How We Should Approach Coronavirus Variant Tracking

 COVID-19 daily cases have plummeted 65% over the last five weeks, mostly because natural immunity from prior infection is much higher than many experts predicted. Augmenting that community immunity are vaccines, which are now being delivered at a rate of approximately 1.7 million per day. By April, the rate of new coronavirus infections in the U.S. is likely to be very low.

But a looming threat -- variants -- means it's too early for us to breathe a sigh of relief. Until this point, reinfections have been rare during the pandemic. But the Brazilian strain of COVID-19 has demonstrated both laboratory and clinical evidence of having partially mutated around natural and vaccinated immunity. The Brazilian and South African variants have a mutation of the receptor-binding domain, which may partially or completely evade testing or antibody therapy. There may also be variants that have yet to be described but may emerge in the coming weeks to months.

Genetic sequencing allows us to understand the unique clinical characteristics of new variants and design a modified vaccine to prevent their transmission next fall. We're going to be living with COVID -19 for a long time. It's like the four other coronaviruses that have circulated seasonally and make up approximately 25% of the cases of the common cold. It appears that COVID-19 has become the fifth -- and the deadliest.

The U.S. had been sampling approximately 250 infections per week and more recently, the number has increased to 4,000 infections per week. But as we hunt for new variants, we should sequence wisely.

In addition to random sampling, we should order gene sequencing for all COVID-19 cases that meet any of the following criteria:

1. Any COVID-19 re-infection
2. Any COVID-19 death in a healthy person under age 50
3. Any COVID-19 infection acquired after recent travel overseas
4. Any COVID-19 infection that tested negative and later tested positive during the same sickness
5. Any COVID-19 infection in which antibody therapy was ineffective and the patient's condition worsened
6. Any atypical COVID-19 infection

Given the risk of the unknown with new variants, any patient meeting these criteria should also undergo detailed contact tracing. We must be on the lookout. Selective sequencing in addition to random sampling for surveillance will also help us understand the prevalence and clinical manifestations of new variants.

Testing for COVID-19 last year was embarrassingly late to market and woefully inadequate for much of the spring and summer. But we can do sequencing right. We should invest in sequencing on a national level. And at the bedside, whenever possible, physicians should order genetic sequencing on all atypical cases and unusual presentations, which could be an early detection system for a future epidemic.

Marty Makary MD, MPH, is editor-in-chief of MedPage Today as well as professor of surgery and health policy at the Johns Hopkins University School of Medicine and author of The Price We Pay: What Broke American Health Care -- and How to Fix It.

https://www.medpagetoday.com/blogs/marty-makary/91237