Kevin Kavanagh, MD: “One of the things that’s really frustrated me with this epidemic and pandemic is that people are totally focused on dying…. But in actuality, the disabilities are much, much more concerning because that is even affecting the young people.”
That coronavirus disease 2019 (COVID-19) might be here to stay doesn’t mean the United States and the rest of the world can’t return to something closely resembling pre-pandemic life, says Kevin Kavanagh, MD, MS. However, the fact that animals can catch COVID-19 is just one reason why the disease is endemic, he notes. “We really do need to learn to live with the virus,” Kavanagh tells Infection Control Today® (ICT®). “Things will get much better, but I don’t think we’re going to be able to eliminate this virus off the face of the earth, similar to what we did with smallpox.” On the other hand, Kavanagh, a member of the ICT® Editorial Advisory Board, says he believes the new COVID-19 vaccines will be effective against the variants of the disease that have recently cropped up. Because, as he points out, “a vaccine causes a myriad of antibodies to be formed to that spike protein, and a virus would have to evade every single one of them to be successful. And that’s a tall order.”
ICT®: The appearance of the new COVID-19 strains made many people wonder what they might have to fear from these mutations. What are your thoughts?
Kavanagh: Well, I think it was because it was timed with the vaccine that people started to pay attention to these mutations. But actually, these mutations have been going on since March 2020. And I wish at that time people [had] said, “Hey, we need to slow down the spread of this virus,” and really observed social distancing, wearing masks and obeying public health advice. You need to remember that the first mutation of significance was probably the D614G mutation, which came to the United States from Europe. That’s the prevalent strain, and it is also thought to be more infectious. This mutation just ratchets up the infectivity of this virus, which is of course a major concern. The more people get infected, the more people will potentially die or become disabled from this disease. However, currently, there’s no indication that the disease it produces is more severe. The jury’s still out on whether or not it can avoid vaccines. But looking at the science, that’s a tall order for the virus…, and it probably will not do that at this point.
ICT®: You mentioned people who might “die or become disabled from this disease.” What disabilities might result from COVID-19?
Kavanagh: Well, one of the things that’s really frustrated me with this epidemic and pandemic is that people are totally focused on dying. In other words, who is going to have a fatality or a fatal result. But in actuality, the disabilities are much, much more concerning because [they are] even affecting the young people. And [COVID-19] can be chronically disabling to people. I’m not saying death isn’t a terrible factor or a terrible outcome, but the disability can be long term. You’ve heard the term long-haulers. And people who are hospitalized oftentimes are discharged with chronic lung, chronic kidney, and chronic heart disease. As you know, I’ve written an article in Infection Control Today® that advocated that, in many ways, COVID-19 is a heart and lung virus because it can have asymptomatic mild carditis, which can present decades later as a cardiac myopathy. This is to me very concerning. And as with any disease, as we learn more and more about [COVID-19], unless people die, those individuals who escaped death are often severely sick and have chronic long-lasting effects…. We really do need to also focus on that. In other words, what is the true toll on our society?
ICT®: How many mutations could we possibly see with severe acute respiratory syndrome coronavirus 2?
Kavanagh: There’s literally been thousands of mutations with this virus. If you go to nextstrain.org, you can see them plotted over time, and over distance and location. But only the mutations which affect either infectivity or affect the spike protein which causes attachment of this virus to the ACE2 enzyme…are important. [They’re] the ones which are discussed in the media and tend to be tracked. This is an RNA virus. It mutates quite a bit. We shouldn’t be surprised at that. But the important mutations are ones of concern and they need to be followed. Now, I should add that infectivity is a lot easier for the virus to mutate than to mutate away from a vaccine. Because as you know, a vaccine causes a myriad of antibodies to be formed to that spike protein. And a virus would have to evade every single one of them to be successful. And that’s a tall order, because in that evasion, the virus also still needs to maintain the ability of that spike protein to attach to the ACE2 inhibitor. Otherwise, it trades survival from the vaccine for loss of being able to infect and reproduce itself within the cell. This is kind of the situation we see with the measles virus, where it does a lot of mutations. But it can’t mutate out of the vaccine’s coverage because if it does, it can’t become infectious. Now, as far as for monoclonal antibodies, or monoclonal cocktails, where you just have a small number of different types of antibodies the virus could evade…. There are some strains now, [including] one that I believe was detected in Scotland and in Romania, …able to mutate and evade, for example, a single monoclonal antibody. But that’s different than evading the whole vaccine. Of course, it’s still possible. And if it does happen, that will be a grave concern. Luckily, with the new types of vaccines we have, they’re kind of printed out in the lab. They’re not cultured, they’re not grown. You type in the sequence of that new spike protein, and out comes an mRNA, which can be inserted into the vaccine. It really is revolutionary, and it adds to safety. That would take 4 to 6 weeks to do. But nevertheless, the big problem is how do you revaccinate the entire world? We need to slow down the spread of the virus so we can slow down its mutations. That is of utmost importance. I think they have to be able to articulate this message to the public, to give this as another reason why they shouldn’t be out and about and gathering. You have to remember, it’s not the vaccines which prevent disease, it’s vaccinations. And we don’t have enough vaccinations that have been performed [yet]. And so, they need to do that. And they also need to remember that if they do see something strange, or they do see a spike in cases, or they see people…developing reinfection, they need to culture that virus and get it genetically sequenced. Contact the local health department. I’m sure they’ll…have instructions on how to do that. And certainly, the state and the CDC [Centers for Disease Control and Prevention] would be interested, because you want to make sure that a spike in reinfections is not being caused by a viral mutant. So that’s going to be of utmost importance, and something they need to be looking out for. [The vaccines] will still be effective. That’s what the good money is on. Can’t guarantee it, but certainly, that is the likelihood and what is expected to happen. But that doesn’t mean we should keep spreading around the virus, because eventually the virus may find a combination that can both maintain its attachment to the ACE2 receptor plus evade the vaccine. It’s just not good to do. This is another reason why this whole philosophy of herd immunity is just rubbish and magical thinking. We’re going to have to learn to live with the virus. We’ve talked about this before. We’re not going to have everybody taking the vaccine, and the virus has already showed up in the animal population of multiple species. It is unlikely that we’re going to totally eliminate the virus. I think getting a vaccine may become a yearly or every-other-year type of ritual that [we’ll] have to start to undertake.
ICT®: Why do you think herd immunity is magical thinking?
Kavanagh: Herd immunity is where there are enough infected individuals who will stop the spread of the virus, and the percentage will depend upon the infectivity of the virus. The more infectious the virus is, the more people who need to be immune. The problem is, if you have animal hosts, if your immunity drops––and it will over a couple of years––they’ll just reinfect you. You won’t be able to truly wipe out the virus. It’s not a good strategy of getting over this, we really do need to learn to live with [it]. Things will get much better, but I don’t think we’re going to be able to eliminate this virus off the face of the earth, similar to what we did with smallpox. And the reason for that is it has an animal host. The idea of going out getting infected and the virus will go away, that’s not going to happen. It’ll get better, infections will drop dramatically, [and] we can return to a more normal life. But I think right now, it’s going to be pretty much endemic either in animals or in ourselves. And that will see it reoccurring in spots or in areas. And if we all let down our guard and let down our ability to fight off the virus by not getting vaccinations, we may go through this again a decade from now. We do need to follow public health advice. And we really need to get vaccinated at this point, especially if you’re a frontline worker. And it’s not if, but when you’ll come down with COVID-19.
ICT®: It seems you’re describing something like the measles and also, in a way, something like influenza [flu] that comes back every year.
Kavanagh: Well, it’s going to be kind of like the flu in that it can mutate and come back, although maybe not mutate quite as fast as the flu. It’s unlike the flu in that it affects every organ of the body. And I think it’s the people who are asymptomatic who have the primary heart and vascular involvement. Although it’s asymptomatic, it still can be affecting those organs. And as you know, they account for up to 50% of the transmissions. And so, in that way, it’s very different. We’ve really never seen anything quite like this. And I believe it’s definitely deadlier than the flu…back in 1918. There are 2 reasons for this. One, the 1918 flu had a tremendous amount of bacterial coinfections, up to 90% in the lungs of individuals. And at that time, medicine couldn’t treat that. So that resulted in a large excess mortality. [Two], when you look at the infectivity of the virus, the 1918 virus was probably more infective. But it wasn’t because of the characteristics of the virus, it was because of the characteristics and behavior of the human population. At that time, we were in World War I. There was an initial outbreak, I believe it was in Kansas at one of the barracks. And from there, it just spread. And you talk about packing people into trains, into ships, into training camps, on the front lines, and [in the] trenches. It just spread the virus like wildfire, and so you had a huge amount of spiking in cases, along with fatalities…. And this occurred worldwide because it was a world war. So yes, you may see more actual fatalities in total from the 1918 flu. But that doesn’t mean that the virus was more deadly, because we were involved at that time in a world war which was optimizing the transmission of that virus throughout our population. And remember, fatalities from a pandemic are equal to both the case fatality rate but also the transmission of the virus. And that is a function of both the infectivity of the virus and the behavior of the population it has infected. So I know that’s kind of a long answer, but this virus is entirely new, although it does have some similarities to some other viruses and other infections, which allows us to predict what’s going to happen.
ICT®: What’s your reaction when you hear about famous people who are caught violating the social distancing rules that they’re telling the rest of us to follow?
Kavanagh: [I feel] massive amounts of frustration, because that creates doubt in the public as to the validity of their advice. And this has been happening, as you know, fairly commonly. You have a number of leaders who are not preaching the message that they are following. But there are also many leaders who are on both sides of the aisle. You can look at Governor Charlie Baker, Governor Larry Hogan, and Senators Mitch McConnell and Bill Frist, all of whom are preaching the correct public health messaging of wearing masks and social distancing. …Frist… recently called upon both his governor and all governors to enact mask mandates during this [terrible surge] that we’re currently undergoing for these few weeks. I do think the messaging is a problem. We need to keep people on track. And I’ll be honest with you, the thing that bothers me more than anything is that it seems like some of our leaders who have voiced so much that this virus is not much to worry about—“don’t wear masks”—seem to be at the front of the line to get the vaccine. …I am [rather] of the opinion, and I hate to say this on record, [that] if you haven’t been following public health advice—you should get a vaccine, of course—maybe you should let others [go] in front of you because you’re responsible for creating the predicament…we’re in. So that is another area that I think is very frustrating.
ICT®: Isn’t that the crux of the situation? Human nature, isn’t that what we’re up against here?
Kavanagh: Oh, yeah, it’s all human nature, but it drives the public crazy. But this virus doesn’t care. The best example I know of is what happened at the Louisville Zoo [in Kentucky] with the snow leopards. I think I mentioned this in my article. The snow leopards, they’re very good at enforcing physical distancing, not so good at wearing masks, and they caught COVID-19. You have to do both. The virus doesn’t care. If you congregate, you give it a chance, and it’s going to spread. Your best defense right now is following public health advice. And when the vaccines are available, please get the vaccine.
ICT®: Any final words of advice for infection preventionists?
Kavanagh: Just that they should reassure people at this point to get the vaccine. The vaccine will in all likelihood be effective because, again, it’s very difficult for the virus to evade the myriad of antibodies that your body will produce to the spike protein, and at the same time maintain its infectivity and ability to attach to the receptor on the cell. So please message your patients not to panic but to…be diligent and follow public health advice, because an even more infectious virus can cause more deaths and is more dangerous. But the good news is, the vaccine still should work [despite the new strains], as should social distancing and wearing masks make you safer. Although this is not good news, it’s not anything I feel panic over. But it is something that should increase our diligence in following public health advice.