Vaccines in Development: Which are Ready for Prime Time?

Vaccine development for COVID-19 is a fast-moving topic. Private industry, academics, and government agencies are working together at rapid speed to generate viable options for billions of people throughout the world without sacrificing safety or introducing unforeseen risk. The goal, as with any vaccine, is to stimulate your immune system to make antibodies against the SARS-COV-2 virus, thereby protecting you from getting sick with coronavirus. The urgency to control the spread has translated into testing of well-known, theoretical, and brand-new technologies. Brilliant minds are hard at work, around the clock, to not only design and test vaccines, but to also determine systems for distribution and administration to help abate the global crisis

There are hundreds of vaccines in the pipeline in various stages of investigation, including 54 (as of this writing) that have advanced to the stage of being tested on people and 10 in late stage (known as Phase III) clinical testing. As of November 2020, there are two that stand out as close to acceptable levels of effectiveness and safety; therefore, plans for mass production, distribution and administration are also underway.

Pfizer and Moderna Both use mRNA Technology

The news that has grabbed recent worldwide attention include announcements by Moderna and Pfizer/BioNTech that Phase III clinical trials of their mRNA vaccine candidates show nearly 95% effectiveness. Many drained global citizens are starting to imagine solutions for this pandemic. Dr. Anthony Fauci, Director of the United States (U.S.) National Institute of Allergy and Infectious Diseases (NIAID) went so far as to claim that “it’s not going to be a pandemic for a lot longer because I believe the vaccines are going to turn that around.”

There are many caveats and precautions to keep in mind, however, not only with vaccine development and confirmation of efficacy and safety, but also with distribution and administration of the shots.

Vaccine Safety & Effectiveness

While these encouraging results bring us closer to a solution, it’s important to understand what they mean. In clinical trials, such as those conducted by scientists at Pfizer and Moderna, there are two groups of people, neither of whom have been previously infected with COVID-19. Participants are randomly assigned to receive injection of either placebo (consisting of saline water) or the experimental vaccine candidate. The participants, doctors, and healthcare providers administering the injection do not know who received vaccine and who received placebo; this is called a randomized, controlled, blinded clinical trial. In medicine, we refer to that design as the “gold standard” of research because we can rely on the results being scientifically valid, rather than the positive effects being from nothing more than luck or chance. Those who received the experimental vaccine in both the Pfizer and the Moderna studies were 90 to 95% less likely to develop coronavirus than those who received placebo injections. For example, in the Pfizer investigation, 170 people, out of almost 44,000 recipients have contracted the virus to date; 162 of them had received placebo, while only 8 had received the vaccine. 

This is promising and exciting. After many months of being sequestered and feeling secluded, we have legitimate reason to feel hope.

After many months of being sequestered and feeling secluded, we have legitimate reason to feel hope.

Now, Pfizer/BioNTech submitted an application for Emergency Use Authorization (EUA) to the U.S. Food and Drug Administration (FDA). The company will continue ongoing research to assess long term immunity (meaning – for how long the vaccine can protect you from contracting the virus), potential negative effects that might occur over time, and ability to confer immunity following exposure to the virus. The last question will explore whether the vaccine is protective if you receive it after you’ve been around someone who has COVID-19. One important element already determined is that it takes roughly 28 days following the second dose of the Pfizer mRNA vaccine until antibodies develop – a crucial step toward conferring immunity. 

Moderna also announced progress on their vaccine, which is based on a similar genetic platform and suggests excellent rates of potential protection.

Vaccine Distribution & Administration

As rates of infection in parts of America and Europe approach their highest levels, everyone eagerly awaits the release of this vaccine. Once authorized by the FDA, public distribution will be complicated and will limit return to our pre-pandemic lives, as will outstanding questions about safety and effectiveness. 

Widespread vaccination in America is still many months away. We must remain vigilant, continue to do everything in our individual and collective power to slow the spread of the virus. Wearing masks, physically distancing, avoiding social gatherings, and practicing hygiene remain the mainstay for stopping the spread of COVID-19 and saving lives. This will be the case for a significant period of time, even after a vaccine is available. Dr. Fauci estimates that high-risk Americans and healthcare workers will be among the first recipients of the vaccine. Ambitious estimates suggest that a sizeable proportion of the U.S. population will receive the vaccine by mid to late spring. But, Dr. Fauci warns, such a “guesstimate” assumes that everything proceeds without setbacks, mistakes, or unanticipated risks.

But, Dr. Fauci warns, such a “guesstimate” assumes that everything proceeds without setbacks, mistakes, or unanticipated risks

Concerns have also been raised about how Pfizer will manufacture and ship the vaccine to hospitals and pharmacies across the globe. Pfizer is manufacturing the vaccine in Kalamazoo Michigan and in Belgium; for Americans, the majority of vaccine doses will come from the Great Lakes state. It is up to federal and state governments, however, to decide to whom to appropriate the doses and the number to request. As mentioned, the vaccine preparation uses mRNA that, once inside your body, enters cells and is coded to produce a protein that mimics spikes on the outside of the coronavirus. These spike proteins “trick” your immune system into responding to this foreign entity as if it were coronavirus. 

The mRNA needs to be kept at temperatures well below zero (more specifically, negative 70 degrees Celsius, which is equivalent to negative 94 degrees Fahrenheit); otherwise, the vaccine will denature (fall apart) and be rendered ineffective and unusable. Pfizer has designed reusable boxes filled with dry ice to keep the vials of vaccine cold enough, and shipping companies, including UPS and FedEx, have designed special compartments to send and deliver the vaccine vials. These special containers hold between 1000 and 5000 vials. 

One potential advantage of the Moderna candidate, which relies on similar mRNA and, therefore, still requires cold storage, is that the temperatures needed for this vaccine to stay stable up to 30 days resemble standard refrigerators and freezers available in pharmacies and hospitals.

Many details are yet to be determined, including that Pfizer reports the plan to ship 50 million doses in December. Twenty-five million of those vials are slated for distribution in the U.S., while the other 25 million will go to other countries. That means that 12.5 million Americans can be vaccinated during this first round, since each person receives two doses, three weeks apart. 

12.5 million Americans can be vaccinated during this first round, since each person receives two doses, three weeks apart. 

Meanwhile, the Bill & Melinda Gates Foundation is at the forefront of global distribution, working with international partners to both quickly develop the second generation of vaccines more suitable for low and moderate income countries and prepare systems for distribution. GAVI, Vaccine Alliance and Coalition for Epidemic Preparedness Innovations (CEPI) are co-leading the efforts of the Access to COVID-19 Tools (ACT) Accelerator to ensure equitable access to COVID-19 tests, treatments, and vaccines. As Melinda Gates says “COVID-19 anywhere is COVID-19 everywhere.”

As Melinda Gates says “COVID-19 anywhere is COVID-19 everywhere.

Distribution Within States’ Purview; But Dollars Fall Short

In the U.S., the logistics of vaccinating and tracking millions of citizens will be left largely to state governments. The Centers for Disease Control and Prevention (CDC) in the U.S. has committed to providing 340 million dollars to the states for these distribution efforts; however, local health departments anticipate much higher costs and have requested another 8.4 billion dollars from the U.S. Congress to adequately and appropriately fulfill this duty. Comprehensive online systems are necessary to keep track of who has received vaccinations. Insufficient funding will slow down the rate of vaccination, especially among citizens who are hard to reach, as well as the process of following who has received their first and second doses. States with large rural populations pose particular challenges for the administration of the vaccine due to the cold storage requirements.

States with large rural populations pose particular challenges for the administration of the vaccine due to the cold storage requirements.

Each of Us Has a Role in Curbing COVID-19

Another problem involves potential resistance to taking the vaccine. There is a worldwide movement of anti-vaxxers, which is based on false data and amplified by social media. Plus, others feel some degree of skepticism because of the speed with which the vaccines are being developed. 

But, as Kavita Patel, MD, a prominent physician and public health expert, points out “vaccines don’t save lives; vaccinations do.” 

Kavita Patel, MD, a prominent physician and public health expert, points out “vaccines don’t save lives; vaccinations do.”

Lessons from the Past

When Elvis Presley was vaccinated on national television in 1956, the polio immunization rate among teens skyrocketed and incidents of polio went down by 90% in just four years. History shows that when prominent Americans, especially from marginalized or high-risk communities, use their platforms to lead by example, people pay attention and heed their advice. Nowadays, those messages can reach far and wide through social media influencers, when first vetted by public health experts. 

Many questions remain unanswered and unexpected challenges will arise along the way. The aim is for scientists and authorities to work hand-in-hand to mitigate polarization and to not only produce safe, effective vaccines but also readily distribute and administer them as swiftly, efficiently, and equitably as possible. 

In the meantime, our job as citizens remains to limit the spread of COVID-19 even after the vaccine is available and distribution has begun. This virus will circulate in the population for a long time to come. Like a mantra, we say again and again:  wear masks, physically distance, avoid social gatherings, and practice hygiene. Plus, while availability of testing has improved, progress is still needed for widespread application in the U.S. and receipt of rapid results. As we face the last quarter of the year since COVID-19 was identified, we still need to set testing as a top priority by enhancing supplies and, perhaps, the possibility of self-administered home testing. 

Written By Rohan Prabhu & Jacki Hart, MD

Isolated Elderly and Stir-Crazy Teens Form Real Bonds, Virtually

My Covid Story

Older adults are at high risk for severe consequences from COVID-19. While this necessitates self-isolation to help mitigate spread and reduce their chances of contraction, the ensuing seclusion is not without its own health risks. The National Academy of Sciences discovered that social isolation and loneliness increase the risk of anxiety, depression, and even premature death in the elderly. Not everyone who is socially isolated (defined as lack of social connections) is lonely and not everyone who feels lonely is socially isolated. Elderly individuals are at higher risk for loneliness and/or social isolation because of factors like living alone, losing friends and family, having a chronic illness, or experiencing hearing loss.

Whether experienced together or separately, loneliness and social isolation are referred to as “poor social relationships,” which increase the risk of heart disease by 29%, stroke by 32%, and dementia by 50%. Among people with heart failure specifically, loneliness was linked to a 4-fold increase in the risk of death, a 68% increased chance of hospitalization, and a 57% rise in emergency department visits.

Disrupted Routines Replaced with Distanced Connections

Many elderly individuals have limited social contact, often restricted to places of worship or community centers. Even routine public encounters in local businesses like grocery stores, pharmacies, or coffee shops are no longer available to the same extent, due to protections set in place against COVID-19. In addition, those who lack close friends or family, or who had relied on care from either paid caregivers or voluntary services, as well as those who were already isolated, are at an increased risk of loneliness and associated health concerns.

Seeking to alleviate the physical and emotional isolation of at-risk seniors, Rabbi Marcia Plumb of Congregation Mishkan Tefila in Brookline, Massachusetts developed the Silverlining Buddy program to replicate volunteer and visiting programs that existed prior to COVID-19. This virtual program is an intergenerational collaboration, managed by Wendy Handler, designed to foster relationships between seniors and college students or young professionals. Understanding the difficulty that technology can present for some seniors, Rabbi Plumb conceived the program as an old fashioned, basic pairing of individuals through telephone contact. With the support of Combined Jewish Philanthropies (CJP), a non-profit organization in Boston, they are expanding the program to use Zoom or other technologies.

The program has successfully matched more than 100 buddy pairs

The program has successfully matched more than 100 buddy pairs, based on community needs and availability. Young adult volunteers undergo basic training and then typically connect with their senior buddies at least once a week. They discuss a myriad of topics ranging from personal life stories to politics to the science behind COVID-19. While the program was initially designed to help reduce loneliness among older adults, Ms. Handler says the program has shifted into more of an equal relationship where the young volunteers get just as much out of the experience as the older adults.

Unexpected Life Parallels

Rosalie, a senior buddy, became involved in the program through her synagogue; she thought it would be fun to talk to someone from a younger generation. She and her buddy, Nikki, a college junior, have a lot in common. Both grew up in Brooklyn, New York. Both had family members who were Holocaust survivors, and they share similar political views. Conversations between Rosalie and Nikki run the gamut from their personal lives, including gardening (a hobby of Rosalie’s) and travel to politics and science. They even exchange recommendations for good books and show each other photos over facetime. Rosalie likes hearing about changes in Brooklyn and she also now appreciates how the pandemic has imposed limitations on the younger generation still in college too. Rosalie says that she and Nikki never run out of topics and that her young companion asks thoughtful questions that make her reflect. “It’s comforting to talk to [Nikki] and hear about her life,” Rosalie said. “I think [the Silverlining Buddy System] is a very interesting and fun concept and perhaps, even after COVID, it would be good to keep it up.” 

Nikki became involved in the program through Companions to Elders, a community service program she helps coordinate for her university. Nikki relays that “[the experience] has made me insert more perspective into my day to day life, because it’s so easy to get absorbed into the bubble of college, when I’m at college, or of my childhood bedroom which I’ve been trapped in for six months! Leaving that world to talk to someone who is pretty far out of that environment gives me more perspective. Takes me out of my head.”

Leaving that world to talk to someone who is pretty far out of that environment gives me more perspective. Takes me out of my head.”

Emma, another student buddy, is a college senior majoring in biology. She said that volunteering has given her the opportunity to empathize with someone older and wiser, and helped broaden her view of the world. “If Marylin (her buddy), who has lived through many ups and downs in history still has hope that we’ll go back to normal day to day life, and is still enjoying each day; I think that just shows that we all should be thankful for what we can do and what we do have during this time.”

The Silver Lining Buddy System offers a unique opportunity that provides a meaningful connection during a time when many of us are feeling disconnected. It should serve as a role model to spawn similar programs. 

Written & Reported by Giovi Hersch
Edited by Dr. Jacki Hart

Long-Haul COVID: We Need to Do Better

Symptoms from COVID-19 can last many weeks, even months, and manifest in strange and unexpected ways. In Britain, the National Health Services (NHS) has formed clinics for long-covid, as they call these persistent cases, as well as support groups. The United States (U.S.) should follow their lead. At the moment, in the U.S, where we refer to prolonged symptoms as Long-Haul Covid, people have been searching for and forming their own support groups through Facebook and Slack. By reaching out to other COVID-19 survivors with symptoms lasting two weeks or longer (the definition of “long-haulers”), people have even taking research into their own hands via surveys amongst the group. 

While people experiencing long-COVID report a list of 64 or more potential lingering symptoms, the top 10 include shortness of breath, chest tightness, fatigue, chills, sweats, body aches, dry cough, low grade fever, headache, and “brain fog” or difficulty concentrating.  

Of note, “long-haulers” who have persistent symptoms generally did not require hospitalization when they first caught COVID-19.

There is much to learn about this condition; with “citizen scientists” taking the lead, they are learning from one another. But, similar to England, the medical community in the U.S. should be finding ways to better support and care for COVID-19 sufferers with long-term complications.

Do you have a story to tell about your symptoms of long-haul COVID-19? Please share with us here.

 By Jacki Hart, MD