Prospects for COVID-19 in 2021
The COVID-19 pandemic has wrought havoc throughout the world in 2020, but 2021 will start seeing improvements
COVID-19 has caused chaos across the globe, though Europe, the Americas and South Asia have been particularly affected. Having struggled to control the virus as was done in East Asia and the Pacific, many countries are pinning their hopes on ending the pandemic through vaccination. Quantity and quality of vaccines rolled out will determine many of the non-pharmaceutical policies that countries may adopt.
What next
Despite vaccines' promising early results, it is unlikely there will be enough doses available in the next few months to lift strict social distancing measures until at least mid-2021 -- and even then, probably only in high-income countries that have pre-purchased supplies. Lower-income countries will likely lag further behind. Repeated regional or nationwide lockdowns are probable during the colder winter months; social distancing, masks and contact tracing are likely to be needed through most of 2021. Further ahead, much will depend on what vaccines become available, and when and where they are widely rolled out.
Strategic summary
- Early results from several frontrunner vaccines are already emerging; emergency use authorisations will probably come before the end of the year.
- It will be difficult to vaccinate the 2.13 billion people estimated to be at risk of severe COVID-19 disease globally.
- High-income countries will be the first to see vaccines rolled out, apart from China and Russia, which have already allowed vaccinations outside clinical trials.
Analysis
Over 250 vaccines are currently being developed; the majority are still in the pre-clinical phase, though ten are in the last phase of clinical trials before they can request authorisation.
The front-runner is the candidate from US pharmaceutical Pfizer and German biotech firm BioNTech. The duo on November 18 announced that they concluded the Phase III study of their mRNA vaccine candidate (BNT162b2) and would request authorisation from the US Food and Drug Administration (FDA) in the coming days. Primary analysis showed that their vaccine was 95% effective: out of 170 confirmed COVID-19 cases, 162 were in the placebo group and only eight in the vaccine group. For people over 65 years of age, efficacy was 94% -- a key question since immune defences wane with age and COVID-19 particularly affects older cohorts.
US pharmaceutical firm Moderna announced on November 16 that its mRNA COVID-19 vaccine candidate (mRNA1273) had 94.5% efficacy, according to an independent committee reviewing its trial data (see INT: Early vaccine hopeful, but more will be needed - November 10, 2020). Russia's Gamaleya Research Center also reported its own viral-vectored candidate (Sputnik V) was 92% effective in early results based on 20 confirmed cases, though there are questions around the trial data.
Limited authorisations could come as early as December
The United Kingdom's Oxford University and pharmaceutical AstraZeneca viral-vectored candidate (ChAdOx1 nCov-19) expects preliminary results by December. A study published on November 19 from the Phase II trial shows it triggers good immune responses in those over 60. US vaccine developer Novavax expects results in the first quarter of 2021 for its recombinant protein candidate NVX-CoV2373.
China's four vaccines (made by three companies, Sinovac Biotech, Sinopharm and CanSino Biologics) and Russia's Sputnik V are on similar timelines, with further interim data expected by the end of the year.
China's vaccines are already available, even as last-stage trials are underway. Sinovac's could be rolled out on a large scale in early 2021. Russia has also authorised vaccines for high-risk groups.
Distribution outlook
High-income countries have made deals with most front-runner companies to provide vaccines for their populations.
All countries have an incentive to acquire as many different candidates as possible to vaccinate their populations and end their epidemics quickly, but only high-income countries can afford to do so. This could mean epidemics in high-income countries are brought under control faster than in low-income countries. According to a Duke University projection, there will not be enough vaccines to immunise everyone in the world until 2024 (see INT: Vaccine nationalism may prolong pandemic - September 2, 2020).
Duke reports that the United States (population 328 million) has pre-purchased 800 million doses from various developers; the EU (population 448 million) has pre-purchased 400 million doses, India (population 1.35 billion) 600 million, and the United Kingdom (population nearly 67 million) 340 million doses. COVAX, a mechanism for all countries in the world to share the risk of developing a vaccine and have access to eventual successful candidates, has pre-purchased 600 million doses. Several low-income countries appear to be depending on COVAX for their allocation.
Assessment
A vaccine that reduces severe illness and mortality would ease the burden of disease on healthcare systems, allowing better care for those who do become extremely ill (from COVID or other diseases) and improving their outcomes.
It is likely that a vaccine that reduces symptoms will also reduce the period of time a person is infectious and viral load -- even if it does not stop transmission completely. This would further help to stem the virus's spread.
Evidence is accumulating that the disease confers immunity for a few months, based on a few reported cases of reinfection, although no conclusions have so far been drawn (see INTERNATIONAL: Immunity will shape pandemic's future - June 26, 2020). Population immunity will eventually make it more difficult for the SARS-CoV-2 virus to spread, which will reduce the incidence of hospitalisations -- although the number of people who have had COVID-19 is still assessed to be around 10% globally, so it will be some time before that happens.
It is possible that there will be enough doses to vaccinate most people vulnerable to severe COVID-19 or enough people to break chains of transmission in 2021. Several vaccine types are likely to emerge that will help stem the pandemic (see INT: Multiple COVID-19 vaccines will aid distribution - November 5, 2020).
However, the logistics of rolling out the vaccine to so many people will be a major challenge; allocation strategies and distribution may not be efficient given that the two front runners require deep freezing storage (see INT: COVID vaccine roll-out will face multiple hurdles - October 14, 2020 and see INT: COVID-19 vaccine allocation may change over time - October 30, 2020).
2.13bn
People estimated to be at higher risk of severe COVID-19 globally
A Lancet study published in June estimated that 22.4% of the global population has at least one underlying condition that puts them at higher risk of severe COVID-19; that is 1.75 billion people. The number rises to 2.13 billion if all people over 60, who are at higher risk by virtue of age, are included. Most are in Europe (39%) and North America (35%), partly because they have older populations. However, severe cases are more likely to be fatal in Africa than elsewhere, likely due to healthcare shortages and other comorbidities (see INT: World may turn corner in COVID-19 fight in 2021 - November 17, 2020).
Meanwhile, the world will need to rely on behavioural change, such as social distancing measures, alongside therapeutic drugs to manage severe illness from COVID-19. Low-cost steroid dexamethasone has been shown to reduce mortality by up to one-third in hospitalised patients with severe COVID-19, but results for other treatments such as antiviral remdevisir and monoclonal antibodies (both far more expensive) are still not conclusive.
Outlook
Repeated regional or nationwide lockdowns are likely during winter months. Social distancing interventions, such as wearing masks, ensuring good ventilation and limiting crowded venues will most likely persist throughout 2021, though they will probably ease during summer (see INTERNATIONAL: Coming months to be pandemic's riskiest - July 30, 2020).
Restrictions may not return in such a severe form after mid-2021 in the northern hemisphere, if a sufficient number of people have been vaccinated by the time cold weather sets in (see INTERNATIONAL: COVID-19 cases will rise in winter - September 8, 2020).
The true effectiveness of the vaccines, their duration of protection, their uptake among the public and the ability to distribute them at scale across the globe will be crucial in shaping the ultimate outlook for the pandemic.
