Vaccination. The concept itself is a covert fundamental of society and culture today as it allows for significant freedom of movement without fear of multiple fatal diseases. It seems as though vaccine development is moving faster and faster every year—indeed in 2020, vaccine development is approaching warp speed!
But, no matter how quickly developed, no vaccine is effective until administered to the target population. So, how does that even happen when the country’s (and the world’s) population seems to have grown at the same warp speed? Let’s start with a bit of historical perspective.
Vaccination, variolation or immunization are much older practices than one might think. Records indicate that crude efforts towards protection through exposure were used as early as 1000 A.D. in Asia. However, most experts seem to agree that by the mid-1500’s, efforts to inoculate against smallpox infection were wide-spread in China and India. In the late 1600’s, insufflation was the common method of inoculation. Dry scabs might be ground into a powder and then puffed up a child’s nose, or the dry scabs might be soaked in water prior to being placed in the nose. Still, another common method was to take fluid from a pustule, place it on a cotton plug and then put the plug up the nose of the child.
By the 1700’s, trade routes had spread the practice to most of Europe and likely also allowed for the further variations in administration. The Chinese even described a method that amounted to a crude attenuated vaccine by carrying the contents of a pustule (pocky matter) at body temperature for a month, or exposing it to steam and herbs prior to placing on cotton and then into the nose. It’s likely that this handling allowed for inactivation of some viral particles and decreased the overall viral load, resulting in a very crude attempt at a modified-live vaccine.
Fast forward to 2020, and smallpox is no longer the major focus of immunization efforts. Today’s medical sciences use a plethora of different approaches to safely stimulate immunity against a number of potentially life-threatening pathogens. Each vaccine type may use a novel platform or delivery system, target a different component of the viral molecule or seek to stimulate a specific portion of the host immune system. While each of these approaches has a unique set of advantages and disadvantages (see above table), all share a common potential point of failure. To be effective, vaccines must be administered on an individual level—no vaccine is effective if it remains in the vial!
The portion of the population that must be immune to confer “herd” immunity varies from disease to disease and is related to how contagious the disease is from person to person. For example, an estimated 94% of the susceptible population must be immune to measles to disrupt transmission. For SARS-CoV-2, current estimates are that 70% of the population must be immune to interrupt transmission. In 2020, the estimated U.S. population is ~330 million. Thus, 231 million (or more) Americans would need immunity conferred by either natural disease recovery or vaccine to effectively interrupt the transmission of SARS-CoV-2. Current estimates are that ~5 million Americans have tested positive thus far; that’s a very long way from 231 million.
So, how do we administer roughly 200 million vaccinations to individuals all across the country? How long will it take? Some estimate that natural immunity may only last months rather than years. So does a vaccination campaign then race against the waning immunity of those recovering from natural infection? Well, we may not know the answer to how long natural immunity lasts, but we do know how to administer mass vaccination campaigns. In fact, much of the infrastructure for such efforts exists in most cities in the U.S. since President Kennedy signed the Vaccination Assistance Act into law in 1962, which provides for the mass vaccination of the population with a focus on pre-school-aged children. Additionally, the act allowed federal funds to go to state and local authorities to support vaccination of the entire population.
The anthrax attacks of 2001 required life-saving medical counter-measures (MCM) to be distributed and administered to nearly 2,000 people in a very short time period. The survival rate for inhalation of anthrax declines precipitously if MCM are not administered within 48 hours of exposure.
In 2004, the Centers for Disease Control and Prevention (CDC) established the Cities Readiness Initiative (CRI). The CRI program is a federally-funded program to enhance local preparedness for biological incidents. The CRI program targets a system of Metropolitan Statistical Areas (MSAs). Each state has at least one MSA and the total population of all the MSAs together is about 60% of the U.S. population.
The CRI programs are responsible for cultivating relationships with large (and not so large) employers in their local areas. Both government and private employers are eligible to participate in efforts to provide lifesaving MCMs to their employees (and their families) by order that the employer serve as a force multiplier for distribution to meet the CRI target distribution window of 48 hours. Jurisdictions are required to maintain written plans for effective distribution schemes down to the smallest of details. Granular information such as driving routes to likely distribution points in a community is included. CRI communities are also required to exercise all components of plans routinely with analysis and corrective actions included in After Action Reports (AAR). Since the CDC funds CRI preparedness efforts, naturally, the local CRI programs are reviewed by CDC personnel regularly as well.
CRI sounds like a great idea; execution seems assured and wide-spread distribution of MCM appears well in-hand. But, anthrax-related medications such as ciprofloxacin do not require refrigeration nor injection. So, how does this change things? The good news is that vaccines requiring refrigeration are not a novel invention and such items are distributed nationwide on the daily. Federally funded CRI programs are required to provide logistics for temperature-controlled distribution plans, as well as inert products not requiring climate control.
With climate control and distribution handled, we should turn our focus to administration of a vaccine in such a circumstance. If the hotly anticipated SARS-CoV-2 vaccine is an oral formulation, then the celebration can begin! By and large, Americans, and humans in general, are much more likely to accept a medication that is orally administered than one that is injected with that super scary object—a needle! However, it is much more likely that the vaccine will require injection instead of a simple gulp.
Many healthcare professionals are discussing vaccines and vaccine development on webinars these days, and when the nearly inevitable question arises of who will administer all these vaccinations, given the current burden on the healthcare system, these otherwise well-informed professionals are at a loss. Many folks are wholly unaware of the legal framework in place in the U.S. for just these events. In fact, the existing framework allows for a broad swath of trained healthcare professionals to join the vaccine administration team, including, but not limited to, pharmacists, nurses, dentists and veterinarians. Additionally, all of those appropriately integrated into the public health response and under the direction of the local public health officer are typically immune from liability while conducting approved activities such as vaccine administration pursuant to a blanket prescription order. The only actions not covered by this umbrella of immunity are those committed outside of assigned tasks or those committed with willful misconduct (Federal Public Readiness and Emergency Preparedness Act (PREP Act)).
I strongly recommend that veterinarians join their local Medical Reserve Corps (MRC) and get engaged, if not involved, in local public health efforts, even outside of a pandemic. Surely during a pandemic veterinary professionals and support staff will find the MRC an incredible outlet for community engagement and soul-satisfaction through community volunteerism. The beauty of integration with the MRC is the “cloak” of protection provided by the program’s practice of full coverage for members while actively employed in assigned tasks.
To the larger issue that will no doubt dominate media coverage and supper table discussions alike, I have no solution. That issue is public acceptance and recognition of the newly-minted vaccine as safe, efficacious and necessary. Accurate information is the only antidote to fear, and if the media coverage of this pandemic to date is any indication, accuracy is not likely to be wide-spread. So, the vaccine may sit idly in a refrigerated container at a point-of-dispensing (POD) staffed by veterinarians and medical professionals alike with no one in which to administer the potentially life-saving MCM.
What to do to resolve this? Veterinarians can begin by making herculean efforts to remain abreast of any developments down the path to a safe and efficacious vaccine. We can also share this information with our colleagues, staff members, clients and anyone who is interested. Tell them it could be worse…at least we are not proposing to stuff a puss-soaked cotton ball up their nose and ask them to leave it there for a few days. +
Resources
- Boylston A. The origins of inoculation. J R Soc Med. 2012;105(7):309-313. doi:10.1258/jrsm.2012.12k044
- https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/herd-immunity-and-coronavirus/art-20486808
- https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html
- https://www.census.gov/popclock/
- https://www.rand.org/content/dam/rand/pubs/technical_reports/2009/RAND_TR640.pdf
- https://www.cdc.gov/cpr/readiness/mcm/cri.html
- Centers for Disease Control and Prevention. Vaccine-Preventable Diseases, Immunizations, and MMWR — 1961–2011. MMWR 2011;60(Suppl):49-57.
- https://www.phe.gov/Preparedness/legal/prepact/Pages/default.aspx
