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But here’s the bad news: Life has become even riskier for unvaccinated people, particularly those who have never had covid-19. (People with prior infections fall into a middle category, since they are at least partly protected but still require vaccination to increase the level and durability of immunity.)
The reasons that the unvaccinated are at higher risk are biological, behavioral and political.
Let’s start with the biological. The human body has not evolved to be any better at fighting the novel coronavirus, so unless our immune system is primed to fight the virus, our vulnerability remains unchanged. While treatments for covid-19 have improved somewhat since early 2020, the chances of hospitalization and death after a covid infection have not gone down much.
But while humans haven’t evolved, the virus surely has. The B.1.1.7 variant, first reported in Britain, is now the most prevalent form of the virus in the United States. This variant is far better at its job than the original coronavirus in two crucial ways: It’s about 50 percent more transmissible and, for someone who catches it, up to 60 percent more likely to be serious.
Then there’s the matter of human behavior: As more of the population is vaccinated, case rates, hospitalizations and deaths are likely to fall (although the current surges in Michigan and a few Northeast states — largely driven by infections in unvaccinated younger individuals — illustrate that improvement is not invariable). Seeing these numbers, unvaccinated people might well conclude that things have become safer and let down their guard.
The problem is that the aggregate numbers — even if they show down-trending test positivity rates, hospitalizations and deaths — may be masking an important duality. The situation may be getting enormously better in the growing vaccinated population, while at the same time growing somewhat worse in the unvaccinated group. Taken together, the overall curve shows moderate improvement. It would be like looking at a graph of lung cancer cases in a population whose rate of nonsmokers is growing. The overall curve looks good, but the risk to an individual smoker hasn’t budged. And if smokers saw the falling case rates, concluded that smoking had become safer and decided to add a pack a day, their risk would go up.
The inclination to act on sunny but partly misleading news will also influence political leaders. These officials are under tremendous pressure to open up their economies and may well see the overall improvements as reason enough to return to normalcy. Their optimistic messaging, along with the practical impact of opening settings such as bars, restaurants and gyms, will further promote virus exposure and cases in unprotected people.
The situation may not be as dire as it sounds. First, every day more unvaccinated people move into the vaccinated category. Second, as the vaccinated group grows larger, the overall impact on cases (not quite herd immunity but the same idea) makes life safer for unvaccinated people. Why? If case rates fall in a community due to more people being vaccinated, eventually unvaccinated people will be exposed to less virus, a downward pressure that may ultimately compensate for the variants’ superpowers and any uptick in risky behaviors. Finally, because the first groups to be vaccinated were those at highest risk of exposure and death, those being exposed today tend to be younger and healthier, individuals whose risk of severe disease and death is relatively low — though far from zero.
ROBERT M WACHTER IS CONTINUED ON THE FOLLOWING BLOG...
FROM THE WASHINGTON POST:
Robert M. Wachter is chair of the department of medicine at the University of California at San Francisco and host of the podcast “In the Bubble.
CONTINUED:
”The problem is that the aggregate numbers — even if they show down-trending test positivity rates, hospitalizations and deaths — may be masking an important duality. The situation may be getting enormously better in the growing vaccinated population, while at the same time growing somewhat worse in the unvaccinated group. Taken together, the overall curve shows moderate improvement. It would be like looking at a graph of lung cancer cases in a population whose rate of nonsmokers is growing. The overall curve looks good, but the risk to an individual smoker hasn’t budged. And if smokers saw the falling case rates, concluded that smoking had become safer and decided to add a pack a day, their risk would go up.
The inclination to act on sunny but partly misleading news will also influence political leaders. These officials are under tremendous pressure to open up their economies and may well see the overall improvements as reason enough to return to normalcy. Their optimistic messaging, along with the practical impact of opening settings such as bars, restaurants and gyms, will further promote virus exposure and cases in unprotected people.
The situation may not be as dire as it sounds. First, every day more unvaccinated people move into the vaccinated category. Second, as the vaccinated group grows larger, the overall impact on cases (not quite herd immunity but the same idea) makes life safer for unvaccinated people. Why? If case rates fall in a community due to more people being vaccinated, eventually unvaccinated people will be exposed to less virus, a downward pressure that may ultimately compensate for the variants’ superpowers and any uptick in risky behaviors. Finally, because the first groups to be vaccinated were those at highest risk of exposure and death, those being exposed today tend to be younger and healthier, individuals whose risk of severe disease and death is relatively low — though far from zero.
The solutions to the problem of heightened risk among unvaccinated people range from very difficult to extremely easy. Very difficult: Convince unvaccinated people that — notwithstanding the general optimism — they may, in fact, be at higher risk than before. Particularly if they’re planning to be vaccinated, now is the worst possible time to let down their guard. They should continue to wear their masks, keep their distance and avoid risky situations — even as they see their vaccinated brethren enjoying their newfound freedom. Equally challenging: Require proof of vaccination (so-called immunity passports) to access places that don’t require masks and social distancing.
Easy: Everyone gets vaccinated when their number comes up. Problem solved.
FACT SHEET FOR RECIPIENTS AND CAREGIVERS
EMERGENCY USE AUTHORIZATION (EUA) OF
THE PFIZER-BIONTECH COVID-19 VACCINE TO PREVENT CORONAVIRUS DISEASE 2019 (COVID-19)
IN INDIVIDUALS 16 YEARS OF AGE AND OLDER
You are being offered the Pfizer-BioNTech COVID-19 Vaccine to prevent Coronavirus Disease 2019 (COVID-19) caused by SARS-CoV-2. This Fact Sheet contains information to help you understand the risks and benefits of the Pfizer-BioNTech COVID-19 Vaccine, which you may receive because there is currently a pandemic of COVID-19.
The Pfizer-BioNTech COVID-19 Vaccine is a vaccine and may prevent you from getting COVID-19. There is no U.S. Food and Drug Administration (FDA) approved vaccine to prevent COVID-19.
Read this Fact Sheet for information about the Pfizer-BioNTech COVID-19 Vaccine. Talk to the vaccination provider if you have questions. It is your choice to receive the Pfizer-BioNTech COVID-19 Vaccine.
The Pfizer-BioNTech COVID-19 Vaccine is administered as a 2-dose series, 3 weeks apart, into the muscle.
The Pfizer-BioNTech COVID-19 Vaccine may not protect everyone.
This Fact Sheet may have been updated. For the most recent Fact Sheet, please see
www.cvdvaccine.com.
WHAT YOU NEED TO KNOW BEFORE YOU GET THIS VACCINE
WHAT IS COVID-19?
COVID-19 disease is caused by a coronavirus called SARS-CoV-2. This type of coronavirus has not been seen before. You can get COVID-19 through contact with another person who has the virus. It is predominantly a respiratory illness that can affect other organs. People with COVID-19 have had a wide range of symptoms reported, ranging from mild symptoms to severe illness. Symptoms may appear 2 to 14 days after exposure to the virus. Symptoms may include: fever or chills; cough; shortness of breath; fatigue; muscle or body aches; headache; new loss of taste or smell; sore throat; congestion or runny nose; nausea or vomiting; diarrhea.
WHAT IS THE PFIZER-BIONTECH COVID-19 VACCINE?
The Pfizer-BioNTech COVID-19 Vaccine is an unapproved vaccine that may prevent COVID-19. There is no FDA-approved vaccine to prevent COVID-19.
Pfizer’s vaccine is the first on the market that consists of actual genetic information from a virus in the form of messenger RNA, or mRNA, a type of molecule whose usual job is to transport copies of genetic instructions around a cell to guide the assembly of proteins. Imagine an mRNA as a long ticker tape carrying instructions. It's fairly delicate stuff, and that's why Pfizer's vaccine needs to be kept at around -100 °F (-73 °C) until it's used.
The new vaccine, delivered as a shot in the arm muscle, contains an RNA sequence taken from the virus itself; it causes cells to manufacture the big “spike” protein of the coronavirus, which the pathogen uses to glom onto a person’s cells and gain entry. On its own, without the rest of the virus, the spike is pretty harmless. But your body still reacts to it. This is what leaves you immunized and ready to repel the real virus if it turns up.
The mRNA in the vaccine, to be sure, isn’t quite the same as the stuff in your body. That’s good, because a cell is full of defenses ready to chop up RNA, especially any that doesn’t belong there. To avoid that, what’s known as “modified nucleosides” have been substituted for some of the mRNA building blocks.
But Pfizer is holding back a little. The spike gene sequence can be tweaked in small ways for better performance, by means that include swapping letters. We don’t think Pfizer has said exactly what sequence it is using, or what modified nucleosides. That means the content of the shot may not be 100% public.
The Pfizer vaccine, like one from Moderna, uses lipid nanoparticles to encase the RNA. The nanoparticles are, basically, tiny greasy spheres that protect the mRNA and help it slide inside cells.
These particles are probably around 100 nanometers across. Curiously, that’s about the same size as the coronavirus itself.
Pfizer says it uses four different lipids in a “defined ratio.” The lipid ALC-0315 is the primary ingredient in the formulation. That’s because it’s ionizable—it can be given a positive charge, and since the RNA has a negative one, they stick together. It's also a component that can cause side-effects or allergic reactions. The other lipids, one of which is the familiar molecule cholesterol, are “helpers” that give structural integrity to the nanoparticles or stop them from clumping. During manufacturing, the RNA and the lipids are stirred into a bubbly mix to form what the FDA describes as a “white to off-white” frozen liquid.
The Pfizer vaccine contains four salts, one of which is ordinary table salt. Together, these salts are better known as phosphate-buffered saline, or PBS, a very common ingredient that keeps the pH, or acidity, of the vaccine close to that of a person’s body. You’ll understand how important that is if you’ve ever squeezed lemon juice on a cut. Substances with the wrong acidity can injure cells or get quickly degraded.
The vaccine includes plain old sugar, also called sucrose. It’s acting here as a cryoprotectant to safeguard the nanoparticles when they’re frozen and stop them from sticking together.
Before injection, the vaccine is mixed with water containing sodium chloride, or ordinary salt, just as many intravenously delivered drugs are. Again, the idea is that the injection should more or less match the salt content of the blood.
Pfizer makes a point of saying its mixture of lipid nanoparticles and mRNA is “preservative-free.” That’s because a preservative that’s been used in other vaccines, thimerosal (which contains mercury and is there to kill any bacteria that might contaminate a vial), has been at the center of worries around over whether vaccines cause autism. The US Centers for Disease Control says thimerosal is safe; despite that, its use is being phased out. There is no thimerosal—or any other preservative—in the Pfizer vaccine. No microchips, either.
The vaccine is still known by the code name BNT162b, but once it’s authorized, expect Pfizer to give it a new, commercial name that conveys something about what’s in it and what it promises for the world.
We thank the following people for explaining the vaccine ingredients: Jacob Becraft and Aalok Shah, Strand Therapeutics; Yizhou Dong, Ohio State University; Jason Underwood, Pacific Biosciences; Andrey Zarur, Greenlight Biosciences; Charles L. Cooney, MIT; and the communications staffs of Pfizer and Moderna Therapeutics.
1 Revised: 25 February 2021
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