The Atlanta Journal-Constitution
Vaccine won’t immediately restore normal life,
It can be viewed as a silver bullet, but reality is far more nuanced.
In the public imagination, the arrival of a coronavirus vaccine looms large: It’s the neat Hollywood ending to the grim and agonizing uncertainty of everyday life in a pandemic.
But public health experts are discussing among themselves a new worry: that hopes for a vaccine may be soaring too high. The confident depiction by politicians and companies that a vaccine is imminent and inevitable may give people unrealistic beliefs about how soon the world can return to normal and could lead to resistance to simple strategies that can tamp down transmission and save lives in the short term.
Two coronavirus vaccines entered the final stages of human testing last week, a scientific speed record that prompted top government health officials to utter words such as “historic” and “astounding.” Pharmaceutical executives predicted to Congress in July that vaccines might be available as soon as October, or before the end of the year.
As the plotline advances, so do expectations: If people can just muddle through a few more months, the vaccine will land, the pandemic will end and everyone can throw their masks away. But best-case scenarios have not materialized throughout the pandemic, and experts — who believe wholeheartedly in the power of vaccines — foresee a long path ahead.
“It seems, to me, unlikely that a vaccine is an off-switch or a reset button where we will go back to pre-pandemic times,” said Yonatan Grad, an assistant professor of infectious diseases and immunology at the Harvard University T.H. Chan School of Public Health.
Or, as Columbia University virologist Angela Rasmussen puts it, “It’s not like we’re going to land in Oz.”
The declaration that a vaccine has been shown safe and effective will be a beginning, not the end. Deploying the vaccine to people in the United States and around the world will test and strain distribution networks, the supply chain, public trust and global cooperation. It will take months or, more likely, years to reach enough people to make the world safe.
For those who do get a vaccine as soon as shots become available, protection won’t be immediate — it takes weeks for the immune system to call up full platoons of disease-fighting antibodies. And many vaccine technologies will require a second shot weeks after the first to raise immune defenses.
Immunity could be short-lived or partial, requiring repeated boosters that strain the vaccine supply or require people to keep social distancing and wearing masks even after they’ve received their shots. And if a vaccine works less well for some groups of people, if swaths of the population are reluctant to get a vaccine or if there isn’t enough to go around, some people will still get sick even after scientists declare victory on a vaccine — which could help foster a false impression that it does not work.
A proven vaccine will profoundly change the relationship the world has with the novel coronavirus and is how many experts believe the pandemic will end. In popular conception, a vaccine is regarded as a silver bullet. But the truth — especially with the earliest vaccines — probably will be far more nuanced. Public health experts fear that could lead to disappointment and erode the already delicate trust essential to making the effort to vanquish the virus succeed.
The drive to develop vaccines is frequently characterized as a race, with one country or company in the lead. The race metaphor suggests that what matters is who reaches the finish line first. But first across the line is not necessarily the best — and it almost certainly isn’t the end of the race, which could go on for years.
Lessons from history
On April 12, 1955, a vaccine against polio was shown effective and safe. Its inventor, Jonas Salk, became a national hero. Church bells rang, and people ran into the streets to hug one another, said Howard Markel, a historian at the University of Michigan.
But there were bumps along the way, even as scientists and public health authorities sought to thwart a disease that was of greatest threat to children. The “Cutter incident” became an infamous moment in medicine, when one of the suppliers of the vaccine failed to fully deactivate the virus in the shot, infecting about 40,000 children, paralyzing 51 and killing five. Those infections seeded their own epidemic, paralyzing 113 others and killing an additional five people.
“What’s incredible is it was only a blip,” Markel said. “Parents were so trustworthy of doctors and scientists, and it went on, people got their shots.”
The Salk vaccination was a transformative moment, but it was also not the end of polio. Over the course of two years, cases in the United States dropped by 80%, but outbreaks continued for several years, even as the vaccine was rolled out. Six years later, an oral polio vaccine that could be given as a sugar cube that dissolved on children’s tongues was introduced. Polio was eliminated in the United States in 1979.
But the polio vaccine came at a distinct moment in American history, Markel said, when people had great faith that scientists, medicine and government institutions could change their lives for the better. For the coronavirus, a relatively small setback — a miscommunication about vaccines, an unpleasant side effect, a much-hoped-for candidate that fails in large clinical trials or a vaccine that is only partly protective — could have outsize effects, especially with anti-vaccine activists already working to sow distrust.
Vaccine performance
Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, testified Friday before Congress that he is “cautiously optimistic” that a 30,000-person, Phase 3 clinical trial that is getting underway will yield an effective vaccine. But there has been little talk about how to think about failures, even though those are an inevitable part of science.
“What happens if any of them fail a Phase 3 trial — are people just going to give up? Is it going to be like entering Dante’s inferno?” Columbia’s Rasmussen said. “I’m really worried people have been relying on this hope that a vaccine is going to fix everything, and vaccines are not perfect, just like any type of therapeutic. They do fail.”
All approved vaccines must be shown to be safe and effective, but that does not mean they perform the same. The measles vaccine is one of the best — 98% effective at preventing disease. But the flu vaccine clocks in most years at 40% to 60% effective. And some vaccines work less well in groups of people — older people, for example, have less robust immune responses and need a special high-dose flu vaccine, or one with an extra ingredient called an adjuvant.
U.S. regulators will require a coronavirus vaccine to be 50% effective, and if a shot just barely clears that bar, public education will be required to help communicate how many people need to receive it to establish herd immunity — a threshold at which enough of the population is immune to stop the spread, when the virus is truly tamed.
“If you get a vaccine that just meets the guidelines, the chances are you’re not going to be able to achieve herd immunity,” said Walter Orenstein, associate director of the Emory Vaccine Center. “You tamp down transmission, substantially. It decreases your risk of getting exposed, but it doesn’t eliminate it. But a 50% effective vaccine is a lot better than 0% effective vaccine. I would take it.”