It is well into 2021. The vaccine is now available. But COVID-19 is still spreading. And while mortality is down, hospitalizations are still high. The economy is still down. You are still struggling to make ends meet. And on top of that, you are just weeks removed from a mild COVID-19 infection that left you incapacitated with a headache and a cough. You have never coughed up so much phlegm in your life until then. But now you are getting better, the symptoms are gone, and you feel like your normal sense again – or at least as close as you can feel to normal in 2021.
You go to check your mail, and you see a letter from the federal government inviting you to take the vaccine and receive a stimulus check. That is money you could really use. And while you heard stories – mostly the stories of the vaccine not doing much of anything, and the occasional story of some one developing an adverse reaction – all you see in this moment is the stimulus check. Much needed economic relief – hope in a time when hope is hard to find.
You quickly scroll through the screening questions, checking off without giving more than a moment’s thought. Until you come across a question that gives you pause – have you in the past four weeks been diagnosed with symptomatic COVID-19? You pause and wonder how to answer. Should you answer yes, knowing that you may not be eligible for the vaccine? Or should you answer no, and ensure yourself the opportunity to receive the stimulus check?
This is a very realistic scenario many of us will face in the not too distant future, and how we collectively respond will impact the overall efficacy of the vaccine. The Centers for Disease Control (CDC) currently recommends that everyone should receive the vaccine, including those who have been previously infected, based upon the risk of reinfection – stating in bold lettering that, “FACT: People who have gotten sick with COVID-19 may still benefit from getting vaccinated”. And has a dedicated webpage to address potential misinformation or conspiracy theories about the vaccine.
But CDC guidelines and recommendations change relatively frequently, with the quarantine restrictions changing recently from fourteen to ten days seemingly more out of economic necessity than true medical data. With one policy expert at the CDC, who chose to remain anonymous, acknowledging economic metrics as one of the main reasons why the quarantine period was reduced.
Which is not bad policy, just indicates that policy in the era of COVID-19 is a complex mix of medical data and economics. And as the underlying economic conditions of the country change, the policies are likely to change as well. So there is good reason to believe that once the vaccine is available, and if things are not advancing as projected, then there will be subsequent policy changes to reflect the current reality.
And truth be told, we will not know how effective the vaccine will be or how long immunity from the vaccine (acquired immunity) lasts until the vaccine is out and available to the public – and we have actual data to evaluate from and to compare with current data.
The scant, preliminary studies currently available show that out of 100 people infected with COVID-19, 70 of them will have a strong antibody response, 20 of them will have a weak antibody response, and the remaining population will have no appreciable antibody response.
Despite the high percentage of people developing some type of antibody responses (natural immunity), we are still not sure how long the antibodies will be present in the body. We are not even sure what constitutes the threshold concentration for antibody immunity for COVID-19 – as most of these studies are small, inconsistently designed, and based on data that is more speculative than reliable. As of now, the most referenced number suggests that antibodies can start to wane as early as 36 days after infection.
From what we currently understand, while natural immunity can mount an appropriate immune response, acquire immunity may still help because the duration in which the antibodies formed from natural immunity may not last very long, and the acquired immunity may prolong the duration of immunity. Hence the recommendation that we should all take the vaccine regardless of whether we have been recently infected or not.
But things that appear simple often prove to be quite complex in these times, and if the preliminary rumblings from the medical community are any indication, the question of whether we should take the vaccine, despite already being infected, may prove to be a sticking point.
Even physicians are divided.
In a recent MedPage article, two physicians, one an Anesthesiologist and one a Pediatric Intensivist, gave different responses as to whether they would take the vaccine despite already being infected with COVID-19 – the former saying he would not, and the latter saying she would.
But the rationale as to why they made their decision is more interesting than the decision itself. The Anesthesiologist believes that he should defer taking the vaccine because some one else may be more vulnerable, or a higher priority, to take the vaccine. But the Pediatric Intensivist believes that she should take the vaccine because her immune response may not maintain the natural immunity needed to sustain protection.
In an internal survey of 10 different physicians, we found that 6 would take the vaccine despite being previously infected while 4 would not, and the rationale for why each physician made their decision was made along similar lines.
Those who believe they should not take the vaccine cite the broad, common good that may come from having others who are perceived to be higher risk take the vaccine. Those who believe they should take the vaccine cite the waning immunity and the risk COVID-19 poses to themselves.
The differing rationale sets the framework for an all too common argument in healthcare policy – a more conceptual, variable benefit to others pitted against a more defined, fixed risk to one’s self. How people perceive public benefit to individual risk determines how people will decide whether they should take the vaccine or not even after being infected.
An ethical issue positioned against a medical issue. A more conceptual argument positioned against a more tangible argument. Each argument fundamentally incomplete. But an argument we have seen over and over in healthcare – whether it is the debate to wear masks, to receive the MMR vaccine, or to adhere to social restrictions.
And it is likely that this issue will be as divisive and politicized as the other issues. But the issue can only be resolved if we look at the argument as a ratio, and optimize each decision as a balance of this ratio – perceived common good relative to individual risk.
Optimizing this ratio will be critical in optimizing the early efficacy of the vaccine – and minimizing the ongoing impact of the pandemic. The proportion of the population that receives the vaccine first will impact the medical and economic impact of the vaccine – be it in terms of hospitalizations, imposed economic restrictions, and any situation in which the worsening medical impact directly incurs a commensurate economic burden. To effectively target the highest risk patients and provide the acquired immunity necessary to achieve acquired herd immunity, we need to optimize the individual risk to each individual.
Define the individual risk through two critical factors: the actual reinfection rates of COVID-19, and the true duration of natural immunity as well as the underlying variables that affect the duration.
These two factors will help calculate the true individual risk to benefit in receiving the vaccine. And consequently, we can better define the overall benefits to targeted populations that are in line to receive the vaccine – stratifying individual risk of reinfections appropriately.
And for those already infected, recontextualizing the argument from taking or not taking the vaccine, to the relative benefit in taking the vaccine. A subtle but invaluable shift in how we decide who receives the vaccine – redefining high risk and vulnerability into more granular, but more accurate terms.
Instead of simply defaulting to blanket recommendations that anybody who is perceived to be high risk should take the vaccine, and reinforcing that default recommendation with a stimulus check.
If we have learned anything about healthcare during this pandemic, it is that no option is an either-or proposition, it is always some complex ratio that balances each available option.
Heatmaps showing opioid sub-epidemics by demography and urbanicity
Total number of deaths in each category from 1999 through 2016 are shown in the upper left corner of each plot. The colors indicate age-adjusted mortality rates per 100,000 people. (Synth Opioids OTM: synthetic opioids other than methadone. This category includes fentanyl and its analogs.)