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Aalmost a year of pandemic terror, the end is in sight. But you still have to squint.
The FDA has granted emergency use authorization for two safe and effective vaccines that science has delivered at record speed. The question now is: how to best distribute them?
The Centers for Disease Control and Prevention’s (ACIP) Advisory Committee on Immunization Practices (ACIP) has issued guidelines that vaccinations should begin with healthcare staff and residents of long-term care facilities, followed by other essential frontline workers and those over 75 years old. How the history of Covid-19 infection should affect the place in the line is only mentioned as a sub-priority: “Healthcare professionals with documented acute infection with SARS-CoV-2 during of the previous 90 days may choose to delay vaccination until the end of the 90 days. day to facilitate the vaccination of health professionals who remain sensitive. “
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Given the low risk of re-infection and the limited supply of vaccine doses, it would be a mistake not to make prior infection a more central consideration in our prioritization of vaccines. With around 75 million Americans having already been infected with SARS-CoV-2, but only 24 million know it, the use of large-scale Covid-19 antibody tests may help better target vaccine allocation to those most at risk. It can save lives and get us back to normal sooner.
This strategy builds on the two biggest discoveries made in the effort against the virus. The first is that after infection, including mild and asymptomatic infections, there appears to be long-lasting and strong immunity for up to six months and more. The fact that there have been nearly 100 million confirmed cases of Covid-19 worldwide and that only a handful of documented re-infections provides compelling evidence of lasting immunity. And even among the rare re-infections, their course will probably be smoother thanks to the memory of the immune system.
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The second breakthrough is the resounding success in developing the Covid-19 vaccine.
This combination of long-lasting immunity and effective vaccines has been the cornerstone of almost all past successes against viruses (HIV, to date, being the main exception). This is how the scourges of smallpox, polio, measles, mumps and other infectious diseases were defeated. And that’s how we’re going to beat Covid-19.
But even in the best-case scenario, it will be months before enough doses of the vaccine have been taken to treat everyone. With epidemiologists estimating that two-thirds of the population must be immunized for the protection of the herd needed to quell the pandemic, an antibody-assisted approach would allow us to reach this threshold more quickly.
Here’s another reason why an antibody-assisted vaccination approach is needed: Due to the combination of inadequate testing and asymptomatic infection, most people infected with Covid-19 are never diagnosed. This is especially true in the states hardest hit by the virus. In New York State, for example, an estimated 30% of the population has recovered from Covid-19 while only 7% have been diagnosed with the virus. The underdiagnosis is not limited to places like New York City, which experienced an early outbreak. It is estimated that over 36% of North Dakotans have been infected, while only 13% have been diagnosed. Given these discrepancies, in states like North Dakota, without the help of antibody testing, I estimate that up to 1 in 4 vaccines could be given to someone who is currently immune to Covid-19.
Although the presence of antibodies is not a perfect measure of immunity, thanks both to the rarity of reinfection and the accuracy of current antibody tests (with false positive rates of around 1% or less), those with antibodies can safely be considered low risk. group. This reality was confirmed in a recent report from the New England Journal of Medicine at the University of Oxford that followed 12,000 healthcare workers for six months and found no symptomatic infections in people with anti- antibodies. SARS-CoV-2.
But theory and practice are two different things. Given the difficulty the United States has had in expanding PCR testing, and with vaccine distribution spraying early, efforts to test sections of the public for antibodies may seem reckless. It is not.
When it comes to testing for antibodies, the process is totally different from PCR-based tests used to detect acute infection. Antibody tests are more like traditional blood tests and are treated like automated immunoassays. This means they can be run in large batches on machines that almost every functioning medical lab already has and can use the existing lab collection infrastructure for collection and processing. As Benjamin Mazer, a pathologist at Johns Hopkins Hospital, told me, “The delays we have faced with PCR testing should not deter people from doing antibody tests if they are needed. The antibody test is much simpler to perform and can be done in hours rather than days. “
An easy place to start would be to test for antibodies in people who already need lab tests for other reasons, such as when they are admitted to the hospital, emergency room, or have a clinic appointment. Standing orders paired with canceled co-payments for others in clinical and commercial labs can further expand access. Batch testing in schools and employers can inform their future vaccination campaigns.
To be clear, it is both safe and beneficial for people previously infected with SARS-CoV-2 to be vaccinated (just like adults who have had chickenpox need a booster to prevent shingles). It is essential that appropriate investments are made to support both tests and vaccination. These efforts must be complements and not competitors. And if access to antibody testing is not readily available, vaccination should never be delayed. Finally, once the supply is sufficient to meet public demand, everyone should be vaccinated, regardless of their antibody status.
I could conclude with an argument about how an antibody-assisted approach would allow the United States to achieve collective immunity faster. Or jumpstart our economy faster. Or protect more frontline workers – nurses, teachers, grocers, delivery drivers, firefighters and more – sooner.
But for me, and I suspect for you too, it’s a lot less abstract than that. For every vaccine we save by using antibody tests, there will be one more that we can give to a high-risk person who is eagerly awaiting their turn in line. And we all have loved ones standing in line: an elderly grandparent, an immunocompromised mother, or a cousin battling cancer.
Considering everything we have done so far to keep them safe – delayed meals, canceled vacations and missed hugs – we must use every weapon in our arsenal against this scourge. This includes antibody testing.
Michael Rose is a medical resident of internal medicine and pediatrics at Johns Hopkins University School of Medicine.
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