Vaccinating New York City

It is a truism in public health that vaccines don’t end epidemics. Vaccinations end epidemics. As 2020 dwindles down to its last dreadful days, the distance to relief from the pandemic can be measured not in weeks or months but in doses of vaccine.

New York will embark next week on the largest vaccination effort at least since 6 million New Yorkers were immunized against smallpox in one month in 1947.

But this time, the whole world is attempting the same thing at the same time as the novel coronavirus continues to spread. The degree of difficulty is heightened because the first three vaccines to become available require two doses, must be refrigerated at different temperatures and will be delivered through a global chain of air shipments that makes the Berlin airlift look like the work of Shleppers Moving and Storage of The Bronx.

What could possibly go wrong?

The first batch of the new Pfizer/BioNTech vaccine is expected in New York next Tuesday (Dec. 15) after final federal approval, according to Gov. Andrew Cuomo. Mayor Bill de Blasio’s office said that by early January there would be enough of the Pfizer vaccine, and another from Moderna, to give 480,000 city residents the first of their two doses.

To say this another way, with second doses due three or four weeks after the first, about 5% of New York City’s 8.4 million people will be immunized around the end of January, based on the mayor’s numbers.

So, an anxious city asks, when will life return to at least a new normal? The mayor’s answer did not specify a date, but signaled it would be a transition that begins now.

“Every person who gets successfully vaccinated changes the playing field,” de Blasio said last Thursday. “As vaccination becomes more and more common, it improves our ability to limit the virus. Remember also that millions of people, obviously, have had the disease already, and from what we’ve seen so far, thank God, are less vulnerable to being infected again, or having a negative impact from the disease ... let people understand: more work to do, stay disciplined, stay focused, but the situation can and will improve with each month.”

Achieving Herd Immunity
Behind the mayor’s forecast of improvement lie a thousand tricky choices and a scary race between the virus and the vaccine to reach enough people to achieve a concept that’s been tossed around a lot since the start of the pandemic: Herd Immunity.

Simply put, for those who haven’t kept up, herd immunity is achieved in a community when enough people (politely known as the herd) have achieved immunity to a virus, either by infection or inoculation, so it stops spreading.

A number of communities, including Sweden, thought they could do this by letting the virus spread. That didn’t work because way too many people ended up getting sick.

Herd immunity is not the same for all diseases. It depends how infectious the virus is. Measles is so infectious, for example, that more than nine out of ten people need to be immunized to stop it from spreading. Growth in anti-vaccination attitudes have recently led to measles resurgence in a number of places, including New York.

Coronavirus is pretty infectious, although not as infectious as measles. So health experts estimate herd immunity will require about 7 out of 10 people to be immune to stop the spread. That would be about 5.8 million New Yorkers (ironically close to the number inoculated against smallpox in 1947).

Right now, we are not even close. The Department of Health reports that as of Dec. 6, at 1 p.m., 307,269 New Yorkers have tested positive for the virus. Clearly, many more people have been infected without being tested. How many? No one knows for certain.

Tests for the antibody triggered by infection show an enormous range across the city, from the one in ten in Battery Park City to nearly half in the Corona section of Queens, according to the health department. Even if you assume, say, a third of New Yorkers were infected (and further assume the infection gives long lasting immunity) that still would leave another 2.94 million New Yorkers to be vaccinated (or infected by the virus) before herd immunity starts to kick in.

At the rate the mayor described for the first month (480,000) this will take six months. It is possible that the availability of vaccine will rise as more vaccines are approved and production ramps up. But the challenges will rise, too.

Building Community Trust
New Yorkers need no primer on how dangerous this virus is. Yet, even here, at what once was the global epicenter, there is considerable skepticism about the vaccines.

“The data shows that 50 percent of the Black and brown community do not trust the vaccine,” said Eric Adams, the Brooklyn Borough president and a leading mayoral candidate. Among front line workers, many fire fighters, ambulance paramedics, transit workers and teachers have expressed resistance to taking the vaccine, according to interviews by their union leaders and others with the New York Post.

At first, there will be many more willing participants than doses of vaccine. But both equity and solid public health will require convincing skeptics. “Merely stating that the vaccine will be available for minority communities is not enough,” Adams said.

“Race doesn’t determine the effectiveness of a vaccine,” said Dr. Jay Varma, the mayor’s senior health adviser, “but racism determines the ability to get vaccines to people and have people accept and use them.”

The approval process for the vaccines must establish safety and effectiveness across diverse populations, Varma said at a briefing last week.

“But really our focus has to be making sure that we really earn the trust of communities, which have a very real reason to distrust medical interventions,” he added, “and we feel strongly that once those scientific reviews are complete, our engagement with the community will help us make sure that vaccines get to those that need the most.”

Dr. Dave Choksi, the New York City health commissioner, said that the city will monitor vaccine distribution in real time through the Citywide Immunization Registry, set up in the 1990’s to record immunizations. If the data show that low-income or minority neighborhoods are not being reached the city will redirect its efforts and doses of vaccine to those neighborhoods, he said.

“Our approach,” he explained, “is to make sure that we’re relying upon the relationships that already exist in communities – community-based organizations, faith leaders, people who are looked to as trusted messengers and partnering with them. Having the humility to say, it’s not just about the message that we deliver, but about the messenger, and sometimes that’s about passing the baton to someone else with respect to delivering the message.”

The political complexity of distributing the vaccines may be as great as the molecular complexity that has been conquered to create them.

“Our goal is to ensure that a safe, effective vaccine gets to everyone who wants it,” said Choksi. Yet, there are also warnings that it may not be enough to just give it to everyone who wants the vaccine.

The New York State Bar Association’s House of Delegates called on the state last month to be ready to mandate vaccinations for everyone, or for groups or communities, if voluntary efforts fall short.

“In balancing the protection of the public’s health and civil liberties, the Public Health Law recognizes that a person’s health can and does affect others,” according to Mary Beth Morrissey, chair of the Bar Association’s Task Force on COVID-19, which proposed the resolutions. “The authority of the state to respond to a public health crisis is well-established in constitutional law. It may become necessary to require that certain individuals or communities be vaccinated, such as health care workers and students, to protect the public’s health.”

Health experts generally are predicting that it will be safe to come out of shelter by spring or early summer. If all goes well. That is what they call a big if.