“You First”: Who Will Be Front in Line to Get a COVID Vaccine?
A small subset of hospitals and institutions in high-risk areas are likely to go first, according to bioethicist Arthur Caplan.
There is a huge amount riding on the discovery of a vaccine effective against the Covid-19 virus.
Making 660 million of anything without a glitch is—to put it mildly—a tall order in a nation that remains short on masks, gowns, and diagnostic tests despite months of trying to meet demand.
The world is waiting for a vaccine that can liberate everyone from the constraints on liberty required by existing efforts to fight the virus with public health measures such as masks, isolation, and quarantining. President Trump, for the most part, has rejected tough public health measures. Instead he has staked his political future and those of the governors and Congressional Republicans who have followed his lead on delivering a vaccine before Election Day as the solution to the COVID-19 pandemic in the USA. Many scientific experts have been sounding encouraging notes about having a vaccine by the end of this year or early next, as have many CEOs among the more than 160 companies chasing various strategies to identify a safe and effective vaccine.
But the reality is that no matter how fast a vaccine appears, those who might benefit will face a significant period of time before they could receive one. This is due to a variety of realities. Any vaccine faces various regulatory hurdles to insure safety and efficacy. This means completing large-scale studies in tens of thousands of subjects hoping for enough cases of blunted natural infection versus a large placebo control group to determine that a vaccine works. And that takes time--plus adding in delays in manufacturing and delivery, which will create logjams for most prospective recipients.
Shipping is not going to be easy with cold chain storage requirements from -20 to -70 degrees Celsius, from factory to a doctor's office, depending on the vaccine. In addition, many of the vaccines under development require two doses--that is 660 million shots to cover just those in the United States. Making 660 million of anything without a glitch is—to put it mildly—a tall order in a nation that remains short on masks, gowns, and diagnostic tests, despite months of trying to meet demand.
There are three scenarios under which a vaccine can appear but without being in any way available to all Americans.
The first is a vaccine under development in the USA or with some USA financing begins to show promise before a full clinical trial is completed. Current vaccine trials are supervised by Data Safety and Monitoring Boards and those committees could tell a CEO eager to be first to market that their vaccine is looking good at the study's half-way point.
The CEO and vaccine manufacturing company's board then let the White House know that a magic bullet which can ensure the President's reelection is in hand. The President, as he has done many times with other COVID treatments, most recently convalescent plasma, intervenes with the FDA and demands approval using an Emergency Use Authorization, or invoking the Federal Right to Try law he and Mike Pence are constantly touting. FDA Commissioner Steve Hahn folds and an extremely limited supply of vaccine, maybe only 100,000 doses, is available just before Election Day.
The second scenario is that another nation discovers a vaccine that looks safe and effective and the USA is able to buy some supply of it. But again, we are likely, initially, to get an extremely limited amount.
Lastly, the vaccine is approved in a standard manner. A full randomized trial is done, the endpoints are met, and no serious adverse events are identified. It is a USA-funded vaccine so most of it is coming here first. Still the vials and needles and plugs need to be quality-controlled and shipped and stored at the right temperatures. Information sheets and consent forms need to be readied, offered, and signed. Odds are you won't see any of this vaccine until late next year. So, who is going to get the first shots?
Some people under all of these scenarios are going to say, "Count me out." They don't trust vaccines or they don't trust the government to provide a safe one. Others may say, "The first one out of the box may be OK, but I am going to wait for the 'best' one before I take one." Even if those numbers are large, it is still certain that there will be more takers than can be vaccinated.
If you look at the discussion of vaccine rationing, almost everybody — including government officials, FDA officials, advisory panelists and ethicists — says the first group that should get vaccinated are at-risk healthcare workers. They say it, although they're not always clear about why.
One reason is that you need to give it to health care workers first because they will keep the healthcare system going. Another is that you need to give it to them first because they face more risk and they should get rewarded for having done and continuing to do that -- their bravery ought to be rewarded and their risk reduced.
A subset of hospitals and institutions in high risk areas will [go first] and that will be it for a significant period of time.
Both of these arguments for health care worker priority are not completely convincing. Food and power and vaccine manufacturing are arguably as important as health care, but workers in those areas don't get priority attention in most guidelines. And many Americans face risks from COVID comparable to health care workers, especially those who are not on the front lines in ERs and ICUs. Prisoners, military personnel who work on warships, the elderly, nursing home residents, and poor minorities are disproportionately affected by COVID. However, none of them are going first, nor is it clear how to weigh their claims in competing against one another for a scarce vaccine.
But, there's something else that's interesting in deciding who goes first. When people all agree, as they almost always do, that it's health care workers who must go first, a huge problem remains. What is the definition of who's a healthcare worker? You could easily get millions and millions of people designated as healthcare workers who would have a claim to go first.
We normally think that health care worker means doctors and nurses. But, if we go beyond those who work in ERs and ICUs, the number is big. And we must, because no ER or ICU can run without huge numbers of supporting individuals.
If you don't vaccinate lab technicians, people who clean the rooms, make food, transport patients, provide security, do the laundry, run the IT, students, volunteers and so on, you're not going to have a functioning hospital. If you don't include those working in nursing homes, home care and hospices along with those making and supplying vital equipment and bringing in patients via ambulances, police cars, and fire trucks, you don't have a functioning ICU, much less a health care system.
The total number involved could easily exceed tens of millions depending on how broadly the definition is set.
So, what is likely to happen is that health care workers will not go first. A subset of hospitals and institutions in high risk areas will and that will be it for a significant period of time. Health care institutions in hot spots, plus the supporting services they need will go first and then vaccine availability will slowly expand to other health care institutions and the essential workers needed to keep them functioning. Then consideration will also be given to how best to control the spread of the virus in selecting hot spots versus saving prisoners or the poor. And you can be sure, whatever the guidelines are, that the military and security folks will demand their share.
For many, many months if not a year or more, most people will not have to face a choice about vaccinating. The supply just won't be there for the general public. It is a small sample of high-risk health care workers including vaccine manufacturing employees and shippers, plus essential workers to keep hospitals and nursing homes going, who will be first in line. Odds are you and your family will still be wearing masks and social distancing well into next year.
How sharing, hearing, and remembering positive stories can help shape our brains for the better
Across cultures and through millennia, human beings have always told stories. Whether it’s a group of boy scouts around a campfire sharing ghost stories or the paleolithic Cro-Magnons etching pictures of bison on cave walls, researchers believe that storytelling has been universal to human beings since the development of language.
But storytelling was more than just a way for our ancestors to pass the time. Researchers believe that storytelling served an important evolutionary purpose, helping humans learn empathy, share important information (such as where predators were or what berries were safe to eat), as well as strengthen social bonds. Quite literally, storytelling has made it possible for the human race to survive.
Today, neuroscientists are discovering that storytelling is just as important now as it was millions of years ago. Particularly in sharing positive stories, humans can more easily form relational bonds, develop a more flexible perspective, and actually grow new brain circuitry that helps us survive. Here’s how.
How sharing stories positively impacts the brain
When human beings share stories, it increases the levels of certain neurochemicals in the brain, neuroscientists have found. In a 2021 study published in Proceedings of the National Academy of Sciences (PNAS), Swedish researchers found that simply hearing a story could make hospitalized children feel better, compared to other hospitalized children who played a riddle game for the same amount of time. In their research, children in the intensive care unit who heard stories for just 30 minutes had higher levels of oxytocin, a hormone that promotes positive feelings and is linked to relaxation, trust, social connectedness, and overall psychological stability. Furthermore, the same children showed lower levels of cortisol, a hormone associated with stress. Afterward, the group of children who heard stories tended to describe their hospital experiences more positively, and even reported lower levels of pain.
Annie Brewster, MD, knows the positive effect of storytelling from personal experience. An assistant professor at Harvard Medical School and the author of The Healing Power of Storytelling: Using Personal Narrative to Navigate Illness, Trauma, and Loss, Brewster started sharing her personal experience with chronic illness after being diagnosed with multiple sclerosis in 2001. In doing so, Brewster says it has enabled her to accept her diagnosis and integrate it into her identity. Brewster believes so much in the power of hearing and sharing stories that in 2013 she founded Health Story Collaborative, a forum for others to share their mental and physical health challenges.“I wanted to hear stories of people who had found ways to move forward in positive ways, in spite of health challenges,” Brewster said. In doing so, Brewster believes people with chronic conditions can “move closer to self-acceptance and self-love.”
While hearing and sharing positive stories has been shown to increase oxytocin and other “feel good” chemicals, simply remembering a positive story has an effect on our brains as well. Mark Hoelterhoff, PhD, a lecturer in clinical psychology at the University of Edinburgh, recalling and “savoring” a positive story, thought, or feedback “begins to create new brain circuitry—a new neural network that’s geared toward looking for the positive,” he says. Over time, other research shows, savoring positive stories or thoughts can literally change the shape of your brain, hard-wiring someone to see things in a more positive light.How stories can change your behavior
In 2009, Paul Zak, PhD, a neuroscientist and professor at Claremont Graduate University, set out to measure how storytelling can actually change human behavior for the better. In his study, Zak wanted to measure the behavioral effects of oxytocin, and did this by showing test subjects two short video clips designed to elicit an emotional response.
In the first video they showed the study participants, a father spoke to the camera about his two-year-old son, Ben, who had been diagnosed with terminal brain cancer. The father told the audience that he struggled to connect with and enjoy Ben, as Ben had only a few months left to live. In the end, the father finds the strength to stay emotionally connected to his son until he dies.
The second video clip, however, was much less emotional. In that clip, the same father and son are shown spending the day at the zoo. Ben is only suggested to have cancer (he is bald from chemotherapy and referred to as a ‘miracle’, but the cancer isn’t mentioned directly). The second story lacked the dramatic narrative arc of the first video.
Zak’s team took blood before and after the participants watched one of the two videos and found that the first story increased the viewers’ cortisol and oxytocin, suggesting that they felt distress over the boy’s diagnosis and empathy toward the boy and his father. The second narrative, however, didn’t increase oxytocin or cortisol at all.
But Zak took the experiment a step further. After the movie clips, his team gave the study participants a chance to share money with a stranger in the lab. The participants who had an increase in cortisol and oxytocin were more likely to donate money generously. The participants who had increased cortisol and oxytocin were also more likely to donate money to a charity that works with children who are ill. Zak also found that the amount of oxytocin that was released was correlated with how much money people felt comfortable giving—in other words, the more oxytocin that was released, the more generous they felt, and the more money they donated.
How storytelling strengthens our bond with others
Sharing, hearing, and remembering stories can be a powerful tool for social change–not only in the way it changes our brain and our behavior, but also because it can positively affect our relationships with other people
Emotional stimulation from telling stories, writes Zak, is the foundation for empathy, and empathy strengthens our relationships with other people. “By knowing someone’s story—where they come from, what they do, and who you might know in common—relationships with strangers are formed.”
But why are these relationships important for humanity? Because human beings can use storytelling to build empathy and form relationships, it enables them to “engage in the kinds of large-scale cooperation that builds massive bridges and sends humans into space,” says Zak.
Storytelling, Zak found, and the oxytocin release that follows, also makes people more sensitive to social cues. This sensitivity not only motivates us to form relationships, but also to engage with other people and offer help, particularly if the other person seems to need help.
But as Zak found in his experiments, the type of storytelling matters when it comes to affecting relationships. Where Zak found that storytelling with a dramatic arc helps release oxytocin and cortisol, enabling people to feel more empathic and generous, other researchers have found that sharing happy stories allows for greater closeness between individuals and speakers. A group of Chinese researchers found that, compared to emotionally-neutral stories, happy stories were more “emotionally contagious.” Test subjects who heard happy stories had greater activation in certain areas of their brains, experienced more significant, positive changes in their mood, and felt a greater sense of closeness between themselves and the speaker.
“This finding suggests that when individuals are happy, they become less self-focused and then feel more intimate with others,” the authors of the study wrote. “Therefore, sharing happiness could strengthen interpersonal bonding.” The researchers went on to say that this could lead to developing better social networks, receiving more social support, and leading more successful social lives.
Since the start of the COVID pandemic, social isolation, loneliness, and resulting mental health issues have only gotten worse. In light of this, it’s safe to say that hearing, sharing, and remembering stories isn’t just something we can do for entertainment. Storytelling has always been central to the human experience, and now more than ever it’s become something crucial for our survival.
Want to know how you can reap the benefits of hearing happy stories? Keep an eye out for Upworthy’s first book, GOOD PEOPLE: Stories from the Best of Humanity, published by National Geographic/Disney, available on September 3, 2024. GOOD PEOPLE is a much-needed trove of life-affirming stories told straight from the heart. Handpicked from Upworthy’s community, these 101 stories speak to the breadth, depth, and beauty of the human experience, reminding us we have a lot more in common than we realize.
A new type of cancer therapy is shrinking deadly brain tumors with just one treatment
MRI scans after a new kind of immunotherapy for brain cancer show remarkable progress in one patient just days after the first treatment.
Few cancers are deadlier than glioblastomas—aggressive and lethal tumors that originate in the brain or spinal cord. Five years after diagnosis, less than five percent of glioblastoma patients are still alive—and more often, glioblastoma patients live just 14 months on average after receiving a diagnosis.
But an ongoing clinical trial at Mass General Cancer Center is giving new hope to glioblastoma patients and their families. The trial, called INCIPIENT, is meant to evaluate the effects of a special type of immune cell, called CAR-T cells, on patients with recurrent glioblastoma.
How CAR-T cell therapy works
CAR-T cell therapy is a type of cancer treatment called immunotherapy, where doctors modify a patient’s own immune system specifically to find and destroy cancer cells. In CAR-T cell therapy, doctors extract the patient’s T-cells, which are immune system cells that help fight off disease—particularly cancer. These T-cells are harvested from the patient and then genetically modified in a lab to produce proteins on their surface called chimeric antigen receptors (thus becoming CAR-T cells), which makes them able to bind to a specific protein on the patient’s cancer cells. Once modified, these CAR-T cells are grown in the lab for several weeks so that they can multiply into an army of millions. When enough cells have been grown, these super-charged T-cells are infused back into the patient where they can then seek out cancer cells, bind to them, and destroy them. CAR-T cell therapies have been approved by the US Food and Drug Administration (FDA) to treat certain types of lymphomas and leukemias, as well as multiple myeloma, but haven’t been approved to treat glioblastomas—yet.
CAR-T cell therapies don’t always work against solid tumors, such as glioblastomas. Because solid tumors contain different kinds of cancer cells, some cells can evade the immune system’s detection even after CAR-T cell therapy, according to a press release from Massachusetts General Hospital. For the INCIPIENT trial, researchers modified the CAR-T cells even further in hopes of making them more effective against solid tumors. These second-generation CAR-T cells (called CARv3-TEAM-E T cells) contain special antibodies that attack EFGR, a protein expressed in the majority of glioblastoma tumors. Unlike other CAR-T cell therapies, these particular CAR-T cells were designed to be directly injected into the patient’s brain.
The INCIPIENT trial results
The INCIPIENT trial involved three patients who were enrolled in the study between March and July 2023. All three patients—a 72-year-old man, a 74-year-old man, and a 57-year-old woman—were treated with chemo and radiation and enrolled in the trial with CAR-T cells after their glioblastoma tumors came back.
The results, which were published earlier this year in the New England Journal of Medicine (NEJM), were called “rapid” and “dramatic” by doctors involved in the trial. After just a single infusion of the CAR-T cells, each patient experienced a significant reduction in their tumor sizes. Just two days after receiving the infusion, the glioblastoma tumor of the 72-year-old man decreased by nearly twenty percent. Just two months later the tumor had shrunk by an astonishing 60 percent, and the change was maintained for more than six months. The most dramatic result was in the 57-year-old female patient, whose tumor shrank nearly completely after just one infusion of the CAR-T cells.
The results of the INCIPIENT trial were unexpected and astonishing—but unfortunately, they were also temporary. For all three patients, the tumors eventually began to grow back regardless of the CAR-T cell infusions. According to the press release from MGH, the medical team is now considering treating each patient with multiple infusions or prefacing each treatment with chemotherapy to prolong the response.
While there is still “more to do,” says co-author of the study neuro-oncologist Dr. Elizabeth Gerstner, the results are still promising. If nothing else, these second-generation CAR-T cell infusions may someday be able to give patients more time than traditional treatments would allow.
“These results are exciting but they are also just the beginning,” says Dr. Marcela Maus, a doctor and professor of medicine at Mass General who was involved in the clinical trial. “They tell us that we are on the right track in pursuing a therapy that has the potential to change the outlook for this intractable disease.”