Point/Counterpoint

Today, will be engaging in an exercise akin to “Point/Counterpoint” as it pertains to mandating vaccination to protect from serious COVID-19 infection.  In doing so, will be addressing issues of ethics and philosophy, as they are critical aspects of the discussion.  That being said, there are beliefs and there are facts, and there will be clear delineations made between the two.

“You can choose a ready guide in some celestial voice
If you choose not to decide, you still have made a choice
You can choose from phantom fears and kindness that can kill
I will choose a path that’s clear, I will choose Freewill”

Rush, Freewill (1980)

The Facts

What is COVID-19?

COVID-19 is the colloquial name for the illness caused by the SARS-CoV-2 strain of a family of viruses known as coronavirus.  Coronavirus infections have been around for quite some time.  First identified in the 1960’s, they were known to cause common cold symptoms, especially in children.  Over the last 20 years however, several strains have emerged that cause symptoms far beyond that of the common cold.  These strains include SARS-CoV-1, MERS, and as of last year, SARS-CoV-2.  Whereas SARS-CoV-1 and MERS caused severe illness, their spread, for various reasons, was fortunately limited in scope.  SARS-CoV-2 has obviously not been as limited in scope.

Current Morbidity and Mortality

Most weeks, I present a section called “Fun With Numbers” to walk through the data, but today will simply give you a brief summary of the data.  On a worldwide level, there have been 74 million cases of COVID-19 infection reported, with 1.7 million resulting in death.  The United States has been among the most severely affected nations.  As of today, we have documented 17 million cases in the United States, with 310,000 cases resulting in death.  The current situation in the United States is not favorable, as there are well over 3000 people now dying daily as a result of COVID-19 infection.  This number is going to continue to escalate over the near term based upon the case rates identified over the last several weeks.  The duration of this escalation is dependent on when Americans decide to comply with basic instructions.

Current Treatment Options

There are few legitimate treatment options available aside from supplemental oxygen, mechanical ventilation, and prayer.  Monoclonal antibody therapy is available currently for those at higher risk.  The therapies have been shown to reduce COVID-19 related hospitalizations or ER visits when compared with placebo in trials performed to date.  It is important to note that these are not therapies to be used in folks that are already sick enough to be in the hospital, as they may actually worsen the outcome for the patient when administered under such circumstances.  It is also worth pointing out that the trial for these therapies are not complete, and they are currently approved under emergency use authorization protocols.   Steroids (specifically dexamethasone) have been shown to be of benefit in hospitalized patients who are already being ventilated.  No benefit for using steroids has been seen in those not requiring at least oxygen support.

The above cut is entitled “What You Want” by John Butler Trio.   For this weeks Trivia Quest, see if you can find the common thread for all the musical interludes this week.  Answer at the conclusion of today’s blog.

Vaccinations

Over the last couple of weeks, the first two vaccines to protect agains COVID-19 have received approval in the United States under emergency use authorization protocols.  The vaccines are the first approved, for use in humans, to utilize mRNA to provide protection from an infectious disease.  mRNA is the template used by all life on Earth to make the proteins that provide them with structure and function.  Other planets?  I don’t know, but you might choose to ask former President Barack Obama.  The vaccines work by introducing viral mRNA to the vaccinated individual.  In the case of the COVID-19 vaccines, the mRNA introduced instructs our bodies to make one of the “spike” proteins that are on the surface of SARS-CoV-2 virus.  Our immune system then recognizes this foreign protein, and generates both antibody and cellular immune responses against the protein, and by extension the COVID-19 virus.  These vaccines are intended to at minimum prevent serious disease caused by the virus, if not infection and transmission altogether.

While the fact is that mRNA vaccines are “new,” it is worth noting that they have been in development for over a decade.  To give you better perspective on how much work has been done on these technologies, please take a peek at a couple of review articles.  First, is a review published by Schlake, et al in 2012 that discusses development of mRNA-vaccine technologies and references studies from as far back as 1989 on the topic.  The second review, by Pardi, et al in 2018 (ie: prior to COVID-19) discusses how far the technology had been developed to that point in time.  Spoiler alert, there has been a ton of research performed.  Some of the research was performed with the intent to make a vaccine to the prior severe coronavirus infections that emerged a decade ago (SARS-CoV-1 and MERS).  It is worth noting that Moderna, the manufacturer of one of the two approved vaccines, had 8 clinical trials ongoing as of April 2019 using the mRNA technologies they used for developing their COVID-19 vaccine. Still looking for more reading? This article in Nature discusses not just the quest for the COVID-19 vaccine, but the implications for approaching other diseases.

While not the original spoofing by SNL of the classic 60 Minutes Point/Counterpoint segment, this one is highlighted simply to put a smile on my partner Dr. Iype’s face.   I can’t diss the original cast though…..click here for some Dan Aykroyd and Jane Curtin related entertainment.

Point/Counterpoint

In this section I am going to briefly take both sides for each topic related to mandating vaccination for COVID-19.  But as we all know, there are three sides to every coin when you include the edge.  Please don’t confuse this with The Edge.  For what it’s worth, U2 does not meet criteria for involvement in this weeks Trivia Quest.

Appropriate for this section, this song is entitled “My Philosophy” from the Ben Fold’s Five.  Got to see these guys at the Khyber Pass in Philadelphia back in the 90’s.  Incredible show.  If you are in Philly, this pub is a few blocks from Independence Hall.  Good eats.  Good beer selection.  

Philosophy

Point

Members of a society share a responsibility to act in a manner to provide the greatest good to the greatest number of people.  The current data on the vaccine, and the general history of vaccine safety, clearly indicate that the number of bad outcomes from getting the vaccine are inconsequential related to the number of lives that can be saved if everyone gets the vaccine.  This viewpoint represents utilitarianism at its finest.

Counterpoint

Members of a society generally desire success for all constituents.  There are many actions that can maximize success for the greatest number of people, but we can never lose sight of the rights of the individual.  To mandate that everyone has to take a vaccine, where there may be a poor outcome for an individual that themselves does not want to take the vaccine, is using that individual as a means to an end.  You can never use a person in such means to an end, even if that end is the greater good of humanity.  This is more of a Kantian way of looking at the situation.

The Edge

While I am a strong proponent for freedom of choice and individual rights, there are consequences to inaction as well as action.  I would not be a proponent of mandatory vaccination.  At the same time, I do not have issue with placing increasingly severe restrictions on noncompliance with vaccination, if by chosen inaction, it places others at risk.  This would include not permitting medical providers to deliver care if they refuse the vaccine, as an example.  Might it one day also mean an employer can refuse to permit workers to be on-site without taking the vaccine?  Schools preventing attendance in person?  Refusal of service at [insert your non-residential happy place here]?  Yes, it might.

Medical

Point

The new vaccines have been reported to be 95% effective.  The companies have reported no serious side effects.  The FDA and CDC are in favor of mass administration of these vaccines, and they are the experts.  They should be given to everyone they recommend it to.

Counterpoint

It’s great that they report 95% efficacy without serious side effects.  What about the allergic reactions I hear about?  Can you prove there are no long-term side effects?  How do you know the vaccine is going to last and I won’t need it every 3 months?  Are the RFID chips in the vaccine going to harm me?  I can keep going here quite easily, but I think you get the point.

The Edge

Initial data on the two COVID-19 vaccines is extremely favorable, and this is why it is being rolled out under emergency use authorization to those at highest risk at this time.  The key to the counterpoint arguments are not based on actual proof of concern at this time, but rather the theoretical.  This is not to suggest that the theoretical are to be taken lightly.  They are legitimate concerns for all involved.  Again, this is why the administration guidelines at this time are what they are.  Everything comes down to risk:reward ratio when talking about medical decision making in cases like these.  There are a lot of unknowns with the vaccine at this time.  One thing that is known is there are no RFID chips in them.  You can now check one worry off your list.  It is true that you cannot prove long-term immunity when not studied for the long-term. Nor can you know long-term side effects in a short-term study.  But there is a lot you can know and expect.  First, there have been close to 100,000 folks that have received one of the vaccines.  They have seen some allergic reactions.  About 1 in 1000 Americans go to the ER due to food related allergic reactions each year.  I have never suggested people stop eating out of concern for such reactions.  This is not to belittle how scary the reactions could be, but they can be treated. The track record for vaccines in general is such that side effects have presented themselves in the near-term.  And yes, there have been some serious adverse effects in the past. 

For elderly and medical providers, the risk of contracting COVID and having a bad outcome are much higher than a similar outcome due to the vaccine.  By the time we have managed to vaccinate that high risk group, we will have far more data to work with for the next tranche of risk and over a longer time window.  If at that time it is clear that it is of higher risk for those folks in the second tranche to get the disease than the vaccine, again the choice is easy.  By the time you get to talking about vaccinating young adults and children there will have been tens of millions of doses administered over many months to further assess the data for the purpose of decision making.

The Cream was late 60’s supergroup that included Eric Clapton, Jack Bruce and Ginger Baker.  Above is a cut entitled “I Feel Free.”

Commentary on Risk

There are risks to everything in life.  In this case, there are risks to individuals based on action as well as inaction.  There are risks placed on others by the choices individuals make as well.  The risk to yourself for being vaccinated was already discussed.  The risk to others when you choose to be vaccinated?  Nothing from the vaccine itself.  However, it is possible that you can be vaccinated, and while protected from severe illness, are capable of both being infected and transmitting that infection to others.  This has implications that are the core of the next couple of sections.

The risks of inaction to yourself?  Obviously, you can get COVID-19 and may suffer or die as a result.  The risks of inaction to others?  Same, you could transmit and cause harm to your fellow human.

With these risks in mind, the last sections of this discussion center around our expectations both on ourselves and for others.

Expectations

Point: Expectations for Someone Choosing To Be Vaccinated

We are now delving back into philosophy a bit.  For the vaccinated individual, many would feel that they no longer have the obligation to wear masks or distance, despite the potential they could be asymptomatic spreaders of the virus.  Why?  Because everybody had choice, and they chose to vaccinate.  If everyone chose as they did, nobody would get worse than a cold from the illness (presumably with the data at hand).  Some more socially conscious may feel that they are still obligated to observe mask wearing and distancing to protect others from their own inaction.

As it is likely that, as with nearly every other treatment, that there will be some vaccinated folks who will still get COVID-19, and die as a result, those who chose to be vaccinated may still expect others to continue to be forced to wear masks, distance, and quarantine.  The theory is that others can choose to place themselves at risk, but their inaction should limit the risk only to themselves.

Counterpoint: Expectations for Someone Choosing Not To Be Vaccinated

For the individual who chooses not to be vaccinated, what expectations should they maintain on themselves?  Some feel it is their choice to do as they wish and that since everyone had the ability to be vaccinated, that they can now do as they wish, accepting the risk to their own well being.  Others would maintain the obligation to protect others from their selection.

For the individual who chooses not to be vaccinated, what expectation should they maintain on others?  Some would feel that others have to continue to abide by full restrictions to protect them.  Others are willing to accept that they made their selection and are willing to bear full risk for their decision.

The Edge

From my perspective there are time windows inherent to any expectations.  For the foreseeable future, there will only be a small portion of the population vaccinated due to supply.  It is not reasonable for a vaccinated individual to think they now have carte blanche to run around and potentially be an asymptomatic spreader of disease.  Given a year or so when everyone will have had the option to be vaccinated, and assuming that the vaccinated truly do not suffer severe disease, I do feel that there should be at most limited restrictions on those who elect to be vaccinated.  As an example of a limitation, an individual may be required to wear a mask in a nursing home despite having been vaccinated due to the extreme inherent risk to that specific population.

Once safety and efficacy data have been fully recognized, I do believe that the vaccinated population has certain rights to be protected from those that chose not to be vaccinated.  To limit access of non-vaccinated to stadiums, workplaces, and nearly any other place where there are mass gatherings is reasonable.  There will inherently be folks that are vulnerable for reasons beyond their control, and it is not fair to them for others to place them at risk.  This should be no more of a decision than when we limited where people can smoke, get drunk, or yell “Fire!”

At the end of the day, my philosophy is simple.  Want to engage in behavior detrimental to yourself?  Have fun, not my problem.  Want to engage in behavior detrimental to others?  Sorry.  Go find similarly minded people and declare an autonomous zone or something.  You’re not that special.  You won’t get a participation trophy either.

Hüsker Dü is an 80’s band led by Bob Mould.  Bob also played with a band named Sugar.  Both bands qualify for today’s Trivia Quest.  For a little Sugar, here is a tune named “The Act We Act” off the album Copper Blue, one of my favorites the year it was released (1992). 

Behavior To Not Emulate

Normally I would apologize if I offended someone.  If you are offended by these next few comments, too bad.

While I inherently disagree with the choices many have made regarding what activities they engage in during these times, I accept and respect that there are situations in which people are making decisions within the parameters that the current laws allow.

**Whether I agree or disagree with those laws is irrelevant.  I am not a politician nor a lawyer.  There are legal aspects to all that was discussed today.  I intentionally did not touch on any of those because I am not an expert in law.  

What I do take major exception to are the behaviors I witness daily in which people are knowingly and intentionally placing others at harm, often without that third parties knowledge.  As some examples from this week alone:

  1.  Child with known exposure to COVID-19, now sick.  Parents refuse testing to avoid knowing that it is in fact COVID-19.  Why?  Because then the whole family would need quarantine.  Parent elected to keep kid home as school mandated such, but sent the others to school and themselves to work.  Gold star earned for selfishness.
  2. Asymptomatic child with known exposure to COVID-19, testing performed as required by school.  Child positive on in office antigen test.  Parent blowing a gasket and cursing at our staff that it must be a false positive.  Takes child to multiple other facilities until a test came back negative.  They felt vindicated.  They placed numerous others in contact with COVID-19 in the process.  Problem?  They were wrong. There are too many false negative on all types of testing.  While an antigen test may miss a lot of asymptomatic positives, it does possess a very high positive predictive value.  This is not the NBA playoffs.  It is not best of 7 wins.  If you are positive, you are positive.  Period.  Stay home like you are instructed.  And stop verbally abusing those dedicated to helping you.
  3. Parent is positive to COVID-19.  Children who are not yet ill are farmed out to grandparents to stay until the parent is done with quarantine.  Even with a NASA approved helmet this is not cool.  I don’t care how many times your parents made you clean your room or eat your veggies when you were young.  I am not sure I even care if they used a switch on you, as you obviously stayed in contact with them despite.  This is not your chance for revenge.
  4. Child has had runny nose and cough for a couple of days.  Fever?  Who knows, kid taking Tylenol and Benadryl.  Sent to school with same on board.  Seriously?
  5. Family quarantined.  Member leaving house to go food shopping and pick up some final holiday gifts because “they have no symptoms.”  Another gold star for selfishness.

Trivia Quest Answer

The answer to today’s musical Trivia Quest is that all bands presented today are trios.    Thanks for playing and reading this far.  Stay safe everyone.

Post authored by Jason Halegoua PhD, MD, MBA, FAAP.  Jason is the founder of Peds First Pediatrics in 2009, and has been a practicing general pediatrician since completing residency at Schneider Children’s Hospital in 2004.  In addition to earning his medical degree from the Medical College of Pennsylvania, Jason earned a PhD in Molecular Pathobiology for his work contributing to the understanding of the genetic regulation of immune responses to murine leukemia viruses from Hahnemann University in Philadelphia and an MBA in Finance from Hofstra University.