The Turn of the Tide
By Nayyer Ali MD
Last week began the rollout of the Pfizer/BioNTech COVID vaccine, followed shortly after by the Moderna vaccine. Both gained rapid FDA approval after their Phase Three trials showed them to be safe and extremely effective. After nine months of living under a pandemic, the way out has been found.
These vaccines come not a moment too soon. After dampening down the pandemic to about 600 deaths per day in September and October, infections soared nationwide in November, and have now led to catastrophic daily deaths and hospitals with full ICUs across the country. Back in the spring and summer, small rural states appeared to spare the infections as people were so few and far between it seemed that a raging pandemic would not hit them. For many in the Trump White House, COVID was a “Blue state” problem, afflicting the Northeast with its large dense cities and places like Chicago and Detroit, who didn’t vote Republican.
But it didn’t stay that way, after sufficient time the virus has made its way into every county in the US. States like South and North Dakota have now lost 1 in every 700 citizens to COVID, and the death toll keeps rising. Everywhere in the nation now there is disease and death, with daily totals going above 3,500 last week on some days. For 2020 as a whole, it looks like there will be 15% more deaths in the US population than should normally happen, giving a window into how destructive this has been. But it is not simply the deaths. For every patient that dies, several spend days to weeks to months in the hospital recovering from life-threatening lung inflammation, or strokes or heart attacks, both of which increase in COVID. Hospitals are full with COVID, and though they can repurpose other portions of their buildings as ICU beds, the real constraint is the number of ICU trained nurses and doctors. Not just any nurse or doctor can take care of extremely sick ICU patients, it requires its own specialized knowledge base and skill set. The health care workers that have been dealing with this disease since March are exhausted, physically, mentally, and emotionally.
How quickly will the vaccines change this picture? Not fast enough. The patients entering hospital this week were infected 1-2 weeks ago, and the ones who are dying have been in the hospital for 1-2 weeks. We will see the effects of vaccines only several weeks after they are administered.
To protect the entire US population we would need to vaccinate 330 million people. That will take months. Fortunately, much of the benefit can be reaped with the first 50 million people. 25% of deaths from COVID come from nursing home patients. The bulk of deaths occur in patients over age 60, or who have significant underlying medical conditions like diabetes, heart disease, or obesity. By targeting these groups first, we can quickly reduce the number of hospitalizations and deaths. In the first phase of the vaccine distribution, nursing home residents around the country will all be vaccinated. In addition, health care workers will get vaccines if they are in direct contact with patients. These two groups will amount to several million people but should all get vaccine in December.
In January, vaccine distribution will ramp up as more doses become available. The next groups will be older adults and essential workers like first responders, grocery store workers, and teachers. Getting teachers vaccinated will be huge, because one of the main concerns about reopening schools is the danger to teachers of getting infected, as many are middle-aged or older.
One wrinkle is that both the Pfizer and Moderna vaccines require 2 doses, about 3-4 weeks apart. The first dose does induce immunity, but the second dose acts a booster that solidifies and strengthens the immune reaction giving the patient protection. In the Phase Three studies both vaccines were found to be over 95% effective in preventing infection, and even in the few patients that got infected, there were no serious cases. The question many are asking is how long does it take to get most of this benefit. From the data, it looks like even within 7-10 days of the first shot, patients have over 90% protection. Some have argued that given the first shot is very effective by itself, maybe we should give a single to most of the country and delay the boosters for several months in order to vaccinate more people immediately. This is an attractive idea, but for now the CDC and NIH have not embraced it.
If we can get the nursing home residents, adults over 70, and those with significant pre-existing conditions vaccinated by end of January, the results will be obvious by early February. Hospitalizations, ICU usage, and deaths will all see sharp declines. By March, the country could return many aspects of life to normal. Going to the movies, sporting events and concerts, cruises, and other high risk activities may still have to wait till May or June when widespread and easily available vaccines will be present.
While Pfizer and Moderna alone can supply tens of millions of patients over the next few months, to get 150 million vaccinated will still be a huge challenge. Johnson and Johnson also has a very good vaccine in trials, and health experts are eagerly awaiting their final data. The JNJ vaccine should report results in January, and could get FDA approval in February. JNJ vaccine will add to the nation’s vaccine supply in two ways. First, they are set up to produce a billion doses of vaccine in 2021, enough to supply the needs of much of the world, and the US has a large contract to get the early production. Secondly, the JNJ vaccine requires only 1 dose instead of two, and does not need to be kept supercold like the Pfizer and Moderna vaccines. This makes it much easier to distribute to more remote locations and to poorer nations.
There will in fact be many vaccines available next year. China has five different vaccines in clinical trials around the world. It is imperative for widespread vaccination to protect not just the citizens of the richest countries but the entire planet. Pakistan’s government is already planning to start vaccinations in January or February. Many Third World nations have not suffered the massive death tolls seen in the US and Europe, for reasons that are not clear. The most likely explanation is that their populations on average are much younger, with far fewer older people that are most susceptible to the dying from COVID. As such, we may not need to literally vaccinate 7 billion people. Perhaps less than 2 billion may end up being sufficient to bring this nightmare to an end.
