Don’t Ease Up On the Brakes!

Covid epidemiology weekly blog

Covid variants are here, and more are coming — but so are vaccines. There’s encouraging news: cases, hospitalizations, and percent test positivity are plummeting in all ages and in all parts of the country, and deaths have begun to decline.

Now the bad news: infections are still VERY high, and higher than at the peak of prior surges. The most likely explanation for the rapid rise and even more rapid fall: travel accelerates viral spread exponentially. We’re recovering from the huge amount of ill-advised travel and indoor contact over the holidays. When people travel, the virus travels.

This is a fight against the virus, but also a fight against becoming numb to the horrifying toll. Far too many who get sick are not recovering. The 7-day average is still 3,000 deaths per day, the number of people killed on 9/11. More than 20,000 died last week. Every life is precious. Every death robs us all.

As more people receive vaccines over the next several months, we can’t afford to ease up on the brakes now! Let’s double down on protection protocols (masks, distancing, limit travel), scale up equitable vaccine delivery, and spur innovation in vaccination and control measures. We can avoid another, steeper curve.

Vaccine Indicators

The sooner we vaccinate and the better we tamp down spread, the lower the risk from variants. We’ve had steady — though rocky and uneven — progress with vaccination. This week, @ResolveTSL and partners the American Public Health Association, Trust for America’s Health, Association of Schools and Programs of Public Health, and Center for Health Security at The Hopkins Bloomberg School of Public Health released recommendations for vaccine indicatorsevery state should collect and publicly share to inform decision-making and provide accountability and transparency in vaccine rollout.

There are two glaring gaps in the information the federal and state governments publish: data on vaccination by race/ethnicity over time, and vaccination coverage of staff and residents in nursing homes. Not coincidentally, there are problems not just with data availability but also with the reality in both areas. These are life and death problems.

First, race/ethnicity. We need to see vaccinations by race/ethnicity over time. Unless this is made available and updated weekly, there’s no way for us to know if we’re getting better at addressing inequality or not. North Dakota is tracking vaccine coverage over time by age. We need the same data collected and reported over time on race/ethnicity, not just cumulatively.

Reports from the Kaiser Family Foundation show that data on vaccination by race/ethnicity is alarming. Ohio has a good Covid vaccination dashboard (see figures below)and, as appears to be case nationally, Black and Latinx people are getting vaccinated at about half the rate of White people, despite having 2–3x the death rate. We MUST do better.

There’s been great progress vaccinating nursing home residents, with about 80% receiving their first dose. However, the proportion of staff who have been vaccinated is under half. Because turnover of residents is high, including people moving between facilities, vaccination of people when they are admitted to nursing homes is essential and needs to be routine.

This will require implementing a model that’s different from the standard pharmacy program for Covid vaccination. Unless there’s focused attention to vaccinating new residents, this will be missed. And in the context of low staff vaccination rates, that would be a deadly mistake.

We MUST do better at reaching staff of nursing homes. Staff vaccination needs focused outreach, education, and engagement. Positive and negative incentives for staff can increase vaccine coverage. But at some point, there’s an ethical question.

A staff member who isn’t vaccinated may introduce infection that spreads throughout a facility and results in the deaths of many residents. This has been an issue with influenza vaccination for years; although there has been progress, still, only about two thirds of health care workers in nursing homes and other long-term care facilities get flu shots.

Thanks to @drgregpoland for raising the issue of health care staff vaccination for years. First must come making vaccination free, convenient, and sensitive, and addressing staff concerns. But at some point, staff choices may have lethal implications.

Vaccine News

There’s been a tsunami of information on vaccines in the past week. The Johnson & Johnson vaccine is promising: single dose, easy to handle, 85% protection against severe illness. Every new way to fight Covid helps. We can expect approval in February and increasingly widespread availability of this vaccine starting in April.

Interesting preliminary, pre-print data suggests that a single dose of the Pfizer and Moderna mRNA vaccines may be sufficient to provide protection in previously infected people. Practically, it would be difficult to get serology data in the contact of a mass vaccination program and so only give one dose to previously infected people, but this may be relevant for individuals. Again, it’s preliminary information and we don’t know how long the protection will last.

A single dose of the AstraZeneca vaccine has been reported to result in stable immunity for at least 3 months, but the data are messy and have not yet been peer-reviewed. The UK’s decision to delay the second dose of this vaccine is reasonable in the context of explosive spread of the predominant variant in that country, but we need much more data.

An approach from Russia using two different vectors also appears to be effective. Remember that old saying: Just because you’re paranoid doesn’t mean they’re not out to get you? Well, just because the data are dodgy, doesn’t mean that the vaccine doesn’t work.

Many different vaccine approaches are still being developed. China has a wide range of vaccines under development, ranging from inactivated, to vector (like the vaccines of AstraZeneca and Johnson & Johnson), to subunit (like the Novavax vaccine). Shouldn’t mRNA be considered a global public good for the benefit of all and widely available?

Thanks to Dr. Tony Fauci for the clear summary below of the different approaches being used for vaccine development in the United States. It’s amazing scientific progress — and also luck: Immunity is robust (unlike TB, malaria, HIV), and mRNA and adenovirus vector technologies were available just-in-time.

There’s also encouraging data from Israel. Vaccination of people over age 60 leads to big reductions (dark blue line in middle and right graphs) of severe illness. Vaccine programs must cover Palestinians in Israel and in the Occupied Territories, who face elevated risks. Disparities and inequalities must be fought everywhere they exist.

Variants threaten

So if we’re ramping up vaccination, and the proportion of people with immunity from infection (which, as another and very interesting study shows, is likely protective) is increasing steadily, what could possibly go wrong?

Variants, that’s what.

In Manaus, Brazil, the P1 variant has caused at least one reinfection. There’s not yet enough data to know if the rapid increase in cases in that city is due to reinfection among people previously infected with other strains (due to waning immunity or immune escape), increased transmissibility of this new variant, or some combination.

One line in a Novavax press release on the company’s South Africa trial reports reinfections with new variant, but provides no data. Tony Fauci provides another good summary of what we know about variants. One thing is clear: we need to pay less attention to individual variants and more to what the variants as a group are telling us.

The virus outnumbers us; we need to outsmart it. It’s in our self-interest to make sure the virus is controlled in the US and globally. With uncontrolled spread, more variants will emerge. And with increasing immunity from vaccine and natural infection, variants that evade these defenses, if they emerge, will spread. This could result in reinfections and also the spread of vaccine-escape mutant strains. Vaccines protect us. We must reduce spread to protect vaccines.

As Dr. Martin Luther King, Jr, said:

“Injustice anywhere is a threat to justice everywhere.”

Uncontrolled viral spread anywhere is a threat to viral control everywhere.

And ill health anywhere is a threat to health everywhere.