Vaccine Readiness

It is estimated that at least 70% of the population needs to be immune in order to begin to see significant herd immunity.  Currently, only about 50% of Americans are willing to get vaccinated.  At this point in time, we have 2 vaccines completing phase 3 trials with emergency use authorization pending.  Pfizer’s mRNA vaccine on 12/10/2020 and Moderna’s mRNA vaccine on 12/17/2020.  Both these vaccines have demonstrated safety and about 95% efficacy in preventing symptomatic disease and about 99% efficacy in preventing severe disease.  We have been told that once given authorization, they can be immediately distributed and ready to be given with 2 days.  The details of the distribution plan are not yet available.  Other vaccines will become available soon afterward.

Initial Distribution

The initial supply of the vaccines will be severely limited and with 50% of Americans willing to receive them, the demand will far exceed the supply.  Therefore, those that refuse the vaccine will not slow the initial effort to protect the country.  The limited supplies will be prioritized to health care providers and other front line workers at high risk of exposure and the elderly and those with co-morbidities predisposing them to severe disease and death from Covid-19.

Hidden Problem

Most companies have not yet begun studying the vaccines in children.  Children make up 25% of the population in the USA.  Although children are at statistically lower risk than adults for severe disease, they also can become seriously ill and die from Covid-19.  In addition, although they are less likely to become seriously ill, they are just as likely to become infected and spread the infection.  Because they are more likely to be asymptomatic or mildly symptomatic, they are an unseen, concealed danger to everyone.  The American Academy of Pediatrics recommends children under 2 years of age not wear masks due to concerns about interfering with breathing.  Adults do not normally isolate themselves from infants and children.  During office visits, my greatest fear is not taking a nasal swab from a possibly Covid-19 positive patient, but instead, examining an unmasked, crying, struggling infant or toddler who is spraying his respiratory secretions throughout the room.  I wear an N95 mask and face shield for those exams.  Vaccinating children for Covid-19 is not the first priority and current vaccine supplies are very limited.  I expect that by the time the vaccine supplies increase substantially, the studies on children will have been completed.

Mid and End Distribution

After the first 100 million doses of vaccine are given an increasing majority of the remaining people will be unwilling to be vaccinated.  Assuming the safety and effectiveness of the vaccines hold up following the initial mass distribution, what strategies are likely to work to allow us to achieve herd immunity? 

• The safety and effectiveness data need to be clearly communicated to the public.
• Comparison data of infection rates in contained groupings like nursing homes, prisons, hospital employees, police force, etc. before and after vaccination.

Guaranteeing Herd Immunity

I never cease to be amazed by how many parents don’t have their children receive routine child vaccinations because they want to protect the health of their children, but rather do it because it is required for school or daycare attendance.  The same holds true for hospital employees, many of whom would refuse influenza vaccine if it were not required for their employment.  Given that is “standard behavior” for our population I propose the following as examples of entities that should require Covid-19 vaccination for their employees:

• Hospitals
• Medical Offices
• Nursing Homes (employees & residents)
• Federal, State, Local Government employees
• Police departments
• Fire departments
• Schools (employees & students)
  • College
  • High School
  • Middle School
  • Elementary School
  • Preschool/Daycare
• Prisons (employees & inmates)
• Public Transportation (Even better if you include passengers)
  • Airlines
  • Buses
  • Boats
  • Taxis, Uber, Lyft
• Delivery Services (UPS, FedEx, Amazon, etc.)
• Gyms
• Restaurants
• Bars
• Personal Services
  • Hair Salons
  • Nail Salons
  • Tattoo Parlors

Until Herd Immunity is Achieved

In the meantime, while we wait to achieve herd immunity, we must do our best to prevent infection spread (Don’t Share Air):

• Avoid contact with people whenever possible
• Social distancing (6+ feet apart)
• Wear a mask if around people
• Meet outdoors instead of indoors if possible
• Wash/sanitize your hands frequently

Conclusion

Many questions remain to be answered:

• How long will immunity last for each vaccine?
• How long will immunity last following a Covid-19 infection?
• Will there be rare serious vaccine side effects found after we have more experience with the vaccines?

Achieving herd immunity is readily achievable, but only if we “put our foot down” and insist it be done.  As of this writing, Worldometer shows 266,016 people have already died in the USA of Covid-19.  We now have the tools to stop it.  Let’s get it done.

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Arnold Solof, MD

   ABC news today relayed a statement from WHO (The World Health Organization) “Globally, about 3.4% of reported COVID-19 cases have died,” WHO Director-General Dr. Tedros Adhanom Ghebreyesus said at a press conference in Geneva on Tuesday. “By comparison, seasonal flu generally kills far fewer than 1% of those infected.”

  The problem with this statement is the denominator which is “reported COVID-19 cases”.  

  We already know that the majority of even reported cases are mild illness and that the infection can, in some cases, be completely asymptomatic.  Until we test general population samples regardless of the presence of any symptoms we will not know how prevalent the virus is in our communities and what the true lethality rate is.

  Let me illustrate some points by comparing COVID-19 with other infectious diseases that have been well studied.  

  When the CDC reports about epidemics like Influenza in their publication MMWR (Morbidity & Mortality Weekly Report) they describe the clinical presentation in terms of percentages of cases with listed symptoms.  So, for example, a Flu outbreak study might reveal 80% of cases with fever, 70 % with cough, 75 % with runny nose, 25% with abdominal pain,  60% with body aches, 15 % with diarrhea,  25% with vomiting, etc.  Note that most cases will not have every possible symptom and that each case might have a different combination of symptoms, even though they are infected with exactly the same virus.   The percentages often vary in different subgroups, so, for example, children with Flu get gastrointestinal symptoms more often than adults and that an individual case might present clinically more like gastroenteritis than Flu.  

  So, considering the above, we have yet to fully define the clinical spectrum of COVID-19 because we are only recognizing the patterns we have already identified.   If COVID-19 were also to cause a greater gastrointestinal pattern in children compared to adults, and a COVID-19 infected child with predominently gastrointestinal symptoms presented to a physician for a diagnosis, it would not be identified.

  Consider the case of meningococcal infections.  Meningococcus is known & feared for causing extremely serious and potentially fatal infections of septicemia and meningitis.  However, outbreaks of meningococcal disease often consist of 1 to a few cases.  Meanwhile, in some of those outbreaks, more than 10% of some populations (eg. college students) could be carrying the bacteria silently with no  symptoms, spreading it around the community.  Only the few unlucky individuals who get the severe forms of the disease are recognized as having it.

  So I anxiously await studies/surveys of samples of the general population so we can get a much more complete and numerically accurate picture of COVID-19 and what we are dealing with.   My suspicion is that the lethality of the virus is much lower than what is currently being reported.  The above studies will provide the answers.

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