Evaluating the Coronavirus Vaccine

Introduction

Following months of research, development, and clinical trials, two COVID-19 vaccines were authorized for emergency use by the United States Food and Drug Administration (FDA). The first in this sequence was the Pfizer-BioNTech vaccine, authorized on December 11, 2020. This vaccine will be available for distribution to individuals over the age of 16. The second authorized vaccine authorized on 18^th December 2020 was the Moderna COVID-19 vaccine, for those over the age of 18.  Although immunization is now available for frontline workers such as residents of nursing homes and healthcare providers, it will be months before the average citizen is vaccinated. Nevertheless, fear has settled in the hearts of Americans, months or possibly a year in advance regarding a vaccine that isn’t even readily available for them. For the COVID-19 vaccine to effectively reverse the effects of the coronavirus in the United States, it is imperative for Americans to make an informed decision about receiving the vaccine. This begins with providing accurate facts, figures, and explanations regarding the immunization as quickly as possible.

The COVID-19 Vaccine Debate

A universal concern of the COVID-19 vaccine is whether or not it can be trusted due to its short timeline from research to distribution. Aware of this paradigm in vaccine development, scientists were methodic in not providing hope for immediate success. It is true that on average, vaccines take 10 years to fully develop and distribute. The quickest any vaccine had been developed prior to the 2020 COVID-19 vaccine was for mumps in the 1960s, with a development timeframe of four years (Ball, 2020.)

Today, the effectiveness or safety of medical developments cannot be assessed based on time alone. There are many factors to consider beyond time. As with the COVID-19 vaccine, some of the factors that have shortened the development timeline are the unique structural integrity of the virus itself and the innovative mRNA virus development stratagem.

COVID-19 Structural Analysis

The coronavirus protein contains a spike module (review figure A) which is compatible with mRNA retroviral immunizations. This protein has the potential for the optimization of antigen design. A strong antigen design ensures that the vaccine has pinpoint accuracy in targeting either the full-length protein of the virus or the receptor-binding domain (Lurie et. al, 2020.)  Additionally,  while COVID’s initial symptoms progress into acute respiratory disorders, the coronavirus is a type SARS/MERS virus. And as plenty of vaccinations for SARS/MERS viruses exist, built using different platforms, meant researchers could easily manipulate the structures of these existing vaccinations to create one that immobilizes the coronavirus. Thus, no time was spent on manufacturing specific vaccination bases (Lurie et. al, 2020.)

Figure A: The COVID-19 Module

*The red clusters indicate the presence of spike modules. These spikes, when replicated in a vaccine, allow for the effective inoculation of antibodies into the target virus cell.

Traditional Vaccine Development

Traditionally, making vaccines required live virus strains suspended in cell culture. The most common class of retroviral cell culture is a shell vial culture. In this type of culture, viral strains are centrifuged onto a single layer of cells and the growth of the virus is determined by changes in antigen patterning. Once these cultures displayed structural changes that hinder its ability to infect, also known as cytopathic effects, researchers were able to confirm that the culture is positive. These concoctions were then purified in bulk  to regulate its effects in the human body (Neergaard, 2020.) It is expected that there is some level of safety concern among vaccine consumers due to mass vaccine production practices and possible errors.

mRNA Vaccine Development

The mRNA approach to vaccine fabrication is radically different from the conventional means of development. By eliminating the requirement for a live strain of the virus to be present in the vaccine. An mRNA vaccine replicates a harmless piece of the target virus with the purpose of generating an immune response. The vaccine then chemically synthesizes RNA to target infectious cells. This modern approach to vaccine production is activated by utilizing a snippet of genetic code that delivers instructions for producing polypeptide chains. These chains then target foreign virus proteins, starting the immune response (Neergard, 2020.) With novel viruses, such as COVID-19, the structure of the protein can be utilized with the advantage of presenting a promising immunogen in the vaccine itself. Another way that mRNA technology reduces the time traditionally associated with vaccine development protocols is that it uses a synthetic processing mechanism. This method does not require facilitating culture growth or fermentation on an inordinate scale. Already, this shaves off a significant portion of time in the development process that would otherwise be allocated to ensuring the safety of the vaccine.

What is in the Vaccine?

The second concern in question regards the composition of the vaccine. Currently, there are two widespread misconceptions that undermine the potential of the vaccine. First, it is alleged that the immunizations will contain microchip tracking devices. Second, there is a notion that live strings of the virus will be present in the vaccination. Moderna and Pfizer, the two major distributors of the COVID-19 vaccine in the United States have debunked these assumptions in their respective official statements with the FDA, confirming that these concerns are invalid.

The mRNA-1273 vaccination that has been authorized under the title of “Moderna COVID-19 Vaccine” by the FDA encodes an S-2P antigen in conjunction with a SARS-CoV-2 glycoprotein. This glycoprotein is an inactive protein agent of the virus. S-2P is stabilized with proline replacements at amino acid positions 986 and 987, located in the top of the central helix in the S2 subunit. These proline replacements ensure that the chemical body is stable. The lipid nanoparticles of the vaccine consisting of four essential fats in a 1:1 ratio of lipid to mRNA. Lipids act to replicate the outermost surface of the coronavirus on ordinary cells, promoting immunity. This concentrated solution is diluted in standard saline (FDA, 2020.)

The Pfizer vaccination authorized under the title of “Pfizer-BioNTech COVID-19” vaccine has a similar chemical composition to its Moderna counterpart. The primary differences between the two vaccines lie in the ingredients used to maintain the pH and stability of each respective vaccine. The Moderna vaccine is suspended in a solution of tromethamine,  tromethamine hydrochloride, acetic acid, sodium acetate, and sucrose (FDA, 2020.) The Pfizer vaccine is suspended in potassium chloride, monobasic potassium chloride, sodium chloride,  dibasic sodium phosphate dehydrate, and sucrose.

Although the ingredients lists are slightly different for each vaccine, ultimately the results are the same, states Jamie Alan, an assistant professor of pharmacology and toxicology for an interview with Prevention. However, the slight formulaic differences could explain the different storage requirements for each. The Pfizer vaccine must be stored at a strict -70 degrees Celsius. On the other hand, the Moderna vaccine must be shipped in -20 degrees Celsius but can be comfortably stored in a refrigerator unit for 30 days afterwards (Miller, 2020.)

*Although the ingredients of the vaccines slightly vary in nature, there are no significant differences between the two vaccines. One is not inherently better than the other. However, it is recommended to talk to your provider before receiving an administration of the vaccine to discuss safety concerns (allergies, possible reactions) pertinent to you.

Conclusion

There are two primary concerns for the American public with regard to the coronavirus vaccines. The first is a debacle of time. While historically vaccines have taken an average of 10-15 years for successful development and testing before public use. The vaccines by Moderna and Pfizer have been developed, tested and distributed in a matter of months. This concern is made invalid when one considers the technological advances made in vaccine development in the years prior to the coronavirus pandemic. Because COVID-19 replicates a SARS/MERS virus, researchers don’t require time to develop a specialized basic suspension for a COVID-19 vaccine. The second is a matter of safety. Both major distribution companies have announced that the vaccine is composed of mRNA, lipids, and a standard saline solution reassuring the public that there will be no viral strain in the vaccine. 

Sabriyah Morshed, Youth Medical Journal 2021

References

@NicholasFlorko, N., Florko, N., Goldhill, O., Branswell, H., About the Authors Reprints Nicholas Florko Washington correspondent Nicholas Florko is a Washington correspondent for STAT, Nicholas Florko Washington correspondent Nicholas Florko is a Washington correspondent for STAT, . . . Says:, R. (2020, December 29). Frustration over vaccine rollout grows as new variant reported in U.S. Retrieved December 31, 2020, from https://www.statnews.com/2020/12/29/public-health-experts-grow-frustrated-with-pace-of-covid-19-vaccine-rollout/

Anne Trafton | MIT News Office. (2020, December 11). Explained: Why RNA vaccines for Covid-19 raced to the front of the pack. Retrieved December 31, 2020, from https://news.mit.edu/2020/rna-vaccines-explained-covid-19-1211

Ball, P. (2020, December 18). The lightning-fast quest for COVID vaccines – and what it means for other diseases. Retrieved December 31, 2020, from https://www.nature.com/articles/d41586-020-03626-1

Fox, M. (2020, December 14). When can I get a coronavirus vaccine? Retrieved December 31, 2020, from https://www.cnn.com/2020/11/30/health/covid-vaccine-questions-when/index.html

Jackson, L., Al., E., Group*, F., Author AffiliationsFrom Kaiser Permanente Washington Health Research Institute (L.A.J.) and the Center for Global Infectious Disease Research (CGIDR), Heaton, P., F. P. Polack and Others, . . . Group, A. (2020, November 12). An mRNA Vaccine against SARS-CoV-2 – Preliminary Report: NEJM. Retrieved December 31, 2020, from https://www.nejm.org/doi/full/10.1056/nejmoa2022483

Lurie, N., Interview with Dr. Nicole Lurie on rapid vaccine development, Author AffiliationsFrom the Coalition for Epidemic Preparedness Innovations, F. P. Polack and Others, S. F. Lumley and Others, & Group, A. (2020, December 31). Developing Covid-19 Vaccines at Pandemic Speed: NEJM. Retrieved December 31, 2020, from https://www.nejm.org/doi/full/10.1056/NEJMp2005630

Miller, K. (2020, December 17). What’s in the COVID-19 Vaccines? We Asked Experts to Explain the Ingredients. Retrieved December 31, 2020, from https://www.prevention.com/health/a35002158/pfizer-vs-moderna-covid-19-vaccine-ingredients/

Neergaard, L. (2020, December 07). Years of research laid groundwork for speedy COVID-19 vaccines. Retrieved December 31, 2020, from https://www.pbs.org/newshour/health/years-of-research-laid-groundwork-for-speedy-covid-19-vaccines

U.S Food and Drug Administration. (2020, December 18). FDA Takes Additional Action in Fight Against COVID-19 By Issuing Emergency Use Authorization for Second COVID-19 Vaccine. Retrieved December 31, 2020, from https://www.fda.gov/news-events/press-announcements/fda-takes-additional-action-fight-against-covid-19-issuing-emergency-use-authorization-second-covid

U.S Food and Drug Administration. (n.d.). Moderna COVID-19 Vaccine. Retrieved December 31, 2020, from https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/moderna-covid-19-vaccine

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The National Psychiatrist Shortage: A Public Health Threat

Introduction

A report published by the Health Resources and Services Administration (HRSA) identified a scarcity of behavioral health professionals as the primary barrier to meeting the national demand for mental health services. In the United States (U.S.), one in five people have some form of psychological disorder (Weiner, 2018). Moreover, as the demand for psychiatrists rises, the size of the workforce curtails. As of September 2020, there were 30,451 practicing psychiatrists in the field. This means there are 9 physicians per 100,000 people and the workforce deficit falls at 6.4%. By 2025, this deficit is projected to escalate to 25%. The demand for psychiatry will outstrip supply by 15,600 psychiatrists (Harrar, 2020). As the gap between those in dire need of treatment and available providers steadily widens, it is crucial to analyze the causes of this imminent threat to public health.

A Further Analysis

Although a 6.4% national deficit in mental health providers doesn’t appear too substandard, the deficit hits worse for many. In a 2017 New American Economy report, it is stated that over 60% of all U.S. counties have no practicing psychiatrists. While there are an estimated 612 psychiatrists per 100,000 people in parts of New York, there is less than 1 in Idaho. In 185 out of 254 counties in Texas, there are 0. Finding a provider is only half the problem.

Those in need of a psychiatrist must also consider their provider’s wait times and if their insurance will cover the cost of consultations. In an interview with Psycom, Dr. Benzion Blech, a neurologist at the Mayo Clinic, reported that just 15% of psychiatrists are accepting new patients. On top of that, the median fee for consultation is $450. Cost is a large factor of concern, especially when it is not covered by insurance. A study in JAMA Psychiatry indicates that 45% of providers don’t accept private health insurances or Medicare (Sherill, 2017). Those lucky enough to have access to a nearby provider ultimately rule out the hope of seeking help due to the exorbitant cost.

How Did the Deficit Come to This State?

Psychiatry is a medical specialty with the highest number of practicing physicians older than 55 (third to hematology and oncology.) The AAMC has reported that there are over 28,000 psychiatrists above the age of 55 currently in practice (Weiner, 2018). As these existing physicians begin to retire, the gap between demand and the psychiatrist workforce will only widen. New physicians must take their place. As such, it is imperative to understand why students in medical schools are not inclined to match with psychiatry residency programs.

Physician Burnout

The administrative burdens that psychiatrists are faced with in the public health community fall into an extensive list. Depending on the state, U.S. hospitals have restrictive regulations on sharing information that can potentially improve patient care. Psychiatrists are provided with minimal support and resources to  schedule and arrange for filing of legal documentations, conduct routine medical examinations, and organize medical records. Subsequently, this limits a physician’s time with patients, weakening the efficacy of care. A study conducted by the U.S. Veterans Affairs concluded that between 2014 to 2017, the percentage of reported psychiatrist burnout increased from 40% to 48%. Further, 90% of the study participants reported the profession was prone to high cynicism and exhaustion.

Low Reimbursement Rates for Practicing Physicians

Federally, reimbursement rates are low for both inpatient and outpatient behavioral health services from Medicaid programs. Federal cuts to such grants have also affected public sector medical centers that treat patients with severe mental disorders. These budget cuts serve to offset the financial losses created by the preexisting low reimbursement rates from Medicaid programs. Because of this, psychiatrists are not reimbursed well by their respective medical institutions and are forced into a position where they cannot accept most health insurances from prospective patients. Patients must be able to pay out of pocket. This creates a cycle where desperate patients pay for consults out of pocket and ultimately refuse treatment when they realize they are unable to pay. A 2017 report by the National Council entails a survey regarding psychiatrist reimbursement. The results show that 75% of the members in the National Council for Psychiatry have been subjected to a median three-year loss totaling to $481,000 in 2013. In 2015, these losses had a median of over $550,000 (National Council, 2017). As a result of these patterns, psychiatrist salaries are among the lowest of all medical specialties.

Workforce of Outsider Providers

Unfortunately, psychiatrists have never been and will never be first responders to any patient who walks into a hospital. Historically, most behavioral disorder diagnoses and initial treatment plans have been given by the patient’s primary care provider. As mentioned earlier in this article, the demand for psychiatrists is projected to exceed the supply by 15,600 psychiatrists by 2025. When this deficit takes place, other healthcare professionals such as internists and neurologists will be expected to take over the duties of psychiatrists. Thus, psychiatry is predicted to soon be an obsolete field.

What Are Some Solutions to Address this Issue?

Currently, the objective is to ensure that the role of psychiatrists in healthcare remain stable and that the efficacy of care delivery to patients is improved. This should be done by remodeling the existing psychiatry recruitment model to better initiate an expansion of the psychiatric workforce. The secondary concern is that the national psychiatrist distribution should be even. Care should be accessible to more people.

Expanding the Psychiatric Workforce Efficiently

The most advisable solution to combat the receding workforce lies in the hands of academic medical centers. These institutions should prioritize recruitment of medical students into psychiatry. Additionally, support programs for psychiatric residency programs should be implemented and funding should be increased. The lack of funding for resident positions through Medicare can only be resolved by Graduate Medical Education (GME) institutions. The two primary factors of institutions with the highest recruitment rates for prospective physicians were strong psychiatry department reputations and extended clerkships (time spent in the 3^rd year of medical school in a clinical setting). Further, to enhance the effect of national care distribution, these funds from the GME institutions should be directed specifically towards teaching hospitals in rural or underserved suburban to urban communities.

Improving Accessibility of Psychiatric Professionals

One method of care delivery that can greatly improve accessibility is telepsychiatry. For reference, telepsychiatry is a form of practice that involves providing care over the telephone. This method of care distribution has the potential to dramatically widen geographic access to psychiatrists. Telepsychiatry is convenient for both providers and patients. It eliminates the requirement of travelling to a clinic and patients can receive care from anywhere. Primarily, this option is used by medical facilities where there are no available psychiatrists. Another method is to provide psychiatrists with adequate staff support to extend their time spent with patients. These staff members can range from licensed psychiatric nurses and pharmacists to non-licensed personnel with little specialty training. Support staff can help physicians with gathering patient records and lab results, arranging appointments and referrals, and further administrative and clinical work. As of now, psychiatrists working in public sector hospitals are less likely to have this support.

All information from section “How Did the Deficit Come to This State?” up to this point is derived from the Mental Health First Aid National Council for Behavioral Health 2017 report, The Psychiatrist Shortage:  Causes and Solutions. It is listed in the references section below “Conclusion.”

Conclusion

Since 2013, there has been a steadily widening gap between the demand for psychiatrists and patients who require access to mental health services. Today, this deficit of psychiatrists lies at 6.4%. Within five years, it is projected to rise to 25%. This is due to the fact that currently practicing psychiatrists are predominantly above 55 years old. They are expected to retire rapidly with an inadequate number of psychiatrists to occupy their former positions. The lack of interest towards clinical psychiatry is that the physician satisfaction rate is lower than that of other medical specialties. Psychiatrists are known to have the lowest reimbursement rates of all medical professions,  are prone to burnout due to substandard support provided by employing healthcare centers, and often aren’t the ones diagnosing and treating patients for psychiatric disorders. The most sensible solution to prolong the life of this diminishing field is to restore GME institutional funding through Medicaid. These proceeds should then be addressed to teaching hospitals within rural and underserved urban communities. This ensures that care distribution is maximized, and prospective psychiatrists are encouraged to pursue employment in areas lacking access to such care. In theory, this would eliminate the cycle of psychiatrists rejecting patients covered by Medicare insurance. The reimbursement rates owed to psychiatrists would be repaid as well. Thus, the incentive for medical students to reconsider psychiatry as a formidable career path is restored.

Sabriyah Morshed, Youth Medical Journal 2020

References

Addressing the Behavioral Health Workforce Shortage. (2016, September). Retrieved from https://www.bhecon.org/wp-content/uploads/2016/09/BHECON-Behavioral-Health-Workforce-Fact-Sheet-2018.pdf

Article by: Sari Harrar, S. H. (2020, September 08). Inside America’s Psychiatrist Shortage (Special Report). Retrieved December 05, 2020, from https://www.psycom.net/inside-americas-psychiatrist-shortage

Health Resources and Service Administration. (November). Retrieved 2016, from https://bhw.hrsa.gov/sites/default/files/bhw/health-workforce-analysis/research/projections/behavioral-health2013-2025.pdf

Miller, P. (2017). 2017 REVIEW OF PHYSICIAN AND ADVANCED PRACTITIONER RECRUITING INCENTIVES. Retrieved from https://www.merritthawkins.com/uploadedFiles/MerrittHawkins/Pdf/2017_Physician_Incentive_Review_Merritt_Hawkins.pdf

The Psychiatric Shortage: Causes and Solutions. (2017, March). Retrieved from https://www.thenationalcouncil.org/wp-content/uploads/2017/03/Psychiatric-Shortage_National-Council-.pdf?daf=375ateTbd56

Sherrill, E. (2017, October 01). Health Insurance Coverage Changes and Mental Health Care. Retrieved December 05, 2020, from https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2652826

Weiner, S. (2018, February 12). Addressing the escalating psychiatrist shortage. Retrieved December 05, 2020, from https://www.aamc.org/news-insights/addressing-escalating-psychiatrist-shortage

An Analysis of Joe Biden’s 7-Point Healthcare Policy

Introduction

With the election hovering over the heads of 328 million Americans, President Donald Trump and former vice president Joe Biden are projecting their final pitches to the American consensus in an effort to sway the course of this year’s election. Although a diverse range of issues have been front and center throughout both candidates’ campaigns, just one of those issues is exorbitantly more pressing to Americans: how each prospective administration would approach the novel coronavirus outbreak. In short, the outcome of the 2020 election hinges on the debacle of who will present the more captivating response to this imminent public health threat. While both candidates have clearly addressed this topic, only one address is considerably more attractive. This point is in favor of Joe Biden’s 7-point healthcare policy.

How Have Trump and Biden Addressed the Coronavirus?

As of August 2020, the United States accounted for 4% of the global population, but 25% of all coronavirus cases (Levitt, 2020.) On many occasions, President Trump has downplayed the severity of the pandemic and falsely suggested that the case count was escalating due to increased coronavirus testing. Thus far, he has pulled the United States out of the World Health Organization (WHO) and pushed for the reopening of schools. He has signed off on legislation that solely pertains to economic relief with no regard to the ongoing pandemic. In contrast, Biden has pledged to place his confidence in scientists and medical leaders. In addition, he would support expanded testing, reverse the decision to withdraw from the WHO, and provide essential workers with additional pay. He would only reopen schools “after sufficient reduction in community transmission” (Levitt, 2020.) These propositions are snippets from Biden’s 7-Point healthcare policy. Medical leaders agree that Biden’s plan is not innovative, but necessary. Dr. Ira B. Wilson, a professor and health service director at Brown University’s Warren Alpert School of Medicine, states in an interview for Healthline: “My perspective on the [Biden] plan is that it is not earthshakingly innovative or anything like that — it’s just the basic work of public health. It’s not like we don’t know how to do this.” Also, in an interview for Healthline, Dr. Amanda D. Castel, a tenured professor in the department of epidemiology at George Washington University, asserts that the issue within the pandemic is that there is a lack of federal strategy in public health crisis management (Mastroianni, 2020.) This brings into question the depth of Biden’s new policy and how the American electorate has reacted to it.  

What is the 7-Point Healthcare Policy?

As the title suggests, there are seven sub-policies to execute under this stratagem:

1.      “Fix Trump’s testing-and-tracing fiasco to ensure all Americans have access to regular, reliable, and free testing.”

A Pandemic Testing Board similar to former President Franklin Roosevelt’s war production board, which improved the efficacy of producing war goods, would be set up. By doing such, Biden hopes to magnify the number of coronavirus tests currently administered in the United States by at least double.

2.      “Fix personal protective equipment (PPE) problems for good.”

Under this sub-policy, federal responsibility would be taken over marginalized and economically unable communities to ensure adequate access to PPE. Biden would also make certain that all goods are American-sourced and manufactured so that the United States wouldn’t be reliant on other countries during a time of crisis.

3.      “Provide clear, consistent, evidence-based national guidance for how communities should navigate the pandemic — and the resources for schools, small businesses, and families to make it through.”

The responsibility of taking the lead on managing the public amidst the current state of public health would be handed to the Centers for Disease Control from the federal government. Instead, the federal government would help schools, small businesses, and families stay afloat during this time. The government would establish a renewable fund for state and local governments to prevent budgeting shortfalls and provide small businesses a “restart package” that would aid in covering the costs of necessary business adaptations to operate safely, such as Plexiglas and PPE.

4.      “Plan for the effective, equitable distribution of treatments and vaccines.”

In the event that a vaccine is released and approved by the Food and Drug Administration, the federal government would introduce it to the market in a manner where price inflation does not occur. The vaccine would be available to all, as opposed to the wealthy and well-connected.

5.      “Protect Older Americans and Others at High Risk.”

As proposed by senator Kamala Harris, this sub-policy intends to establish a COVID-19 Racial and Ethnic Disparities Task Force. This task force would provide oversight and recommendations concerning disparities present in the public health and economic response. Further, the flow of information about the coronavirus would be more transparent, assisting elderly Americans in being informed about what precautions they should take.

6.      “Rebuild and expand the defenses that Trump has dismantled to predict, prevent, and mitigate pandemic threats, including those coming from China.”

The White House National Security Directorate for Global Health and Biodefense set forth by the Obama-Biden administration and eliminated by the Trump administration in 2018 would be reintroduced. The relationship between the WHO and the United States would be mended as it is fundamental to coordinating a global response.

7.      “Implement mask mandates nationwide by working with governors and mayors and by asking the American people to do what they do best: step up in a time of crisis.”

This one is a no-brainer and should have been implemented right when the pandemic started. There would be a nationwide mandate on sporting face masks.

*All information under the heading “What is the 7-Point Healthcare Policy?” is derived from presidential candidate Joe Biden’s official campaign website. For more information on Biden’s policies, visit https://joebiden.com/. Please vote in an informed and responsible manner.

How Has the American Electorate Reacted to Biden’s Plan?

A recent survey publicized by the American Journal of Public Health finds that the number of citizens in the United States that would like the government to partake in a more overshadowing role in the healthcare system than during the first wave of the pandemic increased by an astounding 40%. This indicates that Americans believe that the federal government should quit hiding around and delaying a proper response to the pandemic. However, Dr. Wilson asserts that the difficulty that already surrounds implementing a proper coronavirus response has been gravely heightened because it has now been exposed to partisan lenses. A response to the virus is now political as opposed to protecting American citizens. If Biden wins the election, Wilson warns that federal infrastructure will have to be rebuilt, the WHO has to be re-entered, and American foreign relations must be restored, especially with the Chinese whose trust America has lost (Wilson, 2020.) The relationship with China is particularly of interest because the United States had engaged in a multitude of scientific collaborations with them. As it stands today, the current state of the United States will only make progress on resolving the coronavirus exceedingly difficult. Still, a secondary survey conducted by the American Journal of Managed Care insinuates that voters aged 18-29 trust Biden on taking the lead in healthcare over Trump on an outcome of 62% to 25%. Trump makes up for this gap with his supporters aged 65 and above but still falls short of Biden by five percentage points. It will be interesting to witness the outcome of this year’s election as the survey highlights that healthcare policy is the paramount deciding factor on who the electorate will confide their vote in for 71% of Americans.

Conclusion

This year’s election is likely to be settled based on which candidate presents a better agenda for healthcare policy. While Trump has built an agenda embedded in misinformation, Biden sets forth a plan that is not innovative or original in any form but is necessary to be implemented. Although Biden has maintained bipartisan support on his policies concerning the healthcare system and a proper response to the novel coronavirus pandemic throughout his campaign, undiscussed concerns still remain if Biden is elected president. These concerns are rooted in the extensive aggregate of time required to re-establish the role of the WHO in the United States, repair American relationships with foreign countries that have lost their credence in the United States, and rebuild federal infrastructure. Nonetheless, the 2020 election has been quite the spectacle up to date and will continue to be such no matter who will win the election. With this in mind, be sure to vote if you are eligible. Your vote is pivotal in not only deciding the direction in which healthcare policy will shift moving forwards, but all policy.

Sabriyah Morshed, Youth Medical Journal 2020

References

Barry, C. L., Han, H., Presskreischer, R., Anderson, K. E., & Mcginty, E. E. (2020). Public Support for Social Safety-Net Policies for COVID-19 in the United States, April 2020. American Journal of Public Health. doi:10.2105/ajph.2020.305919

Caffrey, M. (2020, October 8). More Americans Trust Biden to Lead US Health Care System, West Health-Gallup Poll Finds. Retrieved October 24, 2020, from https://www.ajmc.com/view/more-americans-trust-biden-to-lead-us-health-care-system-west-health-gallup-poll-finds

COVID Timeline. (2020, October 21). Retrieved October 24, 2020, from https://joebiden.com/covid19/

Levitt, L. (2020, September 03). Trump vs Biden on Health Care. Retrieved October 24, 2020, from https://jamanetwork.com/channels/health-forum/fullarticle/2770427

Mastroianni, B. (2020, October 20). Why Experts Support Biden’s 7-Point Plan to Beat COVID-19. Retrieved October 24, 2020, from https://www.healthline.com/health-news/why-medical-experts-support-joe-bidens-7-point-plan-to-beat-covid-19#1

Sabriyah Morshed, Youth Medical Journal, 2020

CRISPR/Cas9: A Dangerous Breakthrough in Medicine

Introduction: What is CRISPR/Cas9 and How Does it Work?

Clusters of regularly interspaced short palindromic repeats, commonly known as CRISPR, is a simple yet formidable implement allowing researchers to effectively edit genomes. Some of its potential applications include treatment and prevention of diseases, amelioration of genetic defects, and removal of certain gene types. The CRISPR/Cas9 technology can be deconstructed into four components (CRISPR, spacer, crRNA, and Cas9), each serving its own purpose. The CRISPR is a unique sequence of deoxyribonucleic acids (DNA) consisting of two distinct attributes: recurrent nucleotide progressions and spacers, which are short-variable sequences interspersed between nucleotides [1]. These spacers are derived from the DNA of viruses that have previously attacked the host CRISPR [2]. Once the CRISPR has been fashioned and the virus attacks again, the CRISPR is transcribed and processed into crRNA. The crRNA integrates with a secondary RNA string, the trans-activating crRNA, to provide the Cas9 enzyme with a passage to its target site, where the Cas9 enzyme will then execute what is recognized as a double-stranded break to remove the superfluous module of the genome sequence. One theory as to why CRISPR/Cas9 technology is so attractive compared to other genome editing techniques to researchers and consumers alike is its meticulous accuracy and efficiency in deriving results. It is predicted that the rationale behind this lies in the technology’s prototype adjacent motifs or PAMs. These PAMs serve as a tag, sitting adjacent to the Cas9 enzyme’s target site. Should there be no PAM next to the target site, the Cas9 enzyme will avoid “cutting” the particular genome sequence [1]. Once the cut has been finalized, programmed DNA may take its place.

Why CRISPR: A Deeper Understanding

Over the past decade, four major classes of engineered nucleases have been used for genome editing: meganucleases, zinc-finger nucleases (ZFN), transcription activator-like effector nucleases (TALEN), and CRISPR [6.] Meganucleases are endonucleases that can recognize extended DNA progressions of 14-40 bp via extensive non-modular protein-DNA connectors, but their target specifications have proven to be difficult to re-engineer [6]. Both ZFNs and TALENs are “fusions between arrays of ZF or TALE DNA-binding domains and the non-specific, dimerization-dependent FokI nuclease domain” [6]. Put simply, these three classes of nucleases all rely exclusively on protein-DNA connections to recognize their target sites.

In contrast, the CRISPR/Cas9 endonuclease relies on RNA strands to guide the Cas9 protein to its target site. This process allows researchers to easily modify and reprogram gene sequences. Additionally, due to the Cas9 enzyme’s complex nature of being intersected with a secondary RNA string, it can be re-engineered to recognize a target site based off of a protospacer and a PAM progression [5]. The PAM progression serves as a mediator, ensuring the Cas9 enzyme does not lacerate a necessary fibril of the DNA sequence. Thus, engineers can easily facilitate gene modification by simply editing the composition of the RNA strand conjoined with the Cas9 enzyme. They are not to worry about accidentally fabricating unwanted modifications to the RNA progression because the Cas9 enzyme will not act on it should a PAM not be present. These distinctive aspects of the CRISPR/Cas9 technology promote accuracy by minimizing off-site targeting by the Cas9 enzyme, leaving little to no space for error. Despite the expeditious advances in the field of genetic engineering/modification, bioethical questions are still raised regarding human trials.

Bioethical Concerns

Currently, the majority of all genome editing technologies are being tested in the interest of treatment and prevention of human disease. Genome editing shows considerable promise in treating and preventing both single-gene diseases such as muscular dystrophy and sickle cell disease and more complex disorders such as cancers and human immunodeficiency virus (HIV) [4]. A significant amount of research conducted on genome editing directly affects somatic cells (cells that are not egg and sperm cells). However, at the alarming pace that this field of study is evolving, there is no doubt that gene alteration technology to edit germline cells (egg and sperm cells) will be readily available soon, which is where bioethical challenges are raised. The ability to edit germline cells will enable consumers to enhance normal human characteristics, such as height or intelligence. It will also allow consumers to edit their offspring’s appearance [4].

The second major debacle that is brought into question is human autonomy. When germline editing becomes readily available, it will allow consumers to change normal human attributes in their offspring. This will be a non-consensual act on the parents’ behalf which will impact their offspring. Further, genetic editing will allow consumers to model the perfect human, which in turn, will infringe on a diverse number of societal rights [7]. These societal rights include but are not limited to the right to morality, the right given to doctors to advise patients, the rights scientists are given to conduct research, and the right children should have to consent or not consent to decisions their parents will make that affect their livelihoods.

Based on these ethical challenges, many countries have made it illegal to further study genome editing, more specifically germline and embryo genome editing. However, many more countries are persistent in advancing research and trials into the field.

Conclusion

Genome editing presents an attractive approach and considerable promise to treatment and prevention of human disease. Out of the four common classes of engineered nucleases used in the past decade, CRISPR/Cas9 has shown the most promise regarding accuracy. Its distinct features that make it a favorable tool are its negligible margin of error for targeting off-site DNA progressions via PAMs, its reliance on intertwined Cas9 enzymes and RNA progressions which allow for efficient reprogramming, and its unique PAM system which enables engineers to directly trim an RNA sequence without effectuating complications. However, amidst the steady progress of the genetic engineering field and its universal appeal to researchers, one can make a point to further analyze bioethical inquiries that have arisen before implementing further studies, trials, and inevitably, introducing this technology to the healthcare market.

References

1.     E. P. (2014, July 31). CRISPR: A game-changing genetic engineering technique. Retrieved August 29, 2020, from http://sitn.hms.harvard.edu/flash/2014/crispr-a-game-changing-genetic-engineering-technique/
2.     Barrangou, R., Fremaux, C., Deveau, H., Richards, M., Boyaval, P., Moineau, S., Romero, D.A., and Horvath, P. (2007). CRISPR provides acquired resistance against viruses in prokaryotes. Science 315, 1709–1712
3.     Doudna, J. A., & Charpentier, E. (2014). The new frontier of genome engineering with CRISPR-Cas9. Science, 346(6213), 1258096. doi:10.1126/science.1258096*, E. P. (2014, July
4.     Jiang, W., Bikard, D., Cox, D. et al. RNA-guided editing of bacterial genomes using CRISPR-Cas systems. Nat Biotechnol 31, 233–239 (2013). https://doi.org/10.1038/nbt.2508
5.     What are genome editing and CRISPR-Cas9? – Genetics Home Reference – NIH. (n.d.). Retrieved August 29, 2020, from https://ghr.nlm.nih.gov/primer/genomicresearch/genomeediting
6.     Tsai, S., & Joung, K. (2020). Defining and improving the genome-wide specificities of CRISPR-Cas9 nucleases. Nat Rev. Genet, 1-25. doi:10.1038/nrg.2016.28.
7.     Kersch, L. (n.d.). GENETIC MODIFICATION: THE ETHICAL AND SOCIETAL IMPLICATIONS OF CRISPR TECHNOLOGY. Retrieved August 29, 2020, from https://med.nyu.edu/departments-institutes/population-health/divisions-sections-centers/medical-ethics/sites/default/files/medical-ethics-high-school-bioethics-crispr.pdf

Sabriyah Morshed, Youth Medical Journal, 2020