3rd Out, Bottom of the 1st, Variants on Deck

Public health now has a 3rd arrow in its quiver in the form of another COVID vaccine. The J&J vaccine is the first to offer a single dose with refrigeration requirements suitable for a wider array of health care settings. All that said, vaccine hesitancy remains an obstacle to an effective public health response. In this regard, CTSAs are playing a critical role in addressing public concerns about these vaccines. Vaccine hesitancy is nothing unique to COVID and seems to be present across the spectrum without regard to sex, race, ethnicity, religion, or socioeconomic status.

There is also a long history of vaccine hesitancy. In the late 19th century when Louis Pasteur was advancing vaccinology, a coalition of groups opposed to Britain’s vaccination law (for smallpox) allied with anti-vivisectionists who feared more animal experimentation as a result of vaccine development. None other than Arthur Conan Doyle (creator of Sherlock Holmes) who was a physician himself, wrote frequently in England’s equivalent of Scientific American describing the emerging science of microbiology and the potential for vaccines to eliminate the disease terrors of their times from the general public.

With additional options will come questions regarding performance comparisons and which vaccine is best. Unfortunately, explaining nuances is not commensurate with 30 second soundbites. All these vaccines (and a few more in late-stage development) were designed from a viral sequence now more than one year old. That prototype virus is unlikely to still be in circulation (except in laboratories). In addition, the virus has been gradually mutating with initial natural selection for increased transmission and as recovered cases accumulated, for escape from natural immunity. With directly acting antivirals, we should expect to see resistance as well. As this is a continual process, it is inappropriate to compare trial results from different vaccines conducted at different times and in different geographic locations. Furthermore, as variants of concern continue to arise, infections that occur in previously vaccinated individuals may be due to either a failure to have adequately responded to the vaccine, a good vaccine response but waning protection, or exposure to a vaccine escape variant. Each of these scenarios will have distinct implications for public health responses. In addition, with studies examining additional ‘boosters’ (either as part of the primary vaccination or some periodic immune stimulus) as well as strain change vaccines targeting specific troublesome variants also being called boosters, appropriate messaging will be key to respond to questions and address concerns.

Lastly, let me offer a suggestion for the public messaging we engage in. Please stop using the phrase, “we have no evidence…” What we really mean is, we just don’t know yet. As academic health professionals, we have a very specific definition for what constitutes evidence, but absence of evidence is not evidence of absence. Through the CTSAs, we are not only collecting the evidence for effective health care guidance for COVID as well as public health guidelines, but also have the responsibility to convey these findings with language appropriate for our various audiences (as opposed to peer reviewed journal submissions) including, most importantly, the general public.

Stay safe, test negative!

Life is not a matter of holding good cards, but of playing a poor hand well.

– Robert Louis Stevenson