Vaccinating people who have had covid-19: why doesn’t natural immunity count in the US?
BMJ 2021; 374 doi: https://doi.org/10.1136/bmj.n2101 (Published 13 September 2021) Cite this as: BMJ 2021;374:n2101Read our latest coverage of the coronavirus pandemic
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Dear Editor,
Thank you for your insightful blog in BMJ regarding natural immunity.
For your information, please be advised that the Dutch government announced this week (November 2nd, 2021) its decision to extend the duration of the natural immunity certificate from 180 days to 365 days (https://www.eerstekamer.nl/behandeling/20211102/brief_van_de_minister_va...).
The government’s decision is based on the advice of the Dutch Outbreak Management Team. In its advice, the OMT also refers to this German report of the German virology community, which also proposes to extend the natural immunity certificate to 365 days: https://g-f-v.org/2021/09/30/4411/ ).
Translation of Dutch government decision on extending natural immunity certificate from 180 to 365 days:
"Further to the 127th advice of the Outbreak management advice, I have decided to extend the validity of a corona entry pass on the basis of a recovery certificate issued in the Netherlands from 180 to 365 days.
This decision is based on recent scientific findings about the longevity of natural immunity which occurs after an infection. Experts support the notion that this immunity continues for longer than previously assumed. As is the case for vaccination certificates, it is possible for recovery certificates that someone tests positive. People should then take their own responsibility and self quarantaine. With this decision, I satisfy the commitment made to MP Van Haga during the Budget session of the Ministry of VWS to inform this Chamber as soon as possible of the duration of a recovery certificate.
This decision has consequences for a Digital Covid Certificate (DCC) issued in another European country than the Netherlands. The recovery certificate issued in a DCC has for all EU citizens a validity of 180 days after a positive PCR test. For most countries the QR code then expires. As a consequence, it is technically impossible to use it thereafter. A visitor from another Member State, therefore, can between dag 180 and day 365 not use his recovery certificate for a corona entry pass. I subscribe the importance of equal treatment between Dutch and other EU citizens, but I accept that this is not possible for now.
I commit to make a hard case in the EU that the duration in the EU Regulation of a recovery certificate will be extended to 365 days. (..)”
The conclusion of the German virologists' report ( https://g-f-v.org/2021/09/30/4411/)
reads as follows (in German):
Schlussfolgerungen:
Die nachgewiesene Dauer des Schutzes nach durchgemachter SARS-CoV-2 Infektion beträgt mindestens ein Jahr. Aus immunologischer Sicht ist von einer deutlich längeren Schutzdauer auszugehen, die auf Grund des begrenzten Beobachtungszeitraum aber noch nicht durch entsprechende Studien belegt ist.
Auf Grund dieser aktuellen Erkenntnisse sollten Genesene bei Regelungen zur Pandemie-Bekämpfung (z.B. Testpflicht) den vollständig Geimpften zunächst für mindestens ein Jahr gleichgestellt werden.
Eine Überprüfung des empfohlenen Zeitpunktes einer Impfung nach überstandener SARS-CoV-2 Infektion wird angeraten.
Competing interests: No competing interests
Dear Editor
It would appear to me that basic science of immunology has been ignored in the reaction to COVID-19. The SARS-COV-2 virus has 28 known antigenic sites to which immune reaction is a potential possibility. Spike Protein is only one of the 28 antigens. The current anti-Spike Protein vaccines only target one of the 28 antigenic proteins or sites. This leaves the virus with 27 antigenic sites intact.
Vaccination with the anti-Spike Protein vaccines currently heavily favoured generates antibody and relevant cellular immune reaction to that one antigenic protein
Infection ab-initio (natural infection) with the intact virus presents the body's immune system, (cellular and humoral) with all 28 antigenic proteins. As with traditional vaccines pre-Cov-2
This enables the immune system to respond to all antigenic proteins presented to it in a comprehensive manner rather than selectively to one. In this circumstance it can only mean a more comprehensive robust protective response to the initial whole virus and any future exposure. This will explain the observed advantages of natural infection over the limited effectiveness of the present vaccines.
The current anti-Spike Protein vaccines if they were meant to be stopgap vaccines have served their purpose giving the scientific community time for refocusing and to come up with vaccines that elicit responses and protection in terms of effectiveness and duration, similar to natural infection just like vaccines we had come to rely on over the last century.
A strategy of comprehensive immune reaction to whole virus in the form of attenuated virus product will provide a reasonable and reliable long-term way out of current pandemic
Booster doses of the current vaccines are unlikely to provide the long-term desired results.
It is time to look at what worked in the past and are still relied ipon in areas like measles, mumps, smallpox and other where booster doses are not mandated after every few months.
SARS-CoV-2 may be different from these other viruses but the results indicating the superiority of natural whole virus infection over Spike Protein targeted vaccines do indicate that greater hope lies ahead
Competing interests: No competing interests
Dear Editor
Congratulations to the BMJ for publishing this; BMJ has for decades been the leader in promoting evidence-based medicine and thereby building a strong scientific foundation for the practice of medicine.
The author asks the question many of us have been asking ourselves, and have been seeking in vain for any federal government authorities willing to take the issue seriously.
In the US we have increasing political polarization which unfortunately has now contaminated medicine and public health. Regarding this specific issue, we have on the one hand universal vaccine mandate adherents who are willing to see, for example, nurses who have suffered through severe COVID illness dismissed from their jobs due to their unwillingness to be vaccinated. On the other hand, we have millions of people who refuse to be vaccinated for reasons that range from the perfectly reasonable (the nurse example noted above) to those stubbornly resistant to perceived excessive government intrusion in their lives, to the truly irrational.
Some significant proportion of the opposition to vaccination could be completely eliminated by offering evidence of positive nucleocapsid antibody testing (or, as noted in the article as a qualification in Europe, a previous history of a positive COVID antigen test).
For me personally, I find both sides of the debate to be unnecessarily polarizing, to the detriment of public health. Quite literally, then, "A pox on both your houses!" I am baffled by the unwillingness to take natural immunity into account, and angered by my friends who refuse the vaccine for political reasons.
I see no resolution to this polarization without the recognition by public health authorities that they have been excessively dogmatic, and have thereby greatly decreased the credibility of their message.
If the author and BMJ succeed in encouraging real discussion of this question--Why doesn't natural immunity count in the US?--they will have done a great service to public health in the US.
Competing interests: No competing interests
Dear Editor
An interesting read and something that I think deserves a lot more study. Complex problems require complex analysis ad then an attempt at complex solutions. It's another topic altogether but most healthcare policy makers, however good intentioned their efforts, struggle with an evolving and changing public health crisis.
I think we need to sub-divide and sub-categorize many different sets of populations by age, co-morbidities, active treatment with immunosuppressives (for pre-existing auto-immunity or S/P solid organ transplant versus say stem cell transplants etc. or say chemotherapy for various types of cancers), +/- renal failure, nutritional status & vitamin profile, baseline lifestyle behaviors, environmental exposures (toxins of all kinds, allergens, or say do they swim in a chlorine pool every day etc), medication profile (current as well as recent past) and of course genetics and epigenetics. Do different patients have different quantities of ACE2 expressed on their cells and/or do they have different molecular conformations in ACE2 expression?
Exogenously simulating immunity on a per individual basis is the ideal. Analyzing end-points such as hospitalization rates, subsequent morbidities (so-called "long COVID") and death can serve as a crude guide retrospectively in determining outcomes to compare say antigen proven disease outcomes.
In gross terms we have 6 sub-categories of patients :
1) fully vaccinated with no known antigen proven disease history
2) unvaccinated with no known antigen proven disease history
3) fully vaccinated with known antigen proven disease history
4) unvaccinated with known antigen proven disease history
5) incompletely vaccinated with no known antigen proven disease history
6) incompletely vaccinated with known antigen proven disease history
Maybe following these populations over time, worldwide, would yield so general conclusions?
I would think that measuring viral load by sampling many patients' mucosal tissues (ideally to include bronchoalveolar lavage sampling which is problematic to obtain) amongst these 6 categories would also be interesting (of course adjusted for elapsed time of sampling from when the patient developed symptoms and also estimating event of probable initial exposure (which is itself problematic with all the errors with contact tracing challenges)).
Furthermore, we have no practical methodology to assay each individuals cellular immune function. We simply count blood levels of IgG and IgM and that's it. It is conjunctured that both humeral immunity and cellular based immunity wanes for many viral pathogens from either vaccination or from natural infection but there are exceptions to this.
I still cannot figure out why we don't assay IgA in the nasopharynx for both quantity as well as immune performance. Mucosal immunity in pre-school children can play a significant protective role in that population. Is this why many of them have a shortened clinical course with COVID-19? I've often thought of a pro-snot nasal spray to enhance mucosal protection might be useful in some way. Dry mucosa probably is probably not helpful for the individual.
In parallel, is it conceivable, based on supercomputer molecular modeling that SARS-CoV-2 could mutate into new variants that are novel enough as to evade prior infectious exposure (natural immunity) or vaccine-induced immunity? Some mutations will not confer an advantage for the virus. Some mutations are molecularly weakly less adherent to the ACE2 receptor. I would assume some mutations which are not yet expressed in nature are conceivable. However given that billions of humans are being infected, some with substantial viral loads, it would seem to me that computationally more infectious and/or more dangerous variants of SARS-CoV-2 should arise within a few years but maybe not. Computational biologics may help answer some of these questions.
Competing interests: No competing interests
Dear Editor,
The author failed to consider the level of protection offered by the immune system against new virus variants. There is likely to be a difference in this respect between previous infection and vaccines. (Please see the research reported below.)
The article also does not explain the current high level of cases in the UK, where just over 93% of the population has Covid antibodies (ONS). Surely at this level, if all antibodies were equal, herd immunity would suppress R so that infections would decline rapidly. Instead they are slowly rising.
Much of the research and data cited in the article probably date from before the dominance of the Delta variant. Rising infections and the preponderance of serious disease among the unvaccinated in the UK, suggest that previous infection with other variants has not strongly protected the unvaccinated against the Delta variant.
Vaccination may offer better protection against the inevitable proliferation of new Covid virus variants. This issue is crucial in the public health calculus.
Research reported:
https://directorsblog.nih.gov/2021/06/22/how-immunity-generated-from-cov...
Competing interests: No competing interests
Dear Editor
It would appear that natural immunity to Covid 19 lasts for around 8 months. However, should repeated contact with the virus occur during those 8 months, the existing immunity would deal with the virus, and restart the 8 month immunity protection. Is this not classic Herd Immunity?
Douglas R Hendrie
Self Employed.
No competing interests.
Competing interests: No competing interests
Dear Editor,
Vaccinating people who have had covid-19 can easily be a contentious and debate generating reality; but this is amidst two vital issues --
a) the large populace in the world where vaccine has not reached and hence the community remains unvaccinated and unprotected, pending availability; the financial dimensions and scrupulous calculations behind are sufficiently well known.
b) vaccine reluctance, hesitancy, refusal and adamancy have reached proportions that drew ire from Authority Office. This is a case of the 'perils of plenty' where global brethren find themselves deprived of hope that offers certain protection.
The pandemic has necessitated a revamp in approach to vaccines and vaccinology. There appears a dire need of 'Institutionalized Schools of Thought and Practice' fostering vaccination literacy and a degree of 'self help culture'. The widespread phenomenon of vaccine hesitancy, with academic, cultural, sociopolitical components and consequences thereof demands being revisited as a subject of reflection and enquiry with global strivings, with both the science and philosophy being addressed. Vaccines in general have been regarded as a major victory and advancement of Modern Medicine; covid-19 vaccine(s) have been, with intensive efforts, produced in record time. To see reluctance/hesitancy with availability can indeed be painful and a reason to repent. Global supply continues to remain a challenge, with knots requiring to be sensibly untied.
Prof Murar E Yeolekar, Mumbai.
Competing interests: No competing interests
Dear Editor
I'm thinking about Apples versus Oranges?
Maybe I missed something, but the entire premise of the article seems invalid. Only Natural Immunity offers true immunization protection from the COVID Virus. None of the vaccines were originally intended to immunize the recipient. In fact, none of the vaccines seem to meet any of the traditional definition criteria for a vaccine. The vaccines are produced to limit COVID symptoms. Nothing more. The vaccinated can still get the virus and can still spread it (and variants they produced). That is now very well established.
Competing interests: No competing interests
Dear Editor
Great article. Two important takeaways.
First, the science is greatly unsettled. All you have to do is listen to all the disagreeing scientists!
Second, public health officials want universal vaccination to make their jobs easier. Exceptions are just too complicated. Never mind the public health concerns.
Thanks for providing support for what I've come to suspect.
Competing interests: No competing interests
Re: Vaccinating people who have had covid-19: why doesn’t natural immunity count in the US?
Dear Editor,
As a science communicator by profession, who is concerned about research impact, may I implore those who raise the topic of natural immunity do not fail to discuss how this relates to rising rates of COVID reinfection.
https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/...
Competing interests: No competing interests