| Potential vaccine-induced evolution. a | Vaccination increases the transmission advantage of an escape variant compared with wild type (WT). Here, vaccine escape is complete, allowing the variant to replace the wild type in vaccinated hosts. b | If residual immune protection from vaccination slows the transmission of the variant, the variant cannot spread as readily in the vaccinated population, reducing prevalence and incidence. c | Within hosts, ‘intermediate’ immune pressure could in theory maximize the rate of adaptation. After two doses of vaccine, strong immune responses will likely inhibit viral replication and the emergence of escape mutations. Some have proposed that with just one dose, the rate of within-host adaptation could be high (triangle at top of the curve). We suggest that selection during COVID-19 infections is inefficient (triangle to lower right of curve). Adapted with permission from refs9,48, AAAS. (Image via Courthouse News)
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