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Your COVID Vaccine: Opportunities and Threats

Living through one historical event after another can feel exhausting. It should have been impossible to say this, but the record high numbers of COVID deaths have not even been the top headlines in recent days. While we are living in interesting times, we can at least talk about the promise of breaking dawn: maybe we’re in those coldest hours that come before light, in this case in the form of widespread COVID immunization.


We aim to keep perspective: We here at Public Health Rising are privileged enough to say we can get through a few more months of COVID restrictions, and we know many others are not in a similar position, having lost businesses, their life savings, or more. We can commiserate with friends and family, we can think about a health worker with ulcerating skin on the bridge of their nose from 18 hour shifts in an N95 mask, we can keep our attention on the societal crime of inequity that continues unabated in this pandemic, and we can think about all of our global neighbors who have lived through seemingly never-ending historical events (war, forced migration) and have no promise of a vaccine coming in the next weeks or months.


What we can’t yet do is share the air with people outside of a COVID-safe bubble. What we’re holding out for is vaccination. Here’s an overview of how things are unfolding:


Vaccines: There are dozens of COVID vaccines in development around the world. In the U.S., in addition to the two already rolling out there are only three that may be in position for FDA to grant authorization anytime soon. But vaccine development in India, China, Russia, and elsewhere is critically important for pandemic control. Global efforts have direct bearing on achieving control in the U.S., where another element of the flat learning curve is a long history of not learning that when we fail to care for everyone, we may fail to care for anyone. This is illustrated in our COVID response in a number of ways, such as lack of paid leave that created a disincentive to call in sick when ill, leading to superspreading events and over-run hospitals that do not have the capacity to treat your heart attack, car crash injuries, or cancer. Community immunity (also called herd immunity, but we’re thinking in terms of our social fabric -- not cows) works well when your community has achieved a relatively high level of immunization. Our community is global. So let’s dive into some vaccine info, starting with what we’re seeing in the U.S., and we’re aiming for relatively plain language here without getting into the nuances of classifying next-gen vaccines:

  • Two RNA vaccines from Pfizer and Moderna (currently authorized) and two recombinant DNA vaccines from Janssen (aka. Johnson & Johnson) and Oxford / AstraZeneca (both in advanced trials, with a request for emergency authorization expected in February). The DNA is delivered through a vector virus, so you’ll often see these classified under “vectored” vaccines, but all four of these vaccines bring the code for a fragment of the COVID virus into our cells, and use cellular machinery to translate that code into one of the key COVID proteins that immune cells recognize (that’s the spike protein, and those immune cells generate antibodies against it). The RNA vaccines have shown very high efficacy against COVID disease (around 95%) while Oxford / AstraZeneca efficacy ranges from 62-90% and we’re waiting for data from Janssen.

  • One protein vaccine, from Novavax (another federally supported protein vaccine, from GSK / Sanofi, is delayed significantly). These vaccines use a more traditional approach, with a fragment of COVID (again, the spike protein) injected for recognition by immune cells that generate antibodies. The Novavax vaccine may come forward with a request for FDA authorization by March. Efficacy data are not yet available.

  • Does it matter which of these vaccines you get? Perhaps to some extent -- but if you get called in for vaccination, take it, regardless of manufacturer!

Vaccinations: This is about getting shots into arms, as opposed to “vaccines” -- the stuff inside the shots.

  • Roll out so far has been bumpy, with CDC prioritization guidance changing late and not adopted consistently by states. Centralized vaccine appointment scheduling systems do not exist, phone lines are overwhelmed, and tracking systems have significant blind spots. While CDC data reflects only about 30% of available doses administered, we don’t know how many front line health workers are not being captured in those figures. Unlike typical patients whose vaccines are automatically captured in secure immunization information systems through their electronic medical record, records for staff at many health facilities are kept separately (for privacy assurance reasons) and are not always connected to immunization information systems. So it’s possible there’s a significant number of staff being immunized through occupational health systems that we don’t see reported; and it’s also possible that we have an unreasonable amount of vaccine sitting in freezers. We don’t know. We also don’t know if we’re making progress in equitable distribution of vaccines.

Threats:

  • Globally, availability isn’t emerging quickly enough. In the U.S., achieving equity goals and making decisions on moving through priority phases are hobbled by missing information.

  • Manipulation of prioritization and access to vaccination hopefully represents a very small fraction, but it’s hard to know. Clarity in guidelines and trust in information about vaccine distribution would certainly help people have confidence in an “honor system” and wait their turn, but with different approaches in different states many folks are likely to see that these differences reflect lack of consensus, which can undermine trust. People also see that the U.K. has changed schedules for second doses, and there’s ongoing debate in the U.S. about similar measures, as well as the possibility of changing the amount of vaccine administered in each dose, particularly for the Moderna vaccine. This may be a reasonable consideration (Moderna phase 1 trials showed little difference between 100mcg and 250mcg doses; a 50mcg dose had similar results in phase 2; our current regimen of 100mcg is based on phase 3 trial results, which did not have a direct comparison to 50mcg), but the discussion reinforces perceptions of uncertainty and scarcity.

  • Bad actors are out there (like this, for example). There’s no reason to believe there are a lot of these characters, and in most cases a team is involved and a lone individual should have limited power in health care settings. It will be important that these stories come to light quickly, with transparency and details available to the public to show any situations are being detected, addressed, and communicated.

  • An emerging threat may be variant COVID viruses, although this is not an immediate concern for vaccine efficacy (it does appear to be a concern for accelerated spread of COVID!). A critically important advantage of the leading vaccines is that they present the entire COVID spike protein to the immune system, rather than just a small portion. That means a wider array of antibodies can be generated, and the virus would need to develop multiple additional mutations to escape vaccine-induced protection. That may still occur, but the preliminary signal from circulating variants right now is that current vaccines will still be effective.

  • Finally, confusion between COVID disease and COVID infection is likely to become important as more people receive vaccines and start changing their COVID-safe behavior. It will be some time before we can all stop practicing safe six. COVID vaccines so far have been shown to protect against COVID disease -- if you get infected, you won’t get sick with symptoms. We don’t know much yet about “sterilizing immunity,” which refers to preventing infection in the first place. It’s possible immunized people, without ever developing disease themselves, can acquire COVID infection and transmit to others. Prematurely dropping safety behaviors could cause significant setbacks en route to community immunity.


Parts of this story seem too good to be true: are the first vaccines authorized for use the best that we’re going to see, in terms of safety and efficacy, and in fact may be ushering in the next generation of vaccine advances, including faster development and administration without needles? That will be proven or disproven in coming months, but we’re off to a good start. Other parts seem too painful to register: the potential we have vaccine supplies sitting in freezers while disproportionately impacted communities remain unprotected. Our hope is that soon we’ll be able to start tackling the next big question: as vaccines reach people, will life start to look like it did before the pandemic? Look for that discussion in a future post.

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