to accomplish this, and we're very close. So in theory, it is accomplishable, but whether or not this will be the circumstance here is clearly too early to even imagine or daydream about.

JOHN WHYTE: And many areas of the world are in the single digits in terms of vaccination. As you point out, eradication is a global strategy. And as you and I know, in many ways, there is vaccine nationalism. That's going to be hard to overcome as we think through an eradication strategy. Well then, let's talk about what's an elimination strategy and do you think that's possible given what's been going on in the last few weeks.

ELI ADASHI: So elimination is a less aspirational goal, or a lesser aspirational goal, than eradication because it does not aim to eliminate the virus from the face of the Earth. Instead, it seeks to selectively eliminate the virus from specific regions, nations, continents. But certainly not in a way that would allow us to say this is now behind us.

JOHN WHYTE: But as you point out, it's not complete removal of the virus from the world.

ELI ADASHI: I mean, we probably cannot even, at this point in the history of this pandemic, claim to ever say full-fledged or 100% elimination. But examples of circumstances where one is close would be Israel, for example, wherein vaccination rates are probably the highest they are anywhere at this time. In fact, as you know, they're moving now to administer boosters to individuals over 60 and who are immunocompromised.

So it's a developed nation with 7 million citizens, which is mightily different than a developed nation with 330 million citizens. And while I'm not sure that Israel is free of the nationalism that you alluded to earlier or the anti-vac sentiments that are clearly very strong here, they have been able to accomplish impressive numbers. And there are a few other examples that I think are aspiring to that and, in the final analysis, all of us want to get there.

JOHN WHYTE: Sure. But do you think we'll get there, Dr. Adashi, or we're going to have a cohabitation strategy? Which means somehow it becomes endemic, we figure out a way to live with the virus. That's what some people are saying now: Let's stop focusing on every single case and focus on how do we manage it, how do we minimize death in severe cases.

ELI ADASHI: Yes. I agree with you that cohabitation is the most likely realistic scenario in the near future --

JOHN WHYTE: What's near future? What's near -- that's what everyone wants to know: What's the near future?

ELI ADASHI: We're still talking years, John, I don't think we're talking months. Just look at the vaccination rate in the United States for example, we've got a long way to go.

JOHN WHYTE: Yeah, did you feel differently, say, 2 months ago, when there seemed to be more light at the end of the tunnel? Has the Delta variant changed your perspective in terms of what the end game is?

ELI ADASHI: Well, it did. But you realize, John, that this paper was submitted probably 4 or 5 months ago, and so --

JOHN WHYTE: You were prescient in terms of what was going on.

ELI ADASHI: I was simply uncertain as to the outcome and nobody, even though I know many people who are in the know, I never really received a fully satisfactory explanation of what the near-term or long-term future might be. So that's when I recruited this mini-team of ours and we tried to think through the scenarios. And one of the goals we were hoping to accomplish is to give everybody else a framework to work with so that we all speak the same language in a way.

JOHN WHYTE: Let's talk about that last one, conflagration. Which sometimes means battle, fighting; it means different nuances to folks. What do you mean by it in the setting of COVID-19?

ELI ADASHI: Well, it's effectively a state of war between us, and what I would characterize is an equal-opportunity assassin that is out there to serve itself, survive, and thrive at our expense. It's really --

JOHN WHYTE: That's different than cohabitation because we're not having these frequent episodes or epicenters where people are dying.

ELI ADASHI: No, this is an all-out war that claims more victims, as you know, than conventional wars. And I perhaps will use this opportunity, if you will allow me, to say two more things. One is as bad as the Delta variant may be, the notion of a so-called doomsday variant should still be on our mind because the virus is evolutionarily evolving all the time. And the more living space we allow it, the more likely it is to take advantage of its mutation ability.

What I would say could be a game-changer, and I'm sure you have thought about it, is the one ingredient that is still missing in the total mix, and that is a therapeutic. It would introduce a measure of confidence that the vaccines cannot provide at this point because of the anti-vaccine sentiment, because of the nationalism, et cetera. But just imagine there was an effective therapeutic that your primary care provider could call into the pharmacy, you would take it, and in a matter of days, you'll be back to normal and you certainly avoid hospitalization, let alone in ICU.

JOHN WHYTE: Well, I wanted to ask you that. That was actually going to be my next question: Where is the optimism Dr. Adashi? And your optimism may be, it sounds like, in the role of therapeutics because drugs --

ELI ADASHI: I think so.

JOHN WHYTE: Because people are, typically, aren't as anti-therapeutics. No one saying don't give me monoclonal antibodies, don't give me remdesivir. Even though we're going to continue to have new therapies and additional therapies as really a 360-degree strategy, including more testing and more frequent testing.

ELI ADASHI: This must be a truly difficult problem, or we haven't thrown that enough financial or intellectual resources, or both.

JOHN WHYTE: Well, Dr. Adashi, I want to thank you for your thought leadership on this issue and really creating the dialogue about what is our endgame, because that's what we all want to know.

ELI ADASHI: Absolutely. Thank you very much.

This interview originally appeared on WebMD on August 11, 2021

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