SARS-CoV-2 immune dysfunction may be responsible for the surges we are experiencing in several infections. Similar to what happened in the United States and Sweden, seasonal influenza cases in Australia are 100 higher than the year before. Australian doctors also warn about an “alarming” increase in pediatric influenza hospitalizations and hospitalizations from the respiratory syncytial virus.
In addition, the World Health Organization (WHO) has also sent out an alert regarding severe myocarditis in very young children. An outbreak of 15 babies has occurred in the United Kingdom. This is not due to a vaccine complication and underscores the importance of vaccination during pregnancy.
This is happening as Wang et al in the journal Cell reported “alarming antibody evasion properties of the rising SARS-CoV-2 BQ and XBB subvariants.” Titers against XBB.1 are 66 to 155-fold lower. The authors stated that “…these new subvariants were barely susceptible to neutralization by sera from vaccinated individuals with or without prior infection, including persons recently boosted with the new bivalent (WA1/BA.5) mRNA vaccines.” Unfortunately, the XBB.1.16 has significant immune evasion characteristics and a growth advantage over XBB.1. As of May 13, 2023, XBB.1.16 and XBB.1.9 comprise 27.5% of the isolates in the United States and are rapidly rising.
The WHO is taking a leadership position, calling for a monovalent XBB booster that targets XBB.1.5 and XBB.1.16. The dropping out of the original strain was because it is no longer needed and does not produce an effective immune response against current variants. Concerns regarding immune imprinting may be aggravated by incorporating the original strain’s antigens, but the clinical impact is unknown. As observed with the monovalent BA.5 booster, immune imprinting would be expected to produce a robust response to the original strain with a monovalent XBB booster.
Concerns of immune imprinting and the rapid waning of vaccine and infection-induced immunity make it clear that additional mitigation strategies are needed to mitigate transmission. A recent article studying schools in Switzerland has documented sustained airborne transmission with molecular analysis of air samples. Mask mandates decreased aerosolized particles by 69% (a testament to how masks protect others, not just the wearer), and air cleaners decreased particle concentrations by 39%. Further improvements would be expected by increasing ventilation since the average CO2 levels in the schools were high at 1064 +/- 232 ppm.
We have much to do in the United States to build a resilient and effective health care system to confront the next pandemic. Unspent COVID-19 funds are available, which should be used to expand infectious disease reporting, testing upgrade facility ventilation and air quality, and use upper room UV-C germicidal lighting. There is political pressure to reallocate these funds to help pay down the United States debt. This could leave the United States vulnerable to future infectious disease surges and reduce our ability to mitigate the long-term impact of long COVID.
