Timeline of the COVID-19 Pandemic in the United States

Del Rio provided an overview of the timeline of the COVID-19 pandemic and response in the United States. On January 9, 2020, WHO reported a novel coronavirus and subsequently declared the coronavirus outbreak a public health emergency of international concern on January 30, 2020. The first case in the United States was confirmed on January 21, 2020. The first case in Latin America was reported by Brazil on February 25, 2020, and WHO declared COVID-19 a pandemic on March 11, 2020 (Rodriguez-Morales et al., 2020). The Access to COVID-19 Tools (ACT) Accelerator launched on April 24, 2020, to support collaboration and to accelerate development and production of COVID-19 tests, therapeutics, and vaccines. Global deaths from the pandemic reached 1 million on September 20, 2020. In March 2021, the Alpha variant was identified, followed by the Delta variant in May 2021 and the Omicron variant in November 2021. Del Rio noted that the global public health community was ill-prepared for the rapid evolution of variants of concern.

Del Rio highlighted several recent notable moments in the United States to illustrate the rapidly changing nature of the COVID-19 pandemic and the political interference on public health response efforts. In 2022, the U.S. Supreme Court blocked President Biden's vaccine-or-test mandate for large private companies in January, and a federal judge voided a national mask mandate for airplanes and other travel in April. On May 17, 2022, the United States reached 1 million COVID-19 deaths. President Biden tested positive for COVID-19 on July 21, 2022. The Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices issued a recommendation for bivalent boosters on September 1, 2022, as a response to the emergence of new virus variants. By December 2022, the Omicron subvariants BQ.1 and BQ.1.1 became the dominant COVID-19 variants in the United States, and the U.S. Food and Drug Administration removed the emergency use authorization for bebtelovimab after determining that the COVID-19 treatment was not expected to neutralize these variants.³

COVID-19 Pandemic in the United States (December 2022)

As of December 4, 2022, U.S. COVID-19 cases and hospitalizations were increasing, with daily averages of 51,995 and 35,614, respectively (The New York Times, 2022). Del Rio remarked that despite the increase in cases, the daily mortality rate has continually decreased. However, by December 2022, only 12.7 percent of the U.S. population aged 5 years or older had received an updated booster (CDC, 2022a), and vaccination rates had slowed. He stated that the low number of people over age 60 having received a bivalent booster may be one of the nation's largest vulnerabilities in the current phase of the pandemic. Mortality rates for COVID-19 have been much higher in people over age 50—and particularly in those over age 65—highlighting a need for boosters and other interventions (CDC, 2022c). Moreover, del Rio acknowledged that the pandemic underscored the effects of systemic racism, an underlying problem in the United States that was brought to the forefront of public discourse by violent events that occurred during the same time period.⁴ Del Rio emphasized that the racial disparities seen in COVID-19 case and death rates are evident in other diseases and must be addressed. Otherwise, he maintained, preparedness for the next pandemic will not be achieved.

Examples of Successes, Challenges, and Lessons Learned from the COVID-19 Pandemic Response

Del Rio discussed successes, challenges, and lessons that can be gleaned from the response to the COVID-19 pandemic and are applicable to future outbreaks. He highlighted the development of COVID-19 vaccines as a major achievement. The virus was sequenced on January 10, 2020, and vaccinations for health professionals began on December 11 of the same year, reflecting an unprecedented level of progress in vaccine development.⁵ Collaboration between government, industry, community, and investigators enabled this rapid development. He noted that 2020 has been characterized as “an extraordinary year for science” and that the evolution of science and the achievements that took place should be recognized (Callaway et al., 2020).

Del Rio served as a committee member on a case study of the first year of the U.S. response to COVID-19; he outlined eight conclusions from that study (see Box 2-1) (Feachem et al., 2021). In discussing these conclusions, del Rio noted that the structure of the U.S. public health system—a complex network of state and local departments rather than a centralized system—will continue to pose challenges to national pandemic responses. The structure of the health care system at large also warrants examination, because U.S. hospitals are unprepared to cope with a high influx of influenza patients, demonstrating that they can be overwhelmed even in the absence of a pandemic. He found that U.S. hospitals and health care systems essentially work at capacity on a continuous basis, which challenges efforts to confront any future pandemics. Furthermore, he added, the United States should assume a global leadership position in preventing pandemics.

BOX 2-1

Findings from a Case Study of the U.S. COVID-19 Response.

Lessons from the HIV Pandemic

Del Rio said that the rapid adaptation of the human immunodeficiency virus (HIV) research infrastructure to the development of COVID-19 research networks yielded great benefits. He remarked that he draws on his background as an HIV researcher in looking to the HIV pandemic for lessons applicable to the COVID-19 pandemic (see Box 2-2). For instance, universal precautions in health care became the norm as a result of HIV; the COVID-19 pandemic has similarly underscored the importance of protecting health care personnel. Del Rio posited that the routine use of masks in health care settings may likewise become the norm.

BOX 2-2

Lessons Learned from the HIV Response Applicable to COVID-19.

Atlanta's COVID-19 Response

Because del Rio is based in Atlanta, Tobias asked him about successes and challenges of the local response to the COVID-19 pandemic. Del Rio responded that in lieu of a city health department, the greater Atlanta area is served by 20 county health departments and coordinating efforts between numerous county departments presented challenges. Underlining the importance of coordination, he shared the role that Emory University played in coordinating efforts across its various hospitals and health care systems. Weekly calls helped to ensure that guidelines were consistent across hospitals and that levels of hospital-implemented protection were uniform. This practice avoided variable policies that would have led to mixed messaging and likely public confusion. Noting that he was asked by the Atlanta mayor early in the pandemic to advise the business community, del Rio commended the efforts of local business leaders to provide employees with support and access to testing.

Therapeutics Research

Tobias asked whether any areas of scientific research should be addressed more rapidly in the future. Del Rio stated that the emphasis on the development of vaccines eclipsed that of therapeutics, particularly for mild-to-moderate disease. As an example, he noted that most COVID-19 infections were mild to moderate in September 2020, yet virtually no treatments were available for these patients (Gandhi et al., 2020). Research and development of drugs for mild-to-moderate COVID-19 should have been a focus from the beginning of the pandemic response, he maintained. Investment in COVID-19 vaccine development far exceeded investment in the discovery and development of effective antiviral drugs. Now that it has become clear that breakthrough infections can occur in individuals who received COVID-19 vaccines, he added, the need for effective therapeutics is evident.

Myron Cohen, Yeargan-Bate Professor of Medicine, Microbiology and Epidemiology and associate vice chancellor for medical affairs at the University of North Carolina, responded that research to develop therapeutics for COVID-19 in fact took place at unbelievable speed, and that therapeutics such as Paxlovid were being developed as early as possible. Del Rio agreed with Cohen, adding that his clinical research unit conducted studies with monoclonal antibodies for treatment and prevention concurrently with vaccine studies. However, he noted that the level of investment for vaccine development was not matched for therapeutics development. The coordination that occurred to develop vaccines did not occur in therapeutics research.

Improving the U.S. Health Care System

In response to del Rio's comments that the U.S. health care system is not ideally suited to respond to pandemics, Tobias asked for an example of a system that is better equipped and for suggestions about how the U.S. system could be improved. Del Rio explained that the United Kingdom's national health care system enabled participation in important clinical research through the Randomized Evaluation of COVID-19 Therapy (RECOVERY) study, but the fragmentation of the U.S. health care system prevents such endeavors. Improvements to the health care information system are needed, noted del Rio, to enable data flow via electronic medical records, which would facilitate rapid aggregation of data during a pandemic. He continued that the different existing information systems within the U.S. health care system do not communicate with one another, making it impossible to collect precise data points such as the number of people admitted to the hospital who had been vaccinated for COVID-19. In addition, the United States lagged behind nations such as Israel and Qatar in terms of using integrated data systems to inform care management. Del Rio expressed the need for discussions with major electronic medical records companies to ensure collaborations to develop the capacity to gather medical data required for studies similar to RECOVERY in the future.

Vaccine Accessibility

Noting that only approximately 7 percent of children younger than age 5 years have received COVID-19 vaccinations in the United States, Jason Newland, professor of pediatrics at Washington University School of Medicine in St. Louis, asked about ways to improve access to vaccines.⁶ Newland commented that the vaccine rollout was complicated by the changing recommendations about who should be vaccinated—meaning, for instance, that a family of four may not receive vaccinations for all family members at the same location or at the same time. Del Rio acknowledged that pediatricians are traditionally relied upon to administer pediatric vaccines in the United States, but a plan to provide vaccines for adults universally was not available at the start of the vaccine rollout, let alone for children. He highlighted the contribution of retail pharmacies in increasing access to vaccines, noting the advantage for the public to receive vaccines for COVID-19, influenza, and other diseases in locations outside of the traditional health care settings. However, he maintained that vaccine access could be further expanded and vaccines should continue to be subsidized, fearing that many people will be unable to afford the projected cost of $150 for the COVID-19 vaccine after subsidies end. In the United States, health inequities are substantial and many people lack insurance coverage; therefore charging for vaccinations will challenge the nation's continued effort to address the pandemic. Vaccination should be an intervention that is available, accessible, and free of charge, said del Rio.

Supporting Public Health and the Economy

Ana Bento, director of the pandemic prevention initiative at The Rockefeller Foundation, commented on the friction between the economy and disease control. Noting that disease control efforts and policymaking often take place at the state or county level in the United States, she asked how coordination can be improved to avoid tradeoffs between saving the economy and achieving desired control of a pandemic. Del Rio replied that efforts are needed to convey the value of public health and healthy employees to the business sector. Restrictions on business operations can carry negative consequences, but creative solutions can bypass the need for such restrictions. For example, del Rio recalled advising the Atlanta Opera on methods of hosting concerts; at one point during the COVID-19 pandemic, the Atlanta Opera was the only opera company in the world holding public events and doing so safely. Efforts to ensure the safety of singers and the public included placing the singers inside a large transparent plastic box so that they could sing without masks. Regular testing of singers, musicians, and staff; vaccinations; and other steps such as performances in outdoor tents were used to prevent transmission. The business survived as a result of continuing operations. Public health generally issues restrictions without alternatives, but del Rio characterized this practice as a failure during the COVID-19 pandemic, because many business owners lost their livelihoods and the economy suffered. In contrast, public health and the business sector can work together to incorporate safety practices and support public health initiatives. Del Rio emphasized that the business sector needs to understand the value of public health, and the public health sector needs to understand how businesses operate. A risk mitigation approach can be used to determine which business activities can be carried out safely.

Research on Non-Pharmaceutical Interventions

Kent Kester, vice president of Translational Medicine at the International AIDS Vaccine Initiative, noted that as the COVID-19 pandemic progressed, novel approaches were taken to address room air ventilation, hypercoagulability caused by the infection, and other issues. However, these approaches were not necessarily well-diffused throughout the medical establishment. He asked about potential opportunities to better harness clinical research for non-pharmaceutical interventions. Del Rio replied that a well-established research platform would enable testing of a wide range of pharmaceutical and non-pharmaceutical interventions. For example, RECOVERY was able to quickly determine which therapeutics were effective. In contrast, although many U.S. investigators were also studying different therapeutic options, without the coordinated approach of RECOVERY, their findings were often contradictory—creating confusion about which therapeutics to adopt. The United States should create a research platform that enables the level of coordination occurring in other nations, said del Rio. Pandemics involve a changing environment that necessitates that guidelines and therapeutics also change. The United States lacks the ability to quickly establish and conduct studies to meet the needs of this changing environment. For example, research to develop and gain regulatory approval for antiviral drugs for COVID-19 was conducted in an unvaccinated population (Hammond et al., 2022), but oral antivirals are being used in a predominantly vaccinated population. This example illustrates how the earlier, existing data are now insufficient to determine when and how these oral antiviral drugs should be used.