Viewpoint: Time to Consider Penalties for COVID-19 Unvaccinated

Recently President Joe Biden’s disbanded transition COVID Task Force published a series of Viewpoints in JAMA Network which clearly articulate what we all should know but far too many are afraid to accept.

SARS-CoV-2 is endemic, and we must adapt to live with it. This is based on observing that immunity from SARS-CoV-2, whether from vaccines or infections, is short lived, asymptomatic spread is frequent and the incubation time is very short, making identification of contacts problematic and vaccinations not having enough time to ward off disease.

In Kentucky, my home state, these warnings are largely interpreted as a prescription to ignore the virus and live as usual However, continuing to pay 400 million dollars in insurance allowable hospital charges and bury 600 Kentuckians each year is both immoral and unsustainable.

A second JAMA commentary clearly state that the most effective measure is to “eliminate exposure to potentially infectious individuals”; in other words: Testing and isolation. With the propensity of SARS-CoV-2 to aerosolize, the second most effective measure was attention to ventilation, an intervention which the vast majority of indoor venues, including schools, have all but ignored. In addition, N95 masks need to be readily available for the public. Widespread use of PCR and rapid (home) testing is also key, but rapid tests will not detect low levels of the virus and may miss asymptomatic carriers. Rapid (home) tests are best to screen for high infectivity before an event or to test once one turns symptomatic. Viral load is the highest at the beginning of the symptomatic illness and using a home test on day 1 and, if the test is negative, then again on day 2 or 3 is recommended. This is why rapid (home) tests are sold in boxes containing two tests.

Unfortunately, in my home county, the school system chose to spend 1 million dollars of its COVID-19 funds on resurfacing two outdoor tracks.

There is also a call for a unified tracking and reporting system to collect, “data from all medical and testing facilities, all emergency department cases, and all hospitalizations, ICU admissions, and deaths…,” along with “disease-specific outcomes, and immunizations” which are “merged with sociodemographic and other relevant variables.” This strategy should be applied to all infectious agents and is essentially a call for a unified national health care system. This is why the Ministry of Health Israel and Public Health of England have timely and comprehensive data which can guide their health policy. The United States’ data are based upon incomplete extrapolations which are fraught with errors. Unfortunately, our country is far from adopting universal health care and we are still grappling with deep political divisions among our leaders which is inhibiting our pandemic response.

To this end, it may be more practical to form a national public health care system by building upon the US Veteran Administration’s infrastructure and 4th mission mandate to aid the United States in public health emergencies.

Therapeutics are also problematic. Immunity to natural infections and vaccines are short lived and as stated by Oxford scientist Andrew Pollard, “We can’t vaccinate the planet every four to six months. It’s not sustainable or affordable.” Such a position may be overly pessimistic but no one denies SARS-CoV-2 presents formidable therapeutic challenges. As discussed in a Viewpoint by Borio, et al. Ninety percent of the population may need to become vaccinated before minimizing the effects of the pandemic on daily life. Vaccinations may become annual events and need to be updated to target circulating variants.

There was a call for mandates, vaccine passports, and proof of vaccination or a negative SARS-CoV-2 test before using public transportation or attending indoor events. It was pointed out that “Few countries have ever achieved such levels of coverage of any vaccine without vaccination requirements.”

Rapid development of SARS-CoV-2 therapeutics is needed. Currently, only one monoclonal antibody is effective and the new drug Molnupiravir has “relatively low effectiveness and there are questions about potentially serious adverse effects.” The supply of all therapeutics in the US is severely limited.

Borio, et al. also called for widely available no-cost testing and making sure everyone is offered appropriate and rapid treatment.

Many feel free COVID-19 treatment in combination with mandated healthy living (vaccinations, masks, etc.) are the answer to this pandemic. However, in our regulation adverse society, we may need to pivot to the strategy adopted by Singapore, to have voluntarily unvaccinated individuals to pay at least a portion of their care. It is very easy to act irresponsibly when others are funding your safety net if a bad outcome occurs.

To cope with this pandemic, we need to decrease the spread of this virus. Executive action is needed for the formation of a National Public Health Service, along with the reappointment of a Coronavirus Task Force in the US. Building this pandemic response foundation is an overriding imperative.