Who Gets the Lung? Vaccinated or Unvaccinated?

Two people need a lung to live. One has been vaccinated against COVID-19. The other refused to get vaccinated, got the disease and needs a lung as a result. “These are ethical questions that are starting to be debated," says Kevin Kavanagh, MD, a member of Infection Control Today^®’s Editorial Advisory Board. “There’s no real good right or wrong answer.” Which doesn’t mean that there won’t be some system developed to deal with one of the many long-term problems created by the pandemic. For instance, Kavanagh says it’s possible that an arm of the health care system might be created just to deal with problems resulting from COVID-19 in people who refused to be vaccinated. Also, the unvaccinated might have to pay more for health care coverage. In this wide-ranging interview, Kavanagh also talks about gain-of-function research. Some of it might be worthwhile, but most of it should be discontinued, he says. For instance, avian flu doesn’t usually infect humans, but when it does, there’s a 60% fatality rate. In one gain-of-function project, scientists crossed avian flu with influenza. “So, imagine if that code got out or if that virus was made and spread,” says Kavanagh. “You’d have a virus that would spread like the flu, and it would have a 60% fatality rate. I mean, it’s just to me baffling why this this type of research is being done.”

Infection Control Today^®: Smallpox. A recent article that you wrote for Infection Control Today® reports on a smallpox scare and showed that dangerous pathogens need to be closely monitored. In that article, you also wrote that George Washington ordered his troops to get the smallpox vaccine. And in those days, vaccination against smallpox was serious business. It could get you really sick, correct?

Kevin Kavanagh, MD: Correct. And the vaccines back then weren’t safe. They were trying whatever they can do to avert this disease that can cause a 30% fatality rate. Back then 90% of the armed forces deaths were sometimes due to infections. They weren’t necessarily due to combat. And so infectious disease was a huge problem. And for us to really ignore this problem and say, “Hey, look. We’re not going to get vaccinated. We’re not going to mandate vaccines for our armed forces and have them susceptible to this illness. I think that is unconscionable, and it puts our nation at risk. These are concepts that go back centuries. And infectious diseases are national security problems, especially ones like SARS-CoV-2 that cannot be easily controlled.

ICT^®: You’re saying that the fifth wave of COVID-19 has already begun, right?

Kavanagh: That’s correct. Yes.

ICT^®: [Anthony Fauci, MD, White House chief medical advisor] has said the same thing. But you don’t expect the holidays to be as horrible as last year’s holidays, right?

Kavanagh: Well, they may well [be just as horrible]. And that gets into the spread of the virus and whether or not people get boosters. Even if you’re vaccinated, you can spread the virus, but you’re not as likely to spread the virus. First of all, if you become infected, that’s a prerequisite to spreading the virus. And if you’re vaccinated, you’re not as likely to become infected. If you are infected, you spread the virus for a shorter period of time. And that’s good for the community.

Kevin Kavanagh, MD

So, if you have an unvaccinated person spreading it for nine days, a vaccinated person spreading it for one day, you go out in the community, you’d expect much less community spread. But when you talk about close contacts, and family contacts, they are exposed in an indoor setting to a much higher rate of virus. And when you go visit your friends on the holidays, and you stay, let’s say, for a week, it doesn’t matter whether you expose those people for nine days or one day, they’re still going to get COVID-19. And if you have older individuals there that haven’t had their boosters, or people that are immunosuppressed, you are placing them at then grave risk. So, we may have a significant rise in both cases and hospitalizations. If you look at some of the graphs that are coming out of Germany, out of France, and the start in rising cases that you’re seeing in Iceland and Ireland, this is very concerning. Because again, it’s like compound interest. You go through one wave, then you go through another, you go through another. You have to constantly keep up your guard. And that means we can’t ignore the virus. But we have to change the way that we live so that we can live safely with the virus.

ICT^®: I have a feeling that your answer this next question will be: There’s no real way of knowing. But I have family and friends who didn’t get the vaccine. I’m sure you that have family and friends who didn’t get the vaccine. Now there are some people out there who you could call diehard anti-vaxxers. They just don’t believe in it and are kind of militant about not getting it. There are other people who just don’t seem to care, or just kind of like bump along and not really think about it. Do you see that divide too?

Kavanagh: Well, I do. I think that there are some people who really don’t think that this is serious enough to act. And, again, that’s some of the disinformation and the idea of compound interest that “well, you know, we’re not seeing a whole lot of change this year so it’s not something we have to worry about.” Then there are other people who are anti-vaxxers and who are actually scared of the vaccine. On our last meeting that we had with our Health Watch USA group, we had a presentation and it was a very good one. And it was a presenter who described one of her family members who is 33 years old. Just put off getting vaccinated. Wasn’t an anti-vaxxer. Just didn’t get around to it, and wound up getting severe COVID-19, intubated, almost died. Wound up having to have ECMO [extracorporeal membrane oxygenation] in order to recover. And this was someone who’s 33. So yes, you do see it. And this virus can affect the young and so everybody needs to become vaccinated. And everybody who’s had a previous infection should also become vaccinated. And I would view that as a booster. So, after you’ve recovered from the infection, and you are able to get a vaccine, I would recommend doing that.

ICT^®: Do you see hospitals United States dealing with the problem of vaccine hesitancy among health care workers in unique ways?

Kavanagh:Well, definitely. I think that there will definitely be a lot of carrots out there and examples to try to encourage people to get vaccinated. On the other hand, I’m seeing some sticks starting to emerge. And that is, if you’re not vaccinated, you may not have the same coverage, or the same safety net that vaccinated people do. So, if you’re unvaccinated, you’re going to be at risk of not having maybe timely access to funds that can give you good medical care. Singapore is starting to implement no longer paying for COVID-19 related illnesses that occur in people who voluntarily are unvaccinated. And I think you’re also going to see not only problems with health care coverage, but time off of work, etc. At some point, people are going to say, “Look, we can’t keep affording to pay for the amount of death and disability that’s coming about from people who are unvaccinated.” And, also, you have a huge problem of access to health care with people who have non-COVID-19 diseases. One person with COVID-19 can spend months in the ICU, which would prevent 10 or 20, non-COVID-19 cases from going to the ICU, whether it’s for a coronary bypass, or just angioplasty, or getting a cancer procedure. You have 10 or 20 times the number of patients that can’t get care for other serious illnesses. One of the most debated points at this time is lung transplants. These are very rare, and at the moment almost all the lungs can go to COVID-19 patients who weren’t vaccinated. So, should someone who needs a lung transplant that was vaccinated and needs it for a non-COVID reason; should they be at the end of the line for someone who chose not to be vaccinated? These are ethical questions that are starting to be debated. There’s no real good right or wrong answer. I do think at some point, if this virus doesn’t go away, we may have to set up a separate health care arm for COVID-19 patients. In other words, we had that in the past, for example, with TB hospitals. And have infectious disease hospitals and start to allocate resources just for COVID-19. But a large portion of that, and something that is just critical, is to try to get as many people vaccinated as possible. Because this does decrease the chances of developing long COVID, of getting hospitalized, and of dying. Let alone decreases the chances of spreading an infection. If we don’t do that, I don’t feel we’re going to get control of the health care costs. And even getting our health care system back up and running to the point where we can take care of everybody as efficiently and quickly as they need to be taken care of.

ICT^®: And finally, Doctor, in your smallpox article you write that the recent scare highlighted some of the possible dangers of gain-of-function research. Can you describe in layman’s terms for this beat reporter what gain-of-function research is and what lessons should we take from the recent scare?

Kavanagh: For me, gain-of-function research is making a virus more dangerous to people. Now, the NIH [National Institutes of Health] may have their own definition. But if you’re doing research and a virus becomes more dangerous in the process that’s problematic. Because if that virus gets released, it will then go throughout the community, and it can cause great harm and sometimes irreparable harm. As you know, there was an article that was written I believe about gain-of-function with the Delta variant or with the SARS coronavirus where they came up with a virus that could completely escape immunity with the idea of “well, then we can know about it, developed vaccines, etc.” Although that’s a dangerous experiment, you could argue that that had some benefit. However, I myself haven’t noticed any change in behavior or vaccines developed or anything else based upon the research. So, if the research isn’t actionable, it shouldn’t be performed. And I don’t think at this point, that you need to have vials that say “smallpox” on them sitting around in freezers. Now luckily, the follow-up is these were actually vaccine vials and not vials that had the active virus. But either way, they were sitting in there, no one knew that they were there, no one knew what was in them, and they had smallpox on the vials. These type of lab mistakes can be made anywhere, and there are repositories that still have the live smallpox virus. I think it should be completely eliminated. You know the genetic code so if you had to make the virus, you could actually print it out and make it, make a vaccine for it, and be good to go. There’s no reason to have these dangerous things floating around in freezers or even sitting in a very secure area. Because as you know, one of Murphy’s Laws is anything that can go wrong will go wrong. And it’s mutating like you can’t believe. But some of the research that I read on the SARS-CoV-2 virus, and in coronaviruses in general, is very scary. You’re talking about making 10 or 20 types of immunity-evading viruses that are made in the lab. Some viruses that are more infectious, etc., and then publishing genetic codes. That’s scary. For example, one of the scariest research projects that has taken place has to do with the avian flu virus. Avian flu seldom affects people. But when it does, it’s about a 60% fatality rate. But it doesn’t infect people. Well, they have made an avian flu virus crossed with a human flu virus that will readily infect people. So, imagine if that code got out or if that virus was made and spread. You’d have a virus that would spread like the flu, and it would have a 60% fatality rate. I mean, it’s just to me baffling why this this type of research is being done. If it has to be done, I prefer it to be done on some remote island someplace with no access to the outside world where if the virus got out, you could hit a red button and just kind of incinerate the whole place. Kind of like what you see on TV and the movies. But it shouldn’t be done in a lab that’s sitting in the middle of a highly populated area. That’s a setup for disaster if you do have a lab leak or something happens. And when I say something happens, it could be an earthquake, it can be hit by a tornado. I mean all sorts of scenarios that may be unplanned and nobody’s fault but still result in a disastrous release of a very dangerous pathogen.

This interview has been edited for clarity and length.