Covid Epi Weekly: To Arms, To Arms!

There’s been promising news this past week. Cases in many parts of the country are decreasing, meaning there’s less spread. Hospitalizations are trending down. The Biden-Harris Administration has issued executive orders to speed action in our fight against Covid.

But there’s a long way before we can get control of the virus. In terms of vaccination, we must focus on 3 key things:‌

  1. Get doses out of freezers and into arms ASAP. Vaccine does no good if it’s not given out. We need a strategy to make sure doses can be administered quickly as they become available.
  2. Denominators: What percentage of nursing home residents and staff have been vaccinated? This is the highest risk group; vaccinating these people will sharply reduce spread in long-term care facilities and greatly reduce deaths, even if the overall number of cases in the entire population isn’t substantially reduced.
  3. Improve equity. We need to do better at reaching Black, Latinx, Native American, and all underserved groups now. Racial and ethnic minorities experience disproportionately higher rates of hospitalizations and deaths. They also make up a disproportionately large segment of our front-line workforce — health care workers as well as store employees, delivery drivers, teachers, and everyone else who risks their health by keeping our economy and society functional.

How fast can vaccination help?

Some encouraging data from Israel. The more quickly we vaccinate, the more quickly we reduce deaths. How fast can vaccination against COVID-19 make a difference? Two weeks after 40% of those over 60 who had been vaccinated, the number of critically ill in the age 60+ group grew by 7% compared with the previous week’s growth of over 30%. There was less of a decrease in the growth of critically ill among the 40–55 age group — who were not as widely vaccinated as those over 60. If this trend continues, hospitalizations and deaths may already be dropping.

Source: The Economist. Rapid decrease in critical illness following vaccination.

Better, but still bad

First, let’s get clear about the epidemiology and continued trajectory of the pandemic. Better does NOT mean good!!! In this case, it just means less terrible. The peak of hospitalizations in the prior two Covid surges in the US this past spring and summer was 60,000. Now we’re at 100,000. So our lower number is nearly double what it was at any prior peak.

Thanks to the New York Times for working with Resolve to Save Lives to provide better and more actionable information on Covid risk in every community. Wide swaths of the country remain at extremely high risk, with only isolated pockets of low or even medium risk.

I’m horrified to see so many communities opening up right now because they see that things are getting a little “better” when risk is still very, very high — as is the risk of new, more infectious, and potentially more deadly viral variants.‌

That sickening feeling. Imagine a punch-drunk boxer who has been knocked down twice, staggering up again to face an opponent winding up to deliver a knockout blow. That’s us, now, planning to open again because things are “better.” If communities open now, it’s not going to end well for far too many people.

Vaccine news

There have been a lot of scientific developments on vaccine, not all of of which are encouraging.

The Johnson & Johnson vaccine looks promising and likely to be submitted for approval to the FDA and approved soon. The J&J vaccine, a non-replicating viral vector vaccine that uses a common cold adenovirus and is designed to be given as a single dose, is about as good as a single dose of an mRNA-based vaccine.

In an NEJM article from earlier studies, the immune response continued to build for 57 days after vaccination. Today’s results from the latest trial only show the effects 28 days after vaccination. The jury is still out on whether a second dose would be even more effective.

The J&J vaccine can be kept at regular refrigerator temperatures (no need for deep freeze) and is easier to make, store, ship, and give — at half the price. The company plans to manufacture a billion doses this year.

The Novavax vaccine, also soon to be rolled out, uses an engineered protein and an adjuvant, and is nearly as good as the mRNA vaccines. It’s nearly 90% effective at preventing Covid and, importantly, is effective at preventing severe cases. However, as is the case with other vaccines, it appears to be less effective (but not ineffective) against some of the newer and more transmissible strains, in particular the B.1.351 variant first identified in South Africa.

There’s a tantalizing line in the company’s press release that suggests that placebo recipients in South Africa who were seropositive at trial enrollment became infected with the new strain during the trial. SHOW US THE DATA! This is important and the world needs to know.

Data on study design, data, and effectiveness of the Astra-Zeneca vaccine are still murkier than they should be, and there are now production problems.

It’s possible that we’ll wind up with vaccines that may be relatively more and less effective. But the key is how well do they prevent people from developing illness severe enough to require hospitalization — and so far all of the vaccines seem to do that.

Adapt or else!

SARS-Cov-2 is evolving to adapt to the human context. As we develop vaccines and as more people become infected, the virus will mutate to evade our defenses. We may eventually need multivalent vaccines to fight these multiple strains. This wouldn’t be new. Vaccine protects against 3 different strains of polio, up to 9 of HPV, and up to 23 different pneumococcal strains. This could be where we’re headed with Covid vaccines, but it’s far too soon to know this for sure.

But the vaccines we have now work against strains that are circulating today. Things have gotten off to a bumpy start — this is the most complicated vaccination program in US history — but we have to get vaccines out of freezers and into people’s arms.

‌And we have to make sure that those who have been neglected so far — Blacks, Latinx, Native Americans, the poor, and, surprisingly, primary care doctors — are also prioritized to receive vaccines. First-come, first-served is a recipe to further exacerbate persistent inequalities.

Revealing description of the smoother roll-out in the UK, where they relied on their National Health Service and primary care doctors. Hope we’ll get the hint and strengthen primary care and make it central to our response.

Ramp up vaccination

We can use four platforms to get as many people vaccinated as quickly as vaccines are ready:

  1. All health care systems
  2. Mass vaccination clinics (there’s a great article describing how LA’s Dodger Stadium has been transformed into a high throughput vaccination center) — but it’s important not to reduce post-vaccination observation time to less than 15 minutes in case of very rare but potentially serious allergic reactions
  3. Pharmacies (chains as well as independent pharmacies)
  4. Pop-up, community-outreach sites set up anywhere they are needed that could be run by any of the first three.‌

The Biden-Harris Administration’s goal of vaccinating 100 million people in the next 100 days is ambitious and achievable — but the minimum of what we need to do. Vaccine supplies are short now, but will improve in the coming months. We will then need to parse everything we know about “underlying conditions,” using scientific and medical judgment and not just data, to prioritize those who will get the greatest benefit from vaccination.

‌There are about 81 million people in the US with high-risk health conditions. Some of these higher risk conditions are rare, so there won’t be much specific data about how Covid affects people that have them. CDC might consider subdividing these categories into those who are at very high risk and “only” at high risk, based not just on Covid-specific data but on review of all available scientific information.

‌Going back to nursing homes, if we’re successful, deaths that occur in these facilities will decline as a proportion of all deaths, then plummet dramatically during March. That would be a tremendous step forward. It’s impressive that 1.4 million long-term care residents have already received at least one dose of vaccine.

But we have to know the denominator — how many nursing home residents are there? And we have to do much better at vaccinating staff. There’s a lot of turnover at nursing homes, so we need to vaccinate every resident when they are admitted, as well as every new staff member as part of their onboarding.

There has been some resistance among workers at long-term care facilities, so we may need both positive and negative incentives to encourage staff vaccination. See the graph below and watch this space over the coming months.

Kudos to New York State for robust monitoring and reporting of vaccination data at nursing homes. Minnesota also has a good website reporting statewide data. Up next: Resolve and partners will be releasing recommended vaccine indicators this week as part of our initiative to provide accurate, recent, actionable data for responsible decision-making.

Protect our health care workers

We also need to make sure we protect health care workers as Amanda McClelland and I wrote for CNN. Countries all over the world have failed our caregivers for far too long. We must improve infection prevention and control in all health facilities, strengthen training and continued education so health workers can stay up to date on best practices, and provide socioeconomic, legal, and other support, as well as PPE of course, so they can continue to save lives when we need them most.

Also, in 2021, clean water, sanitation and hygiene (WASH) are not consistently available in about a third of health facilities worldwide. We must provide safe water for hundreds of thousands of health care facilities, among many areas of infection control where we need progress.

Vaccine nationalism

Vaccine nationalism — and failure to support developing economies with massive vaccination campaigns — is self-defeating. New financial modeling by the ICC World Business Organization warns of the cost of vaccine nationalism: $9.2 trillion, with nearly half, $4.5 trillion, incurred by wealthy economies including the United States.

A $27.2 billion investment on the part of advanced economies — the current funding shortfall to fully capitalize the global collaboration to accelerate development, production, and equitable access to COVID-19 tests, treatments, and vaccines — is capable of generating savings of $4.5 trillion, a return on investment as high as 166x.

Inequity causes crushing burdens on those people who are unfairly treated, but it also harms everyone. Uncontrolled disease spread anywhere is a risk everywhere. The only way through this is to scale up production, and this will require not only treating intellectual property as a global good but also vaccine production capacity.

One possible way forward would be to scale up mRNA manufacturing capacity in countries that have large populations and strong pharmaceutical sectors, such as Brazil, South Africa, India, and Vietnam. Because mRNA technology may be able to be used for multiple vaccines and other products in the future, this could be a regional and global benefit.

It will take time — which is why we should explore and consider starting right now. We need global collaborations that recognize the reality of our mutual dependency and mutual accountability.

5 points to wrap up:‌

  1. Lower doesn’t mean low. If floodwaters were over the roof of your house and now are up to the top-floor window, it’s still a flood. Especially if a hurricane (read: more infectious variants) may hit you soon. Until the worst is past, which won’t be for several more months, we need to double down on protection protocols, including wearing masks and minimizing time indoors with people from outside your household.
  2. Don’t focus on individual variants. What variants are telling us is the virus is wily: it can evade our defenses. We need better tracking of not just genomes but how they relate to epidemiology. More infectious variants will spread — that’s how natural selection works.
  3. Masking is important. A mask not worn doesn’t protect anyone; any mask is a lot better than none. Better masks might reduce spread, but this is far from certain. Double masking, surgical masks, and N95/K95/KN94 masks all have theoretical benefits, but the key is to increase the proportion of time people wear ANY mask when they’re in an at-risk situation.
  4. Improve implementation of our “Box It In” strategy to test/isolate/trace/quarantine, even if we can’t do much at the current sky-high levels of spread. When cases come down, we need to be ready to reduce spread even further through rapid isolation and effective tracing. This will help reduce emergence of escape-mutant strains and protect our vaccines so they continue to work.
  5. Congress must act, and act quickly. Funds are needed to reimburse people for isolating or quarantining in order to prevent spread to others. For paid sick leave. For the US Public Health Job Corps. For schools to stay open more safely. For restaurants and bars to stay afloat while they are closed. To protect our country by improving global health security. And much more.‌

Today marks exactly one year since the first of these Friday evening Covid epidemiology roundups. It’s going to take a lot of hard work over the coming months to get control of the virus. But this time next year, I hope to be writing about our successes in stopping Covid and our progress improving our health care and public health systems so that we’ll be able to rapidly and effectively confront the next, inevitable threat.

Government in general, and public health in particular, at its best, is about the organized efforts of society to do what individuals cannot do or cannot do as effectively. It’s worth thinking back to the words and work of FDR’s great Labor Secretary, who was also the first female cabinet member and the longest-serving Labor Secretary:‌

“The people are what matter to government, and a government should aim to give all the people under its jurisdiction the best possible life.

“Most problems have been met and solved either partially or as a whole by experiment based on common sense and carried out with courage.”

– Francis Perkins

President and CEO, Resolve to Save Lives | Former CDC Director and NYC Health Commissioner | Focused on saving lives. twitter.com/drtomfrieden