COVID vaccines are here, but big questions remain about immunity, mandates

Nurse Annabelle Jimenez, left, congratulates nurse Sandra Lindsay after she is inoculated with the Pfizer-BioNTech COVID-19 vaccine, Monday, Dec. 14, 2020, at the Jewish Medical Center, in the Queens borough of New York. (AP Photo/Mark Lennihan, Pool) 
Whoops of celebration, crackling applause and tears of joy erupted as the first health care workers were jabbed with the coronavirus vaccine last week, kicking off the largest mass vaccination campaign in history.
After their second dose, will they have to roll up their sleeves again in six months or a year? Will you?
In this unprecedented, worldwide, real-time experiment, the answers to many questions remain shrouded in mystery. But scientists have been scrutinizing the novel coronavirus for nearly a year, and their understanding of its wily ways grows every day.
What kind of immunity will these shots provide, and how long it will last? When might we reach “herd immunity,” when life can return to normal? Will vaccination be mandatory before we can work, play, learn, travel?
Hope, fear and misinformation are in plentiful supply as the “light at the end of this long, dark tunnel” glistens. So here’s the latest on COVID-19 immunity — and the law regarding mandatory vaccinations — as Moderna’s vaccine is packed for shipment and more of Pfizer’s vaccine wends its way to California.

But a word of caution. “Vaccines are critically important, and it’s quite remarkable how effective the first ones seem to be — but it’s not a cure, and it’s not perfect,” said David D. Lo, distinguished professor of biomedical sciences at UC Riverside.
“No vaccine protects 100% of the people 100% of the time. That’s why people talk about this larger question of ‘herd immunity.’ Some people won’t be able to take the vaccine because of allergies or other issues. How do you protect them? You make sure everyone else is protected.”
Timothy Brewer, professor of epidemiology at UCLA’s Fielding School of Public Health and a member of the infectious diseases division at the David Geffen School of Medicine, agrees.
“This idea about reaching herd immunity through natural infection — there’s no such thing,” Brewer said. “Smallpox never went away until we had a smallpox vaccine. Polio never went away until we had a polio vaccine. Herd immunity is stopping transmission, and that has never happened without a vaccine.”
Well, COVID-19, we have vaccines now.
This undated electron microscope image from the U.S. National Institutes of Health shows the Novel Coronavirus SARS-CoV-2, yellow, emerging from the surface of cells, pink, cultured in the lab. (NIAID-RML via AP) 
How long does immunity last?
This question has inspired some fear and loathing.
Earlier in the pandemic, studies found that some recovered COVID-19 patients experienced precipitous drops in disease-fighting antibodies just months after infection. The milder the case, it seemed, the fewer the remaining antibodies. In some people, no antibodies were detectable at all.
Combined with a handful of confirmed reports of people getting COVID a second time, there was alarm.
But more recent studies are sharpening the picture. Antibodies aren’t the only arrow in the immune system’s quiver: There are also warrior T cells and B cells that appear ready to resume the battle if and when the coronavirus is detected again. A recent study found that, eight months after infection, most recovered patients had enough immune cells to fend off the virus and prevent illness, suggesting immunity could last a year or more.
“The general feeling is, this means there’s at least short-term immunity against repeat, severe disease,” said Marisa Holubar, infectious disease physician at Stanford Health Care.
And even if reinfection is “a thing,” it appears to be much less severe the second time people get the virus, said Andrew Noymer, an epidemiologist and population health scientist at UC Irvine. “But will the vaccine protection be comparable to having survived natural infection? Nobody knows yet. It may even be superior.”
The immune response to natural infection appears dependent on how much virus was encountered — a robust response from surviving a large exposure, a weaker response from surviving a small exposure. Vaccines eliminate that wild card: They’re calibrated to invoke a standard, robust, immune response. That’s why the U.S. Centers for Disease Control recommends that survivors of natural infection also get vaccinated.
And even if immunity only lasts a few months, that’s not so bad: People would simply require more frequent booster shots.
“I get the flu shot every year, tetanus every 10 years,” Lo said. “So this tells you the immune system does what it can, but the reason we have modern medicine is to augment where nature isn’t always up to snuff.”
Sergio Hernandez, an emergency medicine physician, proudly shows his bandage after receiving the first inoculation of the new Pfizer COVID-19 vaccine at Emanate Health Queen of the Valley Hospital in West Covina on Thursday December 17, 2020. (Photo by Keith Durflinger, Contributing Photographer) 
Can we ditch the masks and throw a party?
Unfortunately, no.
Vaccines appear more effective than scientists dared dream at preventing severe illness, but they may still allow folks to become infected — and to infect others.
“If these are vaccines that convert every case into an asymptomatic case, you’ll still shed virus,” Noymer said. “The point is, you can’t just go about your business as if nothing has happened until everyone has vaccine, until we know more.”
Preliminary data from the AstraZeneca vaccine, published recently in the British journal Lancet, suggests that it might, indeed, prevent infection in some people, UCLA’s Brewer said. But similar data for the Pfizer or Moderna vaccines, which use different technology, are not yet available.
“So it will be important for people who have been vaccinated to continue to do all the things to prevent spread — physical distancing, wearing a mask, not going out when they’re sick,” Brewer said.
This will require further appeals to people’s altruism at a time when when their pandemic patience is clearly waning.
“We all need to be part of the community — this is the most naïve-sounding thing I’ve said in a long time — and keep masking until … question mark. June?” Noymer said. “It depends on how quickly we can get doses to everybody. It’s premature to declare victory.”
Will I be forced to get vaccinated?
No one is going to tackle you and plunge a needle into your arm against your will — but there are other ways of inspiring compliance.
“The federal government actually has limited power here, but states have broader authority to act on public health,” said Dorit Rubinstein Reiss, professor at UC Hastings College of Law in San Francisco.
The guiding case law is Jacobson v. Massachusetts, a 1905 Supreme Court decision that’s the foundation of the country’s public health laws, she said. An outbreak of deadly smallpox wracked the city of Cambridge in 1902, and its Board of Health ordered the vaccination of all residents. Henning Jacobson, a pastor, refused. He had suffered a bad reaction to a smallpox vaccine in his native Sweden and argued that requiring him to be vaccinated again was “unreasonable, arbitrary and oppressive,” and an invasion of his liberty.
The U.S. Supreme Court did not agree. “In every well ordered society charged with the duty of conserving the safety of its members the rights of the individual in respect of his liberty may at times, under the pressure of great dangers, be subjected to such restraint … as the safety of the general public may demand,” it said.
Is Jacobson strong enough to support a statewide vaccine mandate? “It’s a question mark,” Reiss said. “Will it hold? It will be up to the courts to decide.”
California has another tool. The Legislature last year passed a law empowering local health officers “to take any action the local health officer deems necessary” to control the spread of communicable disease. That could include vaccine mandates on the county or city level, Reiss said, and will likely play out in court as well.
Vaccines really can’t be mandated before formal FDA approval — right now, they’re available through emergency use authorization. But once they’re approved for regular use, “employers will be a lot less antsy about mandating it. ‘If you want to work here, you have to get your coronavirus shot,’ ” Noymer said.
Employers have broad rights and responsibilities to protect worker health, so vaccination could well be a part of that as long as reasonable accommodations are made for disabilities and religious beliefs, Reiss said. Schools have embraced vaccine mandates for quite some time, but that wouldn’t extend to students unless COVID vaccines were specifically approved for them, which they’re not. Airlines could require proof of vaccination before passengers can board planes, and other nations could deny entry to travelers who don’t have it.
“We already have that,” Reiss said. “Some African countries have yellow fever vaccine requirements for travelers.”
Folks may simply find it’s hard to do the things they want to do without rolling up their sleeves.
What if I still say no?
A new survey by the nonprofit Kaiser Family Foundation found that 71 percent of people would definitely or probably get a COVID vaccine if it were safe and free. Would that be enough to comprise “herd immunity” and stop the virus in its tracks?
It all depends on the transmissibility of the pathogen, UCLA’s Brewer said. Measles is so contagious that some 95 percent of people need to be vaccinated to shut down transmission; even small pockets of unvaccinated people are enough to spark outbreaks, as record-setting case numbers in recent years have illustrated.
COVID may not be as contagious as the measles. Experts estimate that 60-80% of adults will need to be jabbed to curb transmission.
“The more the better,” said Stanford’s Holubar.
A recent study found that vaccines with high efficacy, such as Pfizer’s and Moderna’s, could vastly reduce hospitalization and death — by more than 85% — even if only adults get vaccinated. But if 40% of the population refuse, “vaccination is unlikely to completely eliminate the need for nonpharmaceutical interventions” such as masks and physical distancing.
How long will the vaccinated keep wearing masks to protect those who refuse?
“There’s the question of when you say, ‘You’re on your own, buddy,’ ” Noymer said. “Assuming the vaccine works and is durable, then it’s a fairly open question what our duty is to people who are refusing.”
Holubar, of Stanford, is tired. “The whole health care workforce is tired,” she said. “We have been running on all cylinders for a long time. This is our glimmer of hope. I’m excited to get my vaccine.”
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