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Be Hopeful but Cautious about COVID-19 Vaccine

Mosley, Mark MD, MPH

doi: 10.1097/01.EEM.0000697768.81268.6b
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    Figure:
    COVID-19, vaccine

    I'm sure you're getting the same questions I am: “Are you seeing much of the virus?” “Do you think there will be a second wave?” “Do you really think we should be wearing a mask everywhere?” “I've heard they might have a vaccine available pretty soon. What do you think?”

    You are not only a front-liner, but everyone in your community sees you as a leader, probably for the first time in your career. This is in your wheelhouse. A couple of times every shift, a nurse or someone in your department, regardless of his training, says to you, “Sorry, I don't feel comfortable about what is happening in room X (e.g., mental status, breathing, blood pressure, patient behavior). Can you come there?” Without fail, you stop what you are doing, often immediately, and assess the information you've been given. You doubt this will amount to much, so why do you respond so promptly and seriously? There are at least three reasons:

    • Humility: Your assumption might be wrong, and this might be something life-threatening that needs your immediate action. We can all think of countless times that someone saved us by picking up on something we didn't know about or that we just missed.
    • Respect: You honor the staff by taking them seriously with a prompt evaluation. You value them by thanking them for communicating with you, even if their fears were unjustified. And when things go bad, you sure don't throw them under the bus by proclaiming that they didn't make it seem important when they told you.
    • Responsibility: You do it for the patient and the culture of the department. A good leader does not demand leadership, he earns it. You model the behavior of service to others by doing the hardest work and not leaving it to nurses or students. With the most difficult patients and situations, you want the ball at the end of the game, no matter how tired you are. You do this without hyperbole, without threat, without blaming, without malice. You lay out enormous complexity and emotional challenges like a cool glass of water.

    Humility, respect for others with less experience or education, honor and value of others' efforts without blaming, courage to take full responsibility, strength to finish a conflict with class, all for the purpose of serving others. This is the leadership that is necessary during the COVID-19 pandemic. You already have this.

    We may be needed even more for these leadership skills by our family, friends, and larger community as we approach a vaccine. Like a patient with an unusual disease you've never seen, vaccination may not be an area as comfortable for you as chest pain or trauma, but this may be our time. Good leadership begins with an accurate assessment of terms and barriers. If I may offer a quick and incomplete briefing:

    When everyone begins yelling, “We have a pulse!!” (in this case, they'll yell, “There's an available vaccine!”), you will need to be the one, like you always are, who calmly steps forward, becomes even more watchful, and says, “Good. Now, we need a blood pressure” because you know that a pulse is not an outcome. Even a blood pressure is not an outcome. The ultimate goal is meaningful life. A good leader needs to be thinking of the problems that will occur and keep his eyes on the outcome.

    A few problems to think about with an available vaccine:

    Availability as discovery: There are eight vaccines currently in phase I trials with predictions that one will be available by late 2020 or early 2021. Vaccine development usually takes years, not months. Even the unlikely gift of an available vaccine in 2021 means only that we have discovered it. I would remind us that COVID-19 tests were available to “anyone who wants a test” in mid-March, and as I write this in June, we are still struggling to get sufficient testing, to say nothing about reliability.

    Availability as large-scale manufacturing: There is a chasm between discovery and large-scale manufacturing. After years of developing and testing the Salk vaccine for polio, five pharmaceutical companies were left to produce the vaccine without significant oversight. As speed took precedence over caution, serious mistakes went unreported. Cutter Laboratories distributed a vaccine so contaminated with live virus that it left 164 children paralyzed and 10 dead. (Paul A Offit. The Cutter Incident: How America's First Polio VaccineLed to the Growing Vaccine Crisis. 2007. New Haven/London: Yale University Press.) It is difficult to fathom the resources, materials, planning, infrastructure, labor, and execution to manufacture billions of COVID-19 vaccines on a scale to make it available to the entire world while maintaining quality controls.

    Availability as global distribution: To think of distributing vaccines securely throughout a country as geographically challenging as the United States is unimaginable. To distribute it throughout the globe is insurmountable. And an America-first approach is a completely ineffective strategy unless we literally close all our borders to everyone (which we can't do). In an America-first scenario with international commerce and travel continued, competition kills. (“Even finding a COVID-19 vaccine won't be enough to end the pandemic.” Washington Post. May 11, 2020; https://wapo.st/2A0RT26.)

    Availability as a most effective prioritized distribution: As we know, triage is not first come, first served, and you don't move to the front of the line if you have better insurance. The most effective distribution is often not equitable. The triage of a COVID-19 vaccine in the United States should not be prioritized to the wealthy and famous who have the power to get them but strictly from a scientific evidenced-based perspective to the poor, African Americans, Latinos, and indigenous people. (JAMA. 2020;323[19]:1891; https://bit.ly/2U4BaC7.) The politics of this rational scientific-based decision would be a racial cauldron, not to mention the reluctance of communities that have endured U.S. government experimentation, like African Americans with syphilis. (Susan M. Reverby. Examining Tuskegee: The Infamous Syphilis Study and Its Legacy. 2013. Chapel Hill: University of North Carolina Press.) A vaccine provided to poor people of color will more likely be a vaccine reasonably refused.

    Availability as an effective and safe vaccine: Discovery of a vaccine that is sufficiently immunogenic with minimal adverse effects in vaccine trials is not the same as a vaccine in the community that is effective and safe. Efficacy and safety require large numbers over a fair period of time, even under the best of conditions. Concerns of a new swine flu in 1976 led to a government-backed mass vaccine program that was rushed. Some who received the vaccine had no immune response at all, and a few individuals came down with Guillian-Barré syndrome. (Emerg Infect Dis. 2006;12[1]:29.)

    Availability as a vaccine actually used (not refused): A miracle will be needed to produce a vaccine at warp speed that has better efficacy than the influenza vaccine with fewer side effects than any other vaccine we have produced. More than ever, it's all about trust. (JAMA. May 26, 2020; https://bit.ly/3gPvg1u.) The COVID-19 vaccine will have one shot to be nothing less than perfect in our current cultural climate. Any failure will be fuel to anti-vaxxers.

    But many others are also hesitant. Mistrust of the government as a rule and of this administration in particular runs high, making the adoption of an effective and safe vaccine challenging. Currently, only three of four people would be willing to take the vaccine, and only 30 percent would take it soon after it is available. And this is in the heat of the pandemic when people are more accepting of trying anything. (JAMA. May 18, 2020; https://bit.ly/3gSqiRg.) If the vaccine arrives next year without an alarming second wave, the desire to take a vaccine will diminish further. This does not account for internet conspiracy stories and fake, inaccurate claims (e.g., autism).

    Availability as meeting the outcome of herd immunity: The outcome is herd immunity, not discovery, manufacturing, distribution, prioritized distribution, efficacy and safety, or even public health salesmanship. Many people cannot or will not take the vaccine—children on chemotherapy, pregnant women, the immunocompromised, the underprivileged, the mentally disabled, or even the vaccine-hesitant whose socioeconomic conditions mean they cannot get a vaccine. These are the American citizens who must have herd immunity to survive.

    It is true that getting a good vaccine to one person will protect him, and one goal is to prevent infection in the individual. But a larger goal is to prevent transmission of the virus to others, and the ultimate outcome is herd immunity. Experts say this will require 55 to 82 percent of a population being immunized with an adequate vaccine. (The New York Times. May 28, 2020; https://nyti.ms/370Stt4.) If herd immunity requires that kind of response, we might want to consider putting ourselves on the endangered species list.

    In a world that says, “I am the only science I need,” “I am the only government I need,” and even “I am the only race I need,” many people have migrated into a mental habitat that has quit thinking about a “we” world. It is immunologically lethal to live in an open society with that kind of closed mind. Opinion no longer even cares to look at the complexity of truth. We like or dislike something in a hot minute. Unfortunately, it is not enough to say, “You must do it for the village even if it impedes your personal choice.” It is still sadly uncertain if this current cultural climate can change.

    This challenge will not be easy and probably will not be over for a while. When the media and everyone around you begin yelling, “We have an available vaccine,” we need to be the ones who step calmly closer, watch even more carefully, encourage hope but be exquisitely cautious, and say, “Good. Now we need a blood pressure.”

    Dr. Mosleyis an emergency physician in Wichita, KS.

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