Reducing Cardiovascular Risks During COVID-19 - Episode 5
Deepak Bhatt, MD, MPH: One concern about vaccines is that it does seem like the time to a vaccine, in part, is dependent on how many people you test it in for how long. At least some health care workers I've spoken with have been concerned about a vaccine coming out early because they're concerned that may mean it wasn't tested in enough people or for long enough if there's some rare adverse effect. It will probably be mandated that health care workers get it like how most hospitals, I believe, mandate flu vaccination. What do you think about that potential concern that, if there's a quick vaccine, that the safety may not be as good as a vaccine that's been vetted in the usual manner and that the first people who will essentially be forced guinea pigs would be health care workers, perhaps as a condition of employment?
C. Michael Gibson, MS, MD: That concerns me, Deepak. In vaccine development, you have to trigger an immune response, obviously. You have to have something that's potent enough to give you an immune response. On the other hand, it's a U-shaped relationship. If you have something that triggers too big of an immune response, then you could trigger a cytokine storm when the person gets exposed to the virus.
Deepak Bhatt, MD, MPH: Obviously, everyone’s excited about the potential for vaccine development, but do you think the fact that the virus, as we now know, has some potential for mutation, might impede that effort?
C. Michael Gibson, MS, MD: Yes, Deepak. That's why so many of us were watching that rate of mutation early on. I, for one, was scared when I saw the rate was pretty high. Again, that's the internal mutations. The surface mutations, as we just talked about, are fairly low. There is this one that spread throughout the world, and that gives myself and others some pause that that could mean that we would have to have a type A, B, C, D vaccine because the surface protein is changing. Anthony Fauci, [MD], for whom I have enormous respect as he knows more than anyone about this, is optimistic. He's cautiously optimistic about a vaccine by the end of the year. That's a nice aspirational goal; it could be at the beginning of next year. It's going to be important to get it right, Deepak. You have to have a vaccine that creates an immune response in the person, but you have to be careful. If it creates a situation where the person gets a systemic inflammatory response, gets a cytokine storm when they get infected due to an exaggerated response to a real infection, that can make it worse than if you never got a vaccine.
When you talk about vaccine development safety, yes. If the person tolerate the initial doses, then things can go fine. The real truth will be later if and when they get exposed, do they have a higher risk of a SIRS [systemic inflammatory response syndrome]-like response, which puts them at greater risk. The problem, Deepak, is that it may take quite a while in vaccine development to know if the vaccine is both effective in reducing the risk of coming down with the virus, but also safe in terms of not revving up the immune system too much where someone could have a bad outcome.
Deepak Bhatt, MD, MPH: Those are great points. Will it be like influenza, where a vaccine is partially effective but not effective in every strain from year to year? Will it be like measles, where it’s an effective type of vaccination? There are a lot of questions. Of course, we’ll only find out with time and good science and testing.
Another concern that health care workers have raised that is a legitimate point is that, in part, a vaccine could be developed more quickly if the follow-up duration of people being initially tested is shorter. If one wants long-term follow-up looking for potentially rare adverse effects, that, of course, means a longer time before the vaccine would be ready for widespread use. It's likely that the first group of people getting it might be health care workers. In fact, they may be mandated to get it as a condition of employment, as is the case with many hospitals and the influenza vaccine, where you've got to get the influenza vaccine if you want to work at a particular hospital. What if we are in that situation as health care workers where we've got to get it, but it's not had long-term follow-up? There could be long-term follow-up if you're saying that there would be a vaccine by the end of this calendar year. But that de facto means that there couldn't be, for example, a year of follow-up to make sure there was no bad adverse effect emerging.
C. Michael Gibson, MS, MD: Personally, I'm worried, because I have had SIRS response, a cytokine storm episode, in the past. My body may have some of those Neanderthal genes. Don't say anything, Deepak. It may be revved up, and I would be a little worried if I got a vaccine that hasn't been well-vetted. Would I get a drug that maybe revs up my immune response too much? I would rather have one that gives me some partial immunity than complete immunity. That's just me personally, but you don't have a choice. That's going to be a difficult decision for someone like me, to be perfectly honest.
I did a poll, and I was shocked to see how few people would be willing to take a vaccine when it's developed. You would think everyone would be clamoring for this, but as I recall, the numbers were low: 50%, 60%. Here's what's frightening, Deepak: in certain ethnic communities, like the Latinx community and the African-American community, that number was down in the 20% to 30% range. It is hypothesized to be due to a certain distrust of the system at this point, which is tragic.
What’s scary, Deepak, is that our most vulnerable populations may be very frightened to take the vaccine. The safety issue is critical, so hopefully, we can get the safety and efficacy sorted out quickly. It will be a risk at first. In the poll, I also asked, “Would you rather be in a country that was the first country to get the first vaccine, or would you rather be in a country that was the first country to get the third vaccine?” People unanimously voted they would like to be in the country that was the third country to get this vaccine rather than being the first country. People are hesitant.
Deepak Bhatt, MD, MPH: That's interesting. I hadn't seen that poll of yours. That's the answer I would have given too. I'd rather be in the third country to get a vaccine, where in 1 or 2 other countries, it's proven in a large number of people, and nothing bad has happened. It will be interesting, but as health care workers, I'm not sure how much control we'll have over that choice.
C. Michael Gibson, MS, MD: I don't think we will.
Deepak Bhatt, MD, MPH: It will be interesting to see how it plays out, the medical aspects, and then the superimposed social and cultural aspects. If people are objecting to a measles vaccine right now, you can only imagine what will happen with any type of coronavirus vaccine.
Transcript Edited for Clarity