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Changing Information and Evolving Science

I am now old enough to have seen health care evolve and change considerably. From the treatment of heart attacks, the changes in low back pain management, and HIV care, medicine continues to adapt and change with the more we learn and the use of evidence to guide treatment.

Evidence? I can remember many conversations with patients who felt that the mere mention of “evidence based medicine” or EBM, was a prelude to being told that they were not going to get something they wanted.

What has changed in my career is the movement of the rationale for how we treat various conditions from “peer opinion,” meaning what the experts “best guess” was to the use of research (randomized controlled trials, when possible) to really compare treatment A to treatment B.

The challenge: change. What we know changes constantly. The science continues to evolve and we continue to learn daily.

So, now here we are with COVID-19.

Rapidly, the research is studying every aspect of this infectious disease. This includes everything from how we treat late stage infection in the ICU to how to adequately prevent people from catching this very infectious virus in the first place. We are also trying to understand what impacts someone’s risk for worse outcomes. Patterns are emerging, and more information will come.

One area getting a lot of appropriate attention is the body’s production of antibodies. There are basically two ways to develop antibodies to a virus. We either get them after having the infection (assuming we did not succumb to the disease) or we get vaccines that are usually “attenuated” versions of the virus. This is a process where the virus has been reduced (“de-fanged”) in it’s effect, but still mounts an antibody response.

This is where all the action is…right now.

What we know so far is that COVID-19 does create an antibody response, but as was published in the Journal Blood on October 1, these antibodies only last, or begin to vanish about three to four months after the infection. Also, it seems that the more severe the infection, the higher the amount of antibodies produced.

We are now hearing about the possibility of a vaccine that works through the RNA of the cell which seems to create protection about seven days after the second dose. This could be game-changing. The other caution is that the data needs to be confirmed by other scientists and more people need to be studied to evaluate for side effects. Even if it works, the availability to the general population could be months away. If and when a vaccine becomes available, we would need to prioritize front-line workers and the medically vulnerable.

What does this mean to me as a primary care provider? The jury is still out, but I suspect that COVID-19 may very well become like the flu and may require an annual vaccination. This also means that the other preventive measures like hand washing, masks, keeping hands away from faces, and staying home when you are sick will continue to be important. While it would be nice, I do not think this will ever be a “one and done” situation. For both COVID-19 and the flu, it is possible to spread the virus to others before experiencing any symptoms. People can spread COVID-19 for about two days before experiencing signs or symptoms and remain contagious for at least 10 days after signs or symptoms first appear. (People with the flu are usually contagious one day before showing symptoms and remain contagious for about seven days.)

One more thing, the bottom line, according to the investigators, is that to extinguish the ongoing COVID-19 pandemic, the vaccine must have an efficacy of at least 80%, and 75% of people must receive it. Because this high vaccination coverage seems unlikely to happen soon, other measures such as social distancing and wearing masks will probably be important preventive measures for the foreseeable future. (Source: Bartsch SM, O’Shea KJ, Ferguson MC, et al. Vaccine efficacy needed for a COVID-19 coronavirus vaccine to prevent or stop an epidemic as the sole intervention. Am J Prev Med. 2020;59(4):493−503.)

Further, once we have a vaccine, just like with the flu, there will be prioritization of who should get the vaccine and in what order. The National Academies of Sciences, Engineering, and Medicine outlined recommendations for distribution of COVID-19 vaccines, calling for high-risk health care workers and first responders to receive the first doses, followed by older residents in facilities like nursing homes and adults with preexisting conditions that put them at increased risk. The panel called for states and cities to focus on ensuring access in minority communities and for the United States to support access in low-income countries.

As a family medicine doctor, I always try to remember what a mentor told me years ago: “A plan is today’s best guess.” We have to act on what we know now, and be willing (and open) to new information and learnings. One thing is for sure, change will be the constant.