COVID-19, the new vaccines and rheumatology: Facing the unknown unknowns
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Before I say my piece on this, let me be clear that I am a strong vaccine advocate for all, including my patients with immune-mediated diseases. I am a champion against vaccine hesitancy and like to think my discussions are reflective of shared and informed decision-making.
Having said that, I have to admit that I’m keeping my eyes open during the vaccine roll-out. I am increasingly impressed by how much we don’t know and am dismayed by our community’s rush to judgment either for or against based on thin data.
In terms of efficacy, these vaccines we are administering are incredibly effective. If, at the end of the phase 3, we had vaccines that were even 65% effective we would have been ecstatic. The naysayers, knowing that the vaccines are 90% to 95% effective, are harping on the fact that vaccine breakthrough can and does occur, both with and without robust antibody response. We must remember that we are just beginning to understand immunologic correlates for protection and thus we need to be cautious in how this is discussed with the lay public.
A recent scientific report in The New England Journal of Medicine is excellent and balanced, but the news coverage has at times been horrific: Hold the course and keep vaccinating.
What about the providers who are continuing to check antibody responses on our vaccinated patients? I understand what the intent is: namely, to see if it works. Unfortunately, for the moment, we do not have a biomarker of known test operating characteristics capable of informing us or our patients of true effectiveness. In fact, the CDC strongly advises against such testing until we have a better understanding of its biologic significance.
In our clinic, Cassie and I tell people that the vaccine is their best chance for protection, though — depending on their immunosuppressive regimen and underlying disease state — their response may not be as good as individuals without their disease and treatment, and thus they still need to be cautious and avoid unvaccinated, unmasked people including children when feasible. Not the message they want, but we also tell them that they are certainly more ‘immune’ with the vaccine than without it and, hopefully down the line, we will be able to test for it.
Finally, what about toxicity? The cases of vaccine-induced immune thrombotic thrombocytopenia (VITT) are heartbreaking, complex and fascinating. They are clearly autoimmune complications shared primarily by the adenovirus vector vaccines. Fortunately, they are extremely rare (about one in a million) and seen predominantly in younger women. In VITT, the vaccine triggers an immune response leading to an atypical heparin-induced thrombocytopenia-like disorder, but as of yet there are few predictors other than age and gender.
For my young women, especially with hypercoaguable backgrounds, for now I am urging them to seek non-adenovirus-based vaccines in an abundance of caution after I give them the facts. Some may consider this overreacting, but for now that is my position. The last thing I want to see is a surge of increased vaccine hesitancy in this demographic, and thus a middle path may help mollify this. By the time you read this, I am certain we will have guidance by the Advisory Committee on Immunization Practices and CDC.
Finally, there are growing anecdotes of vaccine-induced autoimmunity, autoinflammation, zoster, skin rashes and more. We can’t deny the reports, but we should not prematurely embrace causality or refute it — the data will be the data. As medical scientists, we are different from most of the well-meaning public as we must, by virtue of belief in science, embrace the possibility that we are wrong. Let me know your take at calabrl@ccf.org or rheumatology@healio.com.
- For more information:
- Leonard H. Calabrese, DO, is the Chief Medical Editor, Healio Rheumatology, and Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, and RJ Fasenmyer Chair of Clinical Immunology at the Cleveland Clinic.
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