One Year Of COVID Vaccines

One year ago today, at 7:00 AM on December 15, 2020, I was one of the first people in the United States to receive a Pfizer COVID-19 vaccination. What a wild and weird year it has been since then.

When the vaccines became available, many physicians thought that vaccination would bring an end to the pandemic by the summer of 2021, myself included. In fact, I was so confident that I timed my retirement to May 2021 to coincide with what was anticipated to be a return to normalcy. I could not have been more wrong.

In the first month of vaccine availability, the demand for vaccines greatly exceeded the supply of vaccines and consequently, a nationwide prioritization plan was developed. In Ohio, our governor directed that the first to be vaccinated were front-line healthcare workers and nursing home residents. It was up to individual hospitals to prioritize their healthcare workers. So, our medical center created a committee to determine which healthcare workers would be first to get vaccinated. We started with doctors, nurses, and respiratory therapists in the emergency departments and the intensive care units. As a critical care physician who was intubating and performing bronchoscopy on COVID patients, I was in the first group. I got the first vaccination appointment on the first day of the roll out at 7 AM on December 15th – not because I was the medical director of the hospital, but because I was the fastest to click on the on-line scheduling app when the emails went out to the ED and ICU staff announcing vaccination eligibility.

In the subsequent weeks, there was much controversy about which groups of healthcare workers would be eligible for vaccination next. Should outpatient primary care physicians be prioritized before radiology technicians? When should pharmacists get their vaccinations? What about housekeeping staff? The medical students lobbied to the Dean that they should get vaccinated and then opinion articles in our local newspaper complained that young medical students who were not caring for COVID inpatients were getting vaccinated before senior citizens with health conditions. Every day, those of us on the prioritization committee got emails from impassioned healthcare workers lobbying to be moved up on the vaccination schedule. January 2020 was a month of endless controversy.

As vaccine production ramped up, the Pfizer and Moderna products became more plentiful. The Governor made the vaccines available to Ohio seniors, followed by grocery workers and then first responders. On March 1, 2021, the Johnson & Johnson vaccine was authorized. On April 19, 2021, COVID-19 vaccines became available for all American adults under FDA emergency authorization and then on August 23, 2021, vaccines were fully approved by the FDA for all American adults. On October 29, the Pfizer vaccine was authorized for anyone over age 5 years old. The COVID pandemic should have been over by December 1st. But it wasn’t and it isn’t.

As of today, the CDC reports that 76.6% of Americans over age 5 have received at least one dose of a COVID vaccine and 64.8% are fully vaccinated. As of today, 29.2% of adults have received a booster dose. But there are still too many who are unvaccinated. Fully 15% of American adults have not received a dose of a COVID vaccine. Some have not been vaccinated because they are among the crazies or have gullibly been misinformed by the crazies; most have not been vaccinated because they are cowards.

So, who is left to get infected?

COVID infection can be prevented by either getting vaccinated or having antibodies from past infection. Neither of these will completely eliminate the risk of future COVID infection but they will reduce it and they will nearly eliminate the risk of dying from it. We have great data on the number of Americans who have been vaccinated but it is more difficult to know how many have already been infected. We have 3 databases that tell us how many Americans have been infected, each with its own advantages and disadvantages:

  1. Nasopharyngeal testing data. When a person gets a nasal swab to test for the SARS-CoV-2 virus, the results of that test are reported to the local health department that in turns reports the information to the CDC. Nasopharyngeal testing data indicates that there have been 50,082,008 cases of COVID or 15.0% of the U.S. population. Death certificate data indicates that there have been 796,010 deaths from COVID. Both of these numbers are underestimates. Many people who are infected do not get tested either because they are asymptomatic or because they choose not to be tested. In addition, many retail self-test kits do not require reporting results to the health department so people who do at-home tests can be positive but the CDC cannot track their numbers. The deaths are tracked by death certificate reports and if a physician does not list COVID on the death certificate, the health department will not know if COVID was responsible. Furthermore, many COVID victims are simply found dead at home without having undergone COVID testing and those patients’ primary care physicians simply make their best guess at the cause of death.
  2. Blood donation antibody data. The CDC has a program that anonymously tests samples from blood donations for antibodies against COVID. However, the antibodies tested can be from either previous vaccination or from previous infection. This data indicates that 91.8% of blood donors have either gotten vaccinated or have been infected. A problem with this data is that blood donors are not representative of the U.S. population at large. Blood donors tend to be more socially responsible and are thus more likely to be vaccinated than the average American. In addition, adults with chronic disease and children under age 16 cannot donate blood. The current data can be found here on the CDC website.
  3. Clinical laboratory antibody data. When a person has blood drawn for a clinical laboratory test, left over blood can be used (anonymously) for testing for COVID antibodies through a second CDC seroprevalence program. These can be blood samples drawn because a person was ill or because a healthy person was getting a routine cholesterol screening test. An important difference with this data versus the blood donation data is that the commercial lab testing only tests for antibodies that result from infection and not antibodies that result from vaccination. According to this data, 29.4% of Americans have been infected in the past. This implies that 87,128,000 Americans have had a COVID infection, nearly double the number determined by the nasopharyngeal testing data. Texas has the highest past infection prevalence at 43% of its population. Vermont has the lowest prevalence at 7.7% of its population A limitation of this data is that older people and chronically ill people are more likely to have blood tests than younger people and otherwise healthy people and so the information may not be representative of the American population as a whole. The up to date data can be found here on the CDC website.

In a previous post, I noted that there are demographic groups of the unvaccinated. They are more likely to be younger, male, Republican, rural residents with lower education levels and lower incomes. This has created a uniquely American political dilemma – this is a group that tends to be very vocal but is a group that does not tend to have a lot of money to spend in the economy. As a consequence, our elected officials can score political points and votes by appeasing them even though they do not have much economic clout. The past year has proven that science and public service announcements will not sway this demographic to get vaccinated. Instead, to convince them to get vaccinated will require harnessing that most powerful of all influencers – American advertising. Our corporate advertising agencies have been enormously successful convincing us to buy stuff that we don’t really need and it is in corporate interest to keep us buying stuff instead of dying from COVID. After all, dead people can’t buy cigarettes, tickets to NASCAR races, or country music records… and dead people can’t vote for the candidates from their favorite political party.

Vaccination is the road to a return to normal

This month, I traveled to San Francisco, California and what a difference it was compared to Columbus, Ohio. In San Francisco, everyone wore masks indoors at stores and public buildings; about half of people even wore masks walking outdoors on the sidewalk. The city has an ordinance that requires showing proof vaccination to enter a restaurant, club, bar, or gym. And the stores and restaurants were full – in short, life is almost back to normal. Shoppers feel safe going into a store and diners feel safe eating in a restaurant. More than 95% of all San Francisco residents over age 12 have received a COVID vaccine. As a consequence, despite the fact that the stores and businesses are bustling, the rate of new COVID infections (30 per 100,000 population) and COVID hospitalizations (only 21 in the past 7 days) are among the lowest in the United States.

Meanwhile, back in Columbus, those few restaurants that elected to require customer vaccination get picketed by anti-vaxxer protesters. Only 73.5% of residents over age 12 have gotten a vaccine. The rate of new COVID infections is currently 300 per 100,000 population and there were 351 COVID hospitalizations in Columbus during the past 7 days. In other words, despite being a much more densely populated community, the rate of COVID infection and hospitalization in San Francisco are only 1/10th of the rates in Columbus.

I felt comfortable shopping in San Francisco. It will be a long time before I am willing to eat in a restaurant or enter a store for anything other than essentials in Columbus.

Internationally, countries with more of their population vaccinated are poised to emerge from the pandemic sooner and return to economic prosperity faster. Those countries with fewer of their citizens vaccinated are doomed to pandemic-induced economic stagnation, supply chain disruption, and prolonged inflation. Countries that are leading in the vaccination race are (percent of population vaccinated):

    • United Arab Emirates (100%)
    • Cuba (90.1%)
    • Cayman Islands (89.9%)
    • Chili (89.8%)
    • Portugal (88.1%)
    • Cambodia (88.1%)

The United States is in 28th place overall with 72% of the total population receiving a vaccine. Among the states, there are some clear winners – New Hampshire (with 92% of its population having received a vaccine) leads the rest of the states followed by West Virginia (89%), Massachusetts (88%), Vermont (87%), and Connecticut (86%),  Ohio (with 59% of its population having received a vaccine) ranks 43rd out of all of the states in vaccination rates. Only Alabama (57%), Tennessee (57%), Louisiana (56%), Indiana (56%), Mississippi (54%), Wyoming (54%), and Idaho (51%) have worse vaccination rates. Ohio is in a race to the bottom – our vaccination rate is currently in-between that of India and Venezuela; more closely resembling a third world country than an industrialized nation. As a rule, businesses and tourists do not elect to go to war zones – the U.S. in general (and Ohio in particular) remains a COVID war zone while our competitors are winning their COVID wars.

If we want to get our Ohio businesses to successfully compete with businesses in other states and if we want to get U.S. tourism to successfully compete with tourism in other countries, then we need to get our populations vaccinated. Countries and states with high vaccination rates are poised to become the economic winners; those that do not will become the losers. After a full year of vaccine availability, we really should have done better.

December 15, 2021

By James Allen, MD

I am a Professor Emeritus of Internal Medicine at the Ohio State University and former Medical Director of Ohio State University East Hospital