"Are we there yet?" No.

The end is near. That is the danger zone.

Michael Shear, M.D.

A psychology of impatience and impending relief is showing up all over America.

There are still angry mask-refusers getting videotaped making a disturbance at stores, but the bigger story is a revolt by restaurant owners and people frustrated at not seeing family for the holidays.

Fox News and other conservative news sources celebrate protesters as victims and heroes, the little guy rebelling against the cold, merciless job-killing Democratic (and sometimes Republican) officeholders. It fits a convenient narrative: Government squashing the forgotten little guy. The people getting sick and dying are offstage and out of mind in this narrative; the story is about big government versus freedom. Of course, we cheer for the scrappy underdog.

There is another bit of psychology at work: We see the finish line. Every passenger on a long flight has experienced it, that excruciating impatience when the plane has landed and it is sitting on the tarmac waiting for a gate slot. We can see the gate! So close! Those moments of useless waiting are the most frustrating.

Today, physician Michael Shear warns us that the journey is not over. Michael Shear, M.D. is an emergency room physician in the Boston area. Like several other Guest Post authors, he is a college classmate. He warns that the benefits of the vaccine are as yet unclear. The side effects are unclear. Whether it is fully effective among vulnerable populations is unclear. Whether it stays effective is unclear.

Protests. Open up now.

We should not assume the best, but even if the best case proves true, most of us won't get the vaccine for a while. We aren't inside the gate until then--and maybe not even then. We are tempted to start being careless and confident now. Not yet, he writes. Keep staying safe. We aren't there yet.

Keep your seatbelt on.

Guest Post by Michael Shear, M.D.

Reflections  on the new COVID vaccines

My daughter and I are often asked if we intend to get one of the new COVID vaccines. We say that, if offered it, we would not be among the first in line. My wife reminds me to be careful how we say this or people will mistake us for anti-vaxxers, which of course we are not. So here is a more complete response that we drafted together.

At the moment, the two vaccines being rolled out seem promising. I’m glad Tony Fauci thinks so! In limited short-term studies they appear to be effective in mitigating illness, and few serious adverse reactions have been reported, though headache, fever, and fatigue are apparently common. However, caveats are warranted.

The mechanism by which the Pfizer and Moderna vaccines induce an immune response is novel and has no track record in humans. These vaccines put bits of messenger RNA into the recipient’s cells. These mRNAs are the instructions that cause ribosomes, the protein-making machinery of the cells, to manufacture proteins similar to those made by the SARS-CoV-2 virus. These proteins are then made available to the recipient’s immune cells, which recognize them as foreign constituents and mount an immune response against them. 

Most conventional vaccines inject the viral protein itself into the vaccine recipient, or sometimes weakened forms of the actual virus, to elicit an immune response. This is more like the process of natural infection. Using the vaccinated person’s own cells to make the foreign protein is what is new. 

One of the major advantages of this process is speed. It is much faster to manufacture the mRNA than it is to raise and harvest the virus, which requires chicken eggs (real eggs, lots of eggs!). That is why we have these new vaccines ready for trial now. Vetting them, on the other hand, still takes time. 

Here are some of the unanswered questions about these vaccines: Which cells will be recruited to make these proteins and will they be damaged in the process? How much illness will be associated with the immune response to these proteins? If a vaccinated person is later exposed to SARS-CoV-2, a renewed immune response will be elicited. If infection still occurs, the hope is that it will be less severe. But since the immune response itself seems to be responsible for some of the more severe effects of SARS-CoV-2, will infection after vaccination sometimes be worse; or will vaccination reactions be more severe if a person has already had COVID?

The Pfizer and Moderna vaccines seem to have dramatically reduced the incidence of symptomatic infection in vaccine recipients. But we don't know if the recipients may still have been infected and thus be potentially contagious to others. And we don’t know how long protection may last.

Moreover, the efficacy or safety of the vaccines may vary within demographic subgroups such as older people, children, pregnant women, and the immunocompromised. Influenza vaccines, for example, are disappointingly less effective in older people. Will COVID vaccines be the same? 

The cold chain and the expertise required to distribute and administer the Pfizer vaccine in particular is daunting. How will you know if the injection that you get has been handled properly and is still effective? 

And what delayed adverse effects of vaccination may appear months or years later? 

What we ultimately want is sufficient immunity in communities so that the virus can no longer find susceptible hosts and can no longer spread. Then the pandemic will be over. Part of this immunity may come from natural infection. Effective vaccination holds out the promise of conferring similar immunity without the suffering and death caused by actual infection. Unfortunately, we don’t yet know if these vaccines provide that sort of immunity.

One hopes that these uncertainties will become clearer in the coming months. A registry of early vaccine recipients would be enormously helpful in following their outcomes, especially in assessing the relative merits of the multiple vaccines that will most likely become available. So far we have not heard of such a registry.

We know that wearing masks in public and “not sharing air with others”, as the epidemiologist Michael Osterholm puts it, are effective measures in protecting us and others from contracting COVID, and in slowing the spread of infection. But this is not where we want to end up. Masking and distancing have themselves caused incalculable hardship and pain. The goal of vaccination is to liberate us from this. 

Nevertheless, the enormous logistical challenges of producing, distributing, and vaccinating enough people to slow the pandemic means that the public health benefits (as opposed to the person protection afforded) are at least several months away, so masking and distancing will continue to be important public health measures for the foreseeable future.

Since vaccination will probably not add much personal protection to masking and distancing, some of us might choose to forgo vaccination until the uncertainties become clearer with time and experience. Others, particularly those who cannot distance, or for whom COVID infection might be catastrophic, may prefer to accept a greater vaccine risk and be vaccinated as soon as it is available to them. In any case, for those who prefer to be more cautious, there should be ample time to decide, without jeopardizing the general welfare.

Achieving herd immunity will require both a very effective vaccine and a high level of acceptance of the vaccine by the community. Acceptance will depend on the community’s trust. That should recommend transparency in the process, candor about the facts, and not over promising or over selling. When people see that vaccination is effective and safe, they will accept it.

Meanwhile, the less virus that’s circulating, the more effective vaccination will be in slowing its spread. So for the time being keep wearing your mask, whether you’ve been vaccinated or not, and make prudent social decisions.