Engaging Unbelievers in a Conversation About Vaccines
Before we continue, in the interest of transparency, let me be clear about where I am coming from: I am a fan of vaccines, get them myself, administer them, and think they are always better than the alternative of getting what you’re being vaccinated against. I voted yes when the leadership of my hospital mandated the annual flu injection or risk termination. In interviews, I repeatedly expressed my belief that all first responders should receive full vaccination to prevent the catastrophic infections they encounter daily. Because of the awful burden on our society, I think we should also mandate COVID-19 and flu vaccines for those who work directly with sick people and continue to do so (with limited exceptions, including religious objections). I also believe that those at risk in nursing homes, as well as people with immunodeficiencies or malignancies, should be vaccinated. Finally, I think all vaccines, not just those for public health emergencies, must remain accessible and inexpensive. We need ongoing community access, education, and mobilization around them, and your role in this process is crucial.
I am concerned. There is too much misinformation out there regarding vaccine protection. We have brewing epidemics with H5N1 influenza, and measles has taken hold and, is ripping through various religious communities, especially among children. Measles can be deadly and is one of the most transmissible infections on earth.
One of the most common causes of death on the planet is Malaria. A vaccine has been available since 2015 (Stephanie Nolen, NYT 7/2024) but was not part of vaccination programs in Africa until 2024. “The number of deaths that could have been prevented,” says the NYT, is 143,000 children. If that does not give you pause, nothing will.
My greatest hope is that we all strengthen our perspective on vaccines, which are always widely and readily available to everyone in our country. Unfortunately, this is not the case worldwide, although the World Health Organization works with Pharma and Philanthropy to get vaccines to third-world countries.
Many media reports broke this down along party lines in the USA (e.g., white male conservatives being the most resistant) or brought up the troubling story of the Tuskegee Study that led to many Black people’s mistrust of the medical system. There is no doubt that people are suspicious and conjure up conspiracy theories, but vaccination also has to do with eligibility, access, and relationships. Our communities play a crucial role in shaping our views on vaccines. People we know or have a connection with are more persuasive than facts or even "charming" doctors.
That said, too much “news” surrounding the rollout of COVID-19 vaccines has been misleading, highly exaggerated, or patently false, making the subject of vaccines polarizing for reasons that are sometimes understandable yet anything but scientific and, most often these days, political. The problem is how many people and so many stories focus on the negative instead of the good vaccines. “Person Dies from Vaccine” or “People Resist Vaccination” is much more powerful clickbait than “Nothing Bad Happens because of Vaccinations.”
A 2021 NPR analysis found that “articles connecting vaccines and death have been among the most highly engaged with content online, going viral to hinder people’s ability to judge the genuine risk of getting a shot.” Modern medicine constantly fights Facebook feeds” and other “news” focusing on side effects, no matter how rare. That fuels our emotions more than science or facts, and it is persuasive. I cannot change emotions or politics in this essay. But what I can deal with before we continue is the anti-vaccine or anti-vaxxer movement.
COVID-19, like influenza and many other illnesses, will be endemic (commonly found) and with us forever. They will change and adapt, and we will need annual vaccinations to cover all the variants that some viruses—even those we thought eradicated—become. That, you know now, is what viruses do; they jump species, change, adapt, and evolve.
Vaccines have been with us for more than 200 years, and no advance in public health short of sanitation has been more critical. Both control infections, the leading causes of death in the world. The word vaccine comes from Vacca, the Latin word for cow. That is because the vaccination story begins with Edward Jenner, an English country doctor who used a live but weakened or attenuated foreign antigen found in the exudate (pus) from an abscess of cowpox and injected it into a boy to create a state of immune protection against the smallpox virus. The inoculation worked. In 1880, Louis Pasteur built on the work of Jenner when he realized old chicken cholera germs could not transmit the disease and used them to develop a lab-created vaccine to inoculate chickens against the disease. He later created animal vaccines against rabies and anthrax.
Jenner and Pasteur’s monumental work using weakened or attenuated organisms to create a state of immune protection is the foundation for the live-attenuated vaccines we are familiar with today. The principles of this vaccination depend on using these organisms—or, more recently, the use of parts of the organism—to produce an immune response. Adaptive and cellular immunity to specific infections can be achieved by deliberately causing that infection with an unmodified infectious agent like Jenner did with smallpox.
Until COVID-19, the most common vaccines were those live-attenuated vaccines from weakened or attenuated live organisms that are grown until they no longer efficiently infect humans and injected into humans to stimulate immunity, not the disease (the live nasal flu vaccine, which is sprayed into noses is also attenuated and was used when the injection form was in short supply). Live-attenuated vaccines are not always suited to combatting mutations, but they are highly effective at what they target. They have eliminated polio in most countries and control the scourge of measles, mumps, rubella, varicella, and pertussis (whooping cough).
First up was the first widespread use of two genetic vaccines. These vaccines inject the coronavirus’s messenger RNA or mRNA genes to make the immune system believe that the virus has infected the cells, provoking an immune response. One of the companies producing this vaccine, the pharmaceutical giant Pfizer, partnered with BioNTech, a small German Company that was working on cancer vaccines, to design it. BioNTech tested 20 different stretches of mRNA out of 33,000 genes to find the portions of the genome that code for the COVID-19 spike protein, the most immunogenic of the proteins from the virus to which the immune system reacts and the protein with which the virus attaches to specific receptors in the nose, eyes, throat and of course the lung, heart, and brain.
Injection of nucleic acids like DNA or RNA was not new to research labs and vaccine makers. DNA from the influenza virus has prevented infections in mice after injection. However, a human genetic vaccine arrived when COVID-19 hit, so no one thought that a genetic vaccine would be the first or most successful vaccine to reach the market. A big reason was that scientists had to make sure dendritic cells—part of your immune system’s central command SWAT team in your innate response—could take up the mRNA in the genetic vaccine and present the spike protein to your T lymphocytes, and subsequently B cells to allow the immune system’s adaptive response to produce the antibody.
Even when a vaccine is effective, it may need adjuvants. For example, Hemophilus influenza type B (a bacterium), a leading cause of bacterial meningitis in children, was reformulated two years after it arrived to be more effective in children under eighteen months. On the flip side, the pertussis vaccine was incredibly effective but was shown to have some side effects and allergic reactions that were more than rare. Its reformulation avoided those effects but made the vaccine less effective, leading to outbreaks in the twenty-first century for the first time since the 1940s. That led to a recommended Tdap vaccine booster (including diphtheria and tetanus) for children 11 or 12.
The solid cellular responses to vaccines involve your MHC class 1 natural-born killer T cells that respond to a viral infection. A booster shot may be needed if that cellular response and the antibody weakens over time. In the case of influenza and infections like COVID-19, there are so many variants and mutations that a yearly vaccine is (or will be) needed as a boost. Influenza changes its proverbial coat yearly; it wears many constantly changing coats (i.e., strains) of varying degrees of deadliness.
The deadliest was the Spanish flu or 1918 influenza pandemic. An H1N1 influenza virus with avian genes, it eventually killed 3% of the U.S. population alone (638,000 people) and reduced life expectancy in the country by twelve years. Unfortunately, there were no flu vaccines back then—influenza was only isolated as a virus in 1933, and a vaccine was not available until after World War II. But even with flu vaccines today, the Spanish flu’s coat-changing descendants avoid our defenses and kill millions when they do. Many scientists believe the Spanish flu never disappeared and continues adapting, evolving, and jumping species. That’s what happens when an infection becomes endemic and variable. We now have a new influenza H5N1, which could cause a pandemic over the next few years.
One of the beautiful things about mRNA vaccines is that they work perfectly independently. They did not need adjuvants or the addition of substances like aluminum salt (the most common vaccine adjuvant and used for nearly a century) to boost the immune system response and make the vaccine more efficient. When the antigen or organism used in a vaccine fails to produce a substantial immune response, and the antibodies disappear quickly, adjuvants probably prevent that by acting on those SWAT team-like dendritic cells. Aluminum is such a suitable adjuvant that it also stimulates the immune response to whooping cough and diphtheria, which is why they are often given together in the Tdap vaccine.
The body has some natural adjuvants or immune boosters, too, like the biomes or the microbial organisms of the bowel and gut, which research has shown is extremely important to vaccine efficacy. When investigators noted that children from poorer countries or low socioeconomic groups did not respond well to the trivalent flu vaccine in contrast to children from wealthier countries and upper-income groups, the quality of intestinal microbiota was thought to be directly involved. Early data also showed that the efficacy of vaccines was less in germ-free mice and mice treated with antibiotics. These conditions would destroy the natural microbial population of the bowel. Studies of genetically identical twins show that they have different immune responses to a vaccine, which most likely depended on those microbial populations or environmental factors and not their genetics, as previously thought. All this re-emphasizes the importance of a healthy gut, but these and other natural adjuvants are not enough of a boost. So, we turn to additives.
As I have and will say, there are tradeoffs to any medications and treatments, and vaccines are no exception. There are side effects and always will be. They are understandable and expected to some degree in everyone, like the sore arm at the site of the injection many of us experience. In the COVID-19 vaccinations, most side effects ran from rashes to muscle and joint pain to a feverish sleepless night. Like most side effects, those were short-lived and relieved with acetaminophen, aspirin, or antihistamines.
But the most important thing to know about vaccine side effects is that they are good. They are signs of your immune system working.
Remember: a virus needs a live body to keep growing. The only way to stop it is death or lowering the number of susceptible members of a population and preventing those who are not vaccinated from being infected. I have preferred the latter since I was a child and had my summers taken away by polio. I can still hear my mother making me avoid swimming holes so I wouldn’t get polio, a disease finally obliterated by Jonas Salk’s injectable vaccine and Sabin’s oral version. The vaccines lead to herd immunity from the horrible paralysis occurring randomly in young children and eventually its eradication in the United States. And we were grateful. There was nothing dramatically polarizing about it.
Remember: Even with the vaccines we have now, the future is not “safe.” There are many diseases for which no vaccine exists, like TB, HIV, and schistosomiasis, a parasitic infestation common in developing countries.
Viruses never disappear. They can evolve. They can jump species. Even pathogens like smallpox might never disappear and could make a comeback with a few adjustments. Polio was on the verge of being eradicated in 2015, and now rogue variants of the vaccine-derived strains are turning up around the world. But unlike the eighteenth and early nineteenth centuries, we now have a deep understanding and technology to adjust these vaccines to continue to protect us from infection. Unless they put your health at risk or you genuinely have a profound religious objection, get them.