More COVID-19 cases but fewer working treatments against shifting virus

Editor’s note: After this story was published, the Food and Drug Administration announced on Jan. 26, 2023 that Evusheld is no longer authorized as a preventative treatment against coronavirus in the U.S. New subvariants causing the majority of cases of COVID-19 in the country are unlikely to be susceptible to the treatment, according to the FDA.

As of January 20, 2023, >90% of circulating SARS-CoV-2 variants in the United States, specifically Omicron BQ.1, BQ.1.1, XBB, and XBB.1.5 sublineages, are unlikely to be susceptible to the combined monoclonal antibodies, tixagevimab and cilgavimab (Evusheld) used for preexposure prophylaxis against SARS-CoV-2 infection (1). The Food and Drug Administration announced on January 26, 2023, that Evusheld is not currently authorized for preexposure prophylaxis against SARS-CoV-2 infection in the United States

It’s beginning to look a lot like another holiday COVID-19 surge is coming.

Physicians and public health officials are tracking a sharp rise in COVID infections in the past month. They’re also coping with a shrinking number of treatments that are effective against the bevy of new variants.

“It’s a mixed bag,” said Dr. Felipe Lobelo, an epidemiologist at Kaiser Permanente of Georgia. “It’s obviously not as disruptive as last winter in terms of the sheer number of cases and hospitalizations, but there’s still a substantial number of deaths across the country. In Georgia, we clearly see an increasing trend over the last few weeks since Thanksgiving.”

COVID cases in Georgia have been steadily rising with the 7-day average of new confirmed cases increasing to 1,079 as of Wednesday, up from 423 a month earlier — a 155% increase, according to DPH data. Due to the prevalence of at-home COVID tests, which are not reported to health officials, the actual case numbers are probably far higher than those numbers reflect.

COVID hospitalizations have also been climbing, reaching 843 on Thursday up from 607 a month ago, representing a 33% increase.

Credit: Miguel Martinez

Credit: Miguel Martinez

And the Georgia Department of Public Health weekly report ending Dec. 14 noted 42 confirmed COVID deaths in the state. Because there’s a lag between when a death occurs and when it is documented by the state, that number doesn’t represent deaths that occurred that week.

Meanwhile, the updated vaccine booster has not been well received by the public. Only 8.9% of people in Georgia who are age-eligible for the booster have received one, according to the latest CDC data Thursday.

And complicating treatment for those who do get COVID, the U.S. Food and Drug Administration recently announced that bebtelovimab, a monoclonal antibody drug given through a vein, is no longer authorized because it is not effective against the leading strains of COVID. It was the last remaining monoclonal antibody treatment authorized.

The FDA recently warned Evusheld, which remains the only preventive medicine for high-risk patients, is losing its effectiveness against the widely circulating omicron variants. Public health experts say while the treatment is still authorized, the days are likely numbered for what has been considered the best safeguard for immunocompromised people, including organ transplant recipients and those undergoing cancer treatment.

There are only three remaining authorized treatments to help keep people at high risk for disease out of the hospital: two antiviral pills and one intravenous medication. Paxlovid and Lagevrio are pills and can both be taken at home. Remdesivir must be administered intravenously in a medical setting. Rather than killing the virus directly, these antivirals are all designed to suppress the virus’s ability to reproduce in the body.

Credit: Emory University

Credit: Emory University

Dr. Aneesh Mehta, chief of infectious diseases at Emory University Hospital, said antivirals in pill form are generally the go-to option for most patients. Paxlovid is the preferred antiviral pill.

While the antivirals have so far maintained their effectiveness against the ever-evolving virus, Mehta said it’s critical for scientists and clinicians to develop more treatment options.

“Our major concern continues to be our highly vulnerable population and that includes our immunocompromised patients, whether they be on medications that make them immunocompromised or have other diseases like cancers that make them immunocompromised, or the elderly population,” he said. “I think our viral medications are going to continue to work but they only have limited effect in stopping the progression in this highly vulnerable population.”

Meanwhile, concerns are rising about the evolving omicron subvariants possibly triggering a wave of infections this winter, even in people who have been previously vaccinated or infected.

The updated “bivalent” booster protects against the original strain of COVID as well as the BA.4 and BA.5 omicron strains. A study of the bivalent booster by the Centers for Disease Control and Prevention found it provided protection against symptomatic infection in about 40% to 60% of cases. Since the study was conducted, newer strains are now responsible for most of the new cases.

Credit: AtlantaProfessionalHeadshots.com

Credit: AtlantaProfessionalHeadshots.com

Dr. Nadine Rouphael, a professor in the Emory Department of Medicine, and others are particularly concerned about the XBB subvariant, which has crept upwards and is now estimated to represent close to 7% of new cases in Georgia and other states in the region, to evade immunity.

Public health experts anticipate the updated booster will continue to protect against severe illness, hospitalization and death. But Rouphael said just how well the latest booster holds up against this newest generation of omicron offshoots remains to be seen.

“Unfortunately, we still have a lot of questions,” said Rouphael who is also the executive director of the Hope Clinic, the clinical arm of the Emory Vaccine Center. “I think we stay vigilant about the risk that’s coming. ... And I think we have to use anything we have in our toolbox.”

Mehta and Lobelo agree. And together, the trio strongly recommended staying up to date on vaccinations, not only COVID vaccines and boosters, but also flu vaccinations. For those who get sick with COVID, they encourage seeking out antivirals for those who are eligible.

Credit: Steve Schaefer

Credit: Steve Schaefer

They also emphasize the role of hydration, nutrition, and rest in recovery. Mehta knows this from first-hand experience.

“When I had COVID A few months ago, I realized that despite me giving advice to my patients, very early on, I wasn’t doing enough to get good (amounts of) fruits and vegetables and getting hydration. ... It just reinforced why I need to talk to all of my patients about the importance of rest and nutrition when they have an illness,” he said.

As the virus changes, Rouphael said expectations for COVID vaccines and boosters also need to change.

“I think some people are thinking like ‘Wow, I took the vaccine, and I should not be facing this (illness),’” she said. “But the role of the vaccine is preventing us from going to the hospital and death.”

Lobelo said he understands people are frustrated, including those who are vaccinated and boosted and still get COVID, sometimes multiple times.

“We are all frustrated with the cards we were dealt from an evolutionary biology perspective,” said Lobelo.

“I think we are in a situation where we as a society, for whatever reason, we are tired, COVID is over, we want to move on. If I don’t think about, if I don’t get a shot, that reflects we’ve moved on,” said Lobelo. “And yes, we’ve moved on but the fire is still there.”