What do we want from our vaccines?

One shot, many goals

“So tell me what you want, what you really, really want”—The Spice Girls, Wannabe

Recent newsletters (here and here) by David Leonhardt of the New York Times included lamentations that parts of the medical community are underselling the COVID-19 (SARS-CoV-2) vaccines. His thesis is that by including warnings that vaccines may not be 100% effective against illness, or against acquiring disease or even possibly onward transmission, that some people may decide the vaccine “isn’t worth it”.

Once upon a time, 1998 to be precise, the Advisory Committee on Immunization Practices, the same body that recommends COVID-19, and all other vaccines, in the US, approved a vaccine that was 78% effective against getting infected by a severe, potentially disabling disease, and 100% against getting any symptoms at all from the disease. In effect, a 100% effectiveness rate against serious illness. It was a three shot series, and while some people would get some vaccine-related reaction to the vaccine, it was deemed safe and effective.

The infection was Lyme Disease (Borrelia burgdorferi) and the vaccine was LYMERix.

When LYMERix was first brought to market, as is true today, there was little we could do for people suffering from Lyme disease other than offer antibiotics after infection. Lyme disease, when recognized early, with a distinctive bullseye rash, is easily treatable, and rarely has long-term effects. But not everybody sees the tick that transmits the disease and not every bite is associated with a visible rash, so sometimes people go on to develop more disabling symptoms, such as arthritis, meningitis, facial nerve palsy or even slow heartbeat leading to fainting. Dying from Lyme disease is rare, but some of the other infections associated with the same tick bite, such as human anaplasmosis and babesiosis can be fatal.

LYMERix was approved for people aged 15-70, and recommended for those “at risk” for getting the infection, such as working or recreating in areas known to have ticks carrrying B. burdorferi. Where I practice in Minnesota, that could be a lot of people, especially those who enjoy hunting, fishing, camping and hiking in these areas.

As part of the counseling for administering the vaccine, I would explain the potential side effects of the vaccine, and I would also explain that people still needed to avoid ticks, and continue to do things like wearing insect repellent, long sleeves and pants and checking for ticks—because the vaccine would not protect against the other tick-borne diseases. A common response to this counseling was, “Well, if I still have to do all those other things to avoid the ticks, then why should I bother with the vaccine?” It became clear that what people were really looking for was a vaccine against changing behavior—specifically, not having to do all the other things to prevent the tick exposure.

Well after the vaccine was on the market, reports began to emerge that some people immunized with the vaccine were developing arthritis. Whether this was due to the vaccine or something else was never clear.

Eventually, with few sales, the manufacturer pulled the vaccine from the market.

Which brings us to the COVID-19 vaccines.

These vaccines have been demonstrated to be very—possibly 100%—effective at preventing death from COVID-19. What is not conclusively known is whether they can reliably prevent a vaccinated individual from acquiring the infection and transmitting it onward—especially in regard to new variants of the virus that might have resistance against the immunity generated from the vaccination. While there is some leeway about a vaccinated individual avoiding quarantine if exposed to the virus, recommendations, for now, are that people who have received the vaccine avoid some of the behaviors that can lead to transmission—such as congregating with other people. In other words, at this point in time, the vaccine is not a free pass to go back to pre-COVID times, drop the mask, go out and party. Which is not to say that it might be just that—we just don’t know for sure right now.

So what do you want from the vaccine?

  1. To not die from COVID-19

  2. To not transmit COVID-19 to other people

  3. To go out and resume a normal life

At this point, (1) not dying seems pretty assured. (2) not transmitting to other seems pretty likely, just not proven. (3)—resuming a normal life—will happen when sufficient herd immunity stops onward transmission.

These vaccines are the best and fastest way to get there.