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In the Bubble: On the Frontlines
All Podcasts Toolkit: Where Is My Vaccine?

Toolkit: Where Is My Vaccine?

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Description

Now that we are a couple of months into the vaccine rollout, we wanted to answer more of your vaccine-related questions. Dr. Bob asks Paul Offit your questions about what more we’ve learned about the vaccines in terms of safety, efficacy and vaccinating kids. Ruth Faden tackles your questions about the ethics of deciding who gets the shots first, jumping the line, and vaccination passports. Plus, Dr. Bob and his wife Katie Hafner discuss what it’s like when one person in a bubble is vaccinated and the other isn’t.

 

Follow Dr. Bob on Twitter @Bob_Wachter and check out In the Bubble’s new Twitter account @inthebubblepod.

 

Follow Paul Offit @DrPaulOffit and Ruth Faden @fadenethx on Twitter.

 

Keep up with Andy in D.C. on Twitter @ASlavitt and Instagram @andyslavitt.

 

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Check out these resources from today’s episode: 

 

 

To follow along with a transcript and/or take notes for friends and family, go to www.lemonadamedia.com/show/in-the-bubble shortly after the air date.

 

Stay up to date with us on Twitter, Facebook, and Instagram at @LemonadaMedia. For additional resources, information, and a transcript of the episode, visit lemonadamedia.com.

Transcript

SPEAKERS

Dr. Paul Offit, Dr. Bob Wachter, Dr. Ruth Faden, Katie Hafner

Dr. Bob Wachter  00:08

Welcome to IN THE BUBBLE. I’m Dr. Bob Wachter. Today is going to be really interesting episode. We’re going to talk about vaccines, but talk about the vaccines in the context of where we find ourselves, which is in the middle of a slow and bumpy rollout, but also a time where we’re learning more and more about the vaccines and their safety and their effectiveness. The other thing that’s happening with vaccines is a lot of discussion and some contentiousness about who goes first and where people stand in line. Those have some major ethical and practical implications. And as you’ll hear, they also have marital implications in my own household. So we will be talking about that, as well.

Dr. Bob Wachter

Our guest today to talk about the vaccine rollout and everything that we’re learning about these vaccines and maybe other vaccines that are coming down the pike are first Dr. Paul A. Offit, who’s one of the world’s leading experts in all things vaccine. Paul is the director of the Vaccine Education Center and attending physician he’s a pediatrician in the Division of infectious diseases at Children’s Hospital of Philadelphia. He’s also the co-inventor of a Rotavirus vaccine, then to talk about the ethical implications and all of the challenging prioritization decisions were being forced to make.

Dr. Bob Wachter

We have one of the world’s leading medical ethicists Ruth Faden, who’s the founder of the Johns Hopkins Berman Institute of Bioethics, and Ruth served as the institute’s director from 1995 until 2016. She is currently the Philip Franklin Waggly professor of Biomedical Ethics at Johns Hopkins. So we’ll begin with Paul and move on to Ruth but we’ll start with discussing the question of marital vaccine dissonance in my own household with my wife, Katie Hafner.

Katie Hafner  02:01

Honey, your voice is bleeding into my ears.

Dr. Bob Wachter 

You sound very clear.

Katie Hafner 

Oh, good. Yeah, that’s my I love my Bumblebee microphone,

Dr. Bob Wachter 

You sound much clearer than usual. This is how we should talk to each other all the time. This is great.

Katie Hafner 

Speak for yourself. The low talker of the household.

Dr. Bob Wachter

If you don’t know as low talker is a Seinfeld reference that one of Jerry’s girlfriend’s was a low talker. And so Katie accuses me of being a low talker. And I accuse her of being a low hearer, but she doesn’t think that’s right.

Katie Hafner 

Except when you’re snoring, there’s nothing low about that.

Dr. Bob Wachter 

Thank you. All right. Appreciate that. That’s support.

Katie Hafner 

Well, you know, we live in earthquake country. And so sometimes I think it’s the big one. But it’s actually

Dr. Bob Wachter

I still am not convinced that I actually snore. Okay, so, in my own household, we’re working through our own version of haves and have nots as it comes to vaccine allocation. As a physician who sees patients, I was in group one A and was vaccinated and, by the way, had virtually no side effects. So please do take the vaccine when you have a chance. My wife is, I think, a little bit behind me in the line. So Katie, I know you went on to the tool in the New York Times to figure out your place online. How’d that turn out?

Katie Hafner 

Did you say a little bit?

Dr. Bob Wachter 

A little bit behind, just a little bit behind.

Katie Hafner 

So yes, I did go on the times thing you know, and you plug in all your information, your age and where you are and what underlying conditions you have. So what I found out is that there are in the United States 268.7 million people in front of me in line. And what’s the population of the United States?

Dr. Bob Wachter 

330 million. So you’re ahead of some people, that’s good.

Katie Hafner

And then in California, I’m behind 31 million people.

Dr. Bob Wachter  04:00

I think we have about 40 million here. So that’s not bad. That’s not bad.

Katie Hafner

Okay, well, wait. In San Francisco. I’m behind 622,857 people.

Dr. Bob Wachter 

Yeah, they’re about 800,000 people who live here. So I thought you were like, right at the end of the line, but that’s just not true. You must feel pretty good about that.

Katie Hafner 

Yeah, I feel really good about that.

Dr. Bob Wachter 

So you have had, it’s hard enough to live with me in general

Katie Hafner 

This is true.

Dr. Bob Wachter 

But now, you don’t need to say that if Kryssy and Alex, if you could edit that out. That’s good. How is it felt for the last few weeks living with a vaccinated person?

Katie Hafner

So do you mean what was it like the other morning when I woke up and I said to you, how did you sleep honey and you said I slept the sleep of the vaccinated?

Dr. Bob Wachter

Maybe that would be one thing? Yeah, sure. What else?

Katie Hafner 

Has there been any gloating? I’m trying to recall.

Dr. Bob Wachter 

Well, I think at one point when I said I’m I need to go out and find a vaccinated wife. You didn’t seem that happy with that comment.

Katie Hafner 

No, no, no. How did that go?

Dr. Bob Wachter 

No, I was kidding. I kid.

Katie Hafner

All right, quite seriously, it is. It’s tough, actually. Because I think you can start to travel. And you can start making plans with friends, which I can’t do. However, I have a question for you, Dr. Wachter, which is, you could still pick it up, right? So you could bring it home. So it’s the worst of both worlds. You can go out there not get it yourself or get it very mildly if you do. But you could give it to me, is this right?

Dr. Bob Wachter 

It’s not clear, as we’ll learn later from my discussion with Paulo fit that that part has not yet been worked out. But I have to say I am treating things as if that is true. Which means I am going to take exactly the same precautions that I have always taken until I’m 100% sure that I am not capable of catching and transmitting it. Now what I will do differently is I will get a haircut and I will see the dentist both of which are sorely needed.

Katie Hafner  06:13

I have been cutting your hair. That’s not been your dental hygienists.

Dr. Bob Wachter 

Right. And I might say a professional haircut you’ve done very well with the watching the YouTube while we do it, getting the hair all over the computer is a little bit nasty.

Katie Hafner

There’s one more thing that is great about your having been vaccinated, which is that I can send you to the store. And I can send you to Walgreens and I have a great reason for doing it, right?

Dr. Bob Wachter 

Yeah, yeah. As you’re feeling sort of jealous and pissed off at me. Is there a part of you that’s actually feeling glad that your husband’s less likely to die of COVID? Has that crossed your mind?

Katie Hafner 

Oh, yeah, yeah. Yeah, actually. True. I’m very glad. And in fact, I know that you have kind of some asthma stuff going on. And so for something that is respiratory, when it gets you, I’m very glad that you’re not going to get sick. Oh, gosh, yeah, I come to think of it. I’m so glad that you probably will not get COVID. Thank you, Pfizer. Thank you, Moderna. Who else are we thanking?

Dr. Bob Wachter 

Just Pfizer for me, but Moderna for other people. Finally, any piece of advice you’d give to people who find themselves in this position where someone is vaccinated and other people are not in the same bubble?

Katie Hafner

Oh, wow. That’s a good one. You know, here’s the thing I’ve talked to other unvaccinated spouses and unvaccinated family members, and they are angry, some of them are actually angry. And they’re thinking they want to game the system. And somehow they should get it and they should pull strings. And for some reason, and believe me, I am not the world’s most mellow person, but I am just fine with it. And I’m surprising myself that I’m fine with it. So here’s what I’m saying is to people is just sort of it will come it will happen. Things are going to get much better in terms of the organization and the vaccine rollout that I guess I have faith, that kind of more faith than I would have had, say six months ago, that things will get straightened.

Dr. Bob Wachter  08:33

Yeah. Good. Well, I think they will. And there’s this guy named Slavitt, who used to host this show whose his job was to figure out how to move things along so that you might find yourself moving from 280 million to 245 million, you know, before you know it. So keep your eye on the line.

Katie Hafner 

Thanks. And should I just stay in my room for the next six months, the dog and I are actually we’re under the dining room table most of the time.

Dr. Bob Wachter 

I think that’s a good place. I will bring food for both of you under the table. That’s the kind of husband I am. Alrighty, thanks.

Katie Hafner 

Thanks for having me.

Dr. Bob Wachter 

Well, thanks to my wife, Katie, I think? We’ll talk about this offline. After the break we’ll hear from Paul Offit. Who will talk about how the vaccine rollout is going and what we’ve learned from the first couple of months of vaccinations.

Dr. Bob Wachter

There you are.

Dr. Paul Offit 

Yeah, I need a haircut. That’s one thing that’s true.

Dr. Bob Wachter

Your hair has gotten shaggier with every interview we’ve done, this is my third- or fourth-time interviewing Paul and each time, it’s like his hair is gonna take up his whole room eventually. So Paul, thanks for being on. We’re two months into vaccines now, from the time that we knew these vaccines were extraordinarily effective, and they appear to be safe. Tell us what we’ve learned in the last two months. Let’s start with safety.

Dr. Paul Offit  10:14

Right? So the two trials that were done the pre-approval trials were 30,00-44,400 persons big. What that can tell you, and is that within two months of getting the second dose, was there any serious side effect problem, and it wasn’t seen. So what that told you is that at least, you didn’t have what appeared to be any serious side effect that was relatively uncommon. The one thing that popped up before the emergency approval was Bell’s palsy. There were four cases of Bell’s Palsy in the Pfizer 44,000-person trial, there were three cases of Bell’s Palsy in the Moderna 30,000-person trial, if you added up that added up to seven cases of Bell’s Palsy among 37,000 people in the Placebo group, it was one case among 37,000 people. So if you do it sort of per year per 10,000 people that was basically eight per year per 10,000 people versus 1.2 per year per 10,000 people.

Dr. Bob Wachter 

Can you let folks know what Bell’s Palsy is?

Dr. Paul Offit 

Sorry. So Bell’s Palsy is a facial paralysis, usually on one side of your face, which causes sort of grouping and eyelid grouping and stuff. And it’s pretty noticeable, and typically temporary, but occasionally can be permanent or at least long lived. So people were worried about that pre approval, because the rate was about seven-fold greater than the background rate. And so we’ve been looking for that. Now the vaccine has been given to more than 12 million people, at least the first dose of vaccine has been given to 12 million people, you do have to wait a couple months, three months after that dose to make sure Bell’s palsy doesn’t occur. But right now, that doesn’t seem to have happened. You know, it’s the tyranny of small numbers generated from a large database.

Dr. Paul Offit 

It’s always a problem, you know, with the vaccine we worked on at children’s hospitals. Well, Philadelphia, the Rotavirus vaccine, you know, there were five cases of Kawasaki disease, which is you know, sort of a multi-inflammatory multi system inflammatory disease in the vaccine group and none in the placebo group that was studied post licensure because there was a worry that that might be a problem, but it wasn’t. But there are also five cases of arm and leg fractures in the Placebo group and none in the vaccine group. That was different observation. The Rotavirus vaccine prevented arm and leg fractures.

Dr. Bob Wachter  12:28

That’s spectacular.

Dr. Paul Offit 

The FDA didn’t  give Merck a license for that.

Dr. Bob Wachter 

They did not give you that indication that this is a way to prevent fractures. So the point is, in a big study, just you’re going to have some statistical blips that may turn out not to be clinically meaningful. How about the allergy? So the allergies, you know, that was worrisome in some, in some of the first experiences as people rolled out the vaccine and I think Alaska, we saw a few cases of fairly severe allergy. So what have we learned over the past couple of months?

Dr. Paul Offit 

Right, so the CDC just put out a report a few days ago in their journal morbidity and mortality weekly report. Looking at Pfizer’s vaccine and severe allergies and stated that the risk is roughly was 11 cases per million. So roughly one per 100,000 people who got this vaccine could have a severe allergic reaction. That’s greater than typical for vaccines, typically, about one per million people who get a vaccine will have a severe allergic reaction, which is why everybody who gets a vaccine should stay around, where they got the vaccine to make sure that they don’t have an allergic reaction for at least 15 minutes. If you’ve ever had a severe allergic reaction to anything else ever, then you should stay around for 30 minutes.

Dr. Paul Offit

So let me say this, that, you know, it’s not like people now weren’t staying around, because that was a standard protocol anyway, that would you need to stay around for 15 minutes. So I mean, you know, it’s you worry, because watching someone have a severe anaplastic or allergic reaction, we know where their blood pressure can drop, they can have fainting, they can have rapid heartbeat, weak pulse. I mean, it’s pretty scary to watch. But it does happen immediately. It’s readily recognizable. It’s easily treated with epinephrine, and nobody has died from that. So that’s good. But I think it is, it is a little scary for people.

Dr. Bob Wachter  14:07

And people have been concerned that the trials were fast warp speed, and we only watched folks for a couple of months after their vaccine. So how do we know that there’s not going to be some long-term nasty side effect that only emerges after six months or a year? So what do you think about that?

Dr. Paul Offit 

Right? So we have had a discussion with people to CDC about this is one of the sorts of things we do to try and tease out our historical memories. Vaccines can certainly cause serious, permanent and occasionally fatal side effects. That’s true. The oral polio vaccine could itself cause polio, which would occasionally be fatal. The yellow fever vaccine could cause something called visceral tropic disease, which is essentially a form of yellow fever, which could occasionally be fatal. All those side effects they occur within six weeks of getting a dose. So although they can cause long term harm, and occasionally you know, permanent or fatal harm.

Dr. Paul Offit

It all happens within six weeks of a dose. So when these two trials were done of 30,000 44,000 people, and the FDA insisted that you have at least two months of safety data after the last dose, they were basically saying, we are going to capture something bad if it happens, and is relatively uncommon. Now, we’re not going to capture it if it’s rare. I mean, 20,000 people isn’t 20 million people. And so now that it’s been out there, and it’s in billions of people, I think people can feel a little better that there’s not a serious rare side effect. But again, we need to keep looking.

Dr. Bob Wachter 

Great. Have we learned anything more about the effectiveness of the vaccines than what we knew a month and a half, two months ago, when the reports came out that they were 95% effective?

Dr. Paul Offit 

Right. Now, that’s a really good question. I mean, what those studies told you was the efficacy of the vaccine. So we know that they were 95% efficacious, under very controlled conditions. But that doesn’t mean it’s going to be 95% effective when it’s out there in the real world. And that’s the difference between efficacy and effectiveness. The Pfizer vaccine is a perfect example, there’s a vaccine that has to be shipped and stored at minus 80 degrees centigrade, which is dry ice, which we’ve never done for a vaccine before. It has a five-day refrigerator life. And then once you know, you start giving the vaccine, it has a six-hour life.

Dr. Paul Offit  16:09

When those studies were done, I can promise you that all the investigators do that, they were carefully supervised to make sure that they did it that way. But when it gets out there into the real world into retail pharmacies, which aren’t used to doing this mass vaccination with a product like that, you may find that there are differences. And so that that’s going to be the key question. I certainly people will look at this as we move along to see whether the effectiveness matches the efficacy.

Dr. Bob Wachter 

And when you hear of cases of someone who got their two shots and came down with COVID, how do you interpret that?

Dr. Paul Offit 

That doesn’t worry me, I think that the key thing when you’re trying to make a vaccine is does natural infection protect against disease, because if it doesn’t, you’re gonna have a hard time making a vaccine and they all, I mean gone, or you can get gonorrhea again. And again, you can get a strep throat again, and again, that’s why we don’t have vaccines against those diseases. Because if natural infection doesn’t protect, you’re going to have a hard time with making a vaccine. Natural infection appears to protect against this disease. Now, it doesn’t protect against naturally all disease, I mean, you still may get a mild infection or even a moderate infection,.

Dr. Paul Offit 

What you want from a vaccine is that it protects against moderate to severe disease, that’s the most important thing, because that keeps you out of the hospital, and it keeps you from dying. That’s the goal of this vaccine, basically to make it so that we can retake our hospitals again. So we can flatten the curve so that we’re not overwhelmed. If you have a mild infection, you know, nobody wants to have a mild infection. But the but it’s much better than having a moderate or severe infection. So that’s the goal so that people still have, for example, have a mild infection after getting two doses of vaccine that that doesn’t bother me. But we’ll see.

Dr. Bob Wachter 

Do we know anything more about the length of immunity? How long it’s going to last?

Dr. Paul Offit

No, but I think there’s reasons for optimism, certainly after dose two, there’s a clear evidence that depending on which trial you’re looking at, you either have T-helper cells, which are the kind of cells that that help B-cells make antibodies, or and then in one trial, both t helper cells and cytotoxic T-cells, cytotoxic T-cells are the kind of cells that kill virus infected cells, when you see that when you see a detectable frequency of those T-cells. I think that that is a good sign for relatively long-lived immunity, but which I mean, it could be two, three years’ worth of immunity, probably not decades, but at least a few years of immunity. After that dose, I don’t think those one is going to do that because those one didn’t induce that detectable T-cell response. So that’s why it’s so important to get that second dose.

Dr. Bob Wachter

So several listeners asked the question, we’re all asking, why has the rollout been so slow?

Dr. Paul Offit  18:36

We just didn’t prepare for it. I mean, short, the we were, you got to give this last administration credit for making the vaccine. This was a remarkable achievement, really a remarkable, unanticipated accomplishment to be able to, you know, within 11 months of isolating the virus and genetically sequencing the virus that you could then have two large clinical trials, which showed that the vaccine was highly effective. So they did the vaccine part really well, they just didn’t do the vaccination part well, which meant that while they were manufacturing that vaccine at risk, they were willing to take the risk, we’ll pay hundreds of millions of dollars to manufacture these vaccines, not knowing whether they work not knowing whether they’re say willing to throw out hundreds of millions of doses.

Dr. Paul Offit

While they were doing that. They should have also put in place a public health system which currently doesn’t exist for mass vaccination, just start to put that in place, you know, get these sites ready. In, especially in my state, you know, these, we have in the center of the safeties, the retail pharmacy free zones, very sparsely populated and our Secretary of Health wants to put in their immunization clinics, which requires money, which requires personnel, which needs the federal government to help with and she’s been cleaning for that for the last two months, and is just now starting to be able to get through but it shouldn’t have taken this long.

Dr. Bob Wachter 

Donovan asked, or made the point that Israel appears to have been an all-star here having vaccinated a quarter of its population, how could they do that so quickly and efficiently and what could we learn from them?

Dr. Paul Offit  20:01

that they were much better organized about this, it’s a smaller country. It was a little easier. I mean, we, you know, it’s a federalist system here. We have a lot of different states that all act differently. And I just think that you’re seeing some states get much better now vaccinating others not. I think we’re just going to learn this bit by bit.

Dr. Bob Wachter 

A number of our listeners asked when kids will get vaccinated and how important will it be for the kids to get vaccinated? Or can you get to the state that we all are hoping for in the schools, if the adults are all vaccinated.

Dr. Paul Offit

It’s important for children to be vaccinated. I mean, children can suffer this disease, not commonly, I mean, there’s about I think the people, less than 21 years of age make up about 26% of the population, but only 0.08% of deaths. I mean, those who are in nursing homes, but they can suffer. I mean, we at Children’s Hospital Philadelphia, we have a COVID Ward, which is full of children primarily with, you know, the so called MISC disease, which is this Multi System Inflammatory Disease, they can have severe pneumonia, and they can occasionally die.

Dr. Paul Offit 

Probably a little more at died of this disease and then died typically a flu every year. But you know, we also vaccinate children against flu. And children can transmit the disease and it makes it easy for them to go back to school. So we’re now doing trials in children depends on who’s doing the trial, but some one company is doing this down to two months of age.

Dr. Bob Wachter

And is there any reason to believe that the kids will have a different, the vaccine will work less well or have a different safety profile on kids?

Dr. Paul Offit 

Yeah, I’m not sure they’re going to be efficacy trials, like the trials that were just done for an adult, I think they’re going to be more like immuno bridging trials, where if we see that there’s at least a fairly consistent immune response. Even if it’s not a direct immunological correlate, there’s a consistent immune response, it’s being induced in children at a certain dose, we have sought to do dose ranging trials and children to see what dose works best. And then you get a consistent dose that induces high levels of neutralizing antibodies. I think that’s the way they’re gonna go with that instead of doing efficacy trials as a guess.

Dr. Bob Wachter

We just did a show on the new variants. And obviously, it’s something everyone is concerned about talking about, what is your take on what the variants are going to mean for us in terms of vaccination over the next two or three months? Does it change the need for speed? Does it change the efficacy of the vaccines? How is this all gonna play out to your mind?

Dr. Paul Offit 

Right. So, Coronavirus has mutated, just like all single stranded RNA viruses, it they mutate the good news, they’re actually fairly slow, mutators coronaviruses aren’t fast mutators, like flu, which is a ridiculously fast mutator. And so you’re already starting to see these various viruses like the UK virus, the so called B117 variant, the one that happens when you note that there’s a variant that’s coming up, and we need to be much better at this country of doing sequency than we’ve been.

Dr. Paul Offit

UK is way ahead of us in this, there’s no reason for that we can do this. When you identify a variant, what you need to immediately do is take that variant and then test it in the lab to see whether or two things occur. One, whether people who the series that you take from people who have survived this infection, neutralize that virus, meaning kill the virus in the lab, don’t let it. Those antibodies don’t let that virus infect cells in the laboratory.

Dr. Paul Offit

Then you take antibodies from people who’ve gotten the vaccine, either Pfizer vaccine, Moderna vaccine, to see whether those antibodies also neutralize the virus because that’s the critical question. When people use so called monoclonal antibodies, which just represent recognize one epitopes. It’s very interesting, very interesting. from a scientific point of view, that’s not the information you need initially, do the so-called polyclonal antibodies that are generated by natural infection immunization, neutralized those. So we know that information for the UK strain.Yes, they do. So that variant has not drifted away from the vaccine at all. Then you have this other one, the South African variant, which has a particular mutation.

Dr. Paul Offit 

Which seems to and again, still looking for those data from what I’ve understood, so that we should have those data by tomorrow. But that does seem to lessen to some extent the ability of those so called polyclonal [UNCLEAR] from natural immunization from natural infection or immunization to kill that virus, but it still does kill it. It looks like so it’s not it hasn’t really significantly drifted away from the vaccine yet, but that would be a problem. I mean, think about, you know that we would have to make a whole new vaccine for a virus that circulated isn’t recognized at all by you know, either antibodies generated from natural infection or immunization.

Dr. Paul Offit 

That would be a problem. That’s why we need to look very hard at these things. And that’s why I think it’s a good idea that the government is now going to really restrict access to people in this country. Unless their screen I just wish they did it immediately. I don’t know why we had to wait two weeks.

Dr. Bob Wachter  24:38

Do you think the likeliest outcome let’s say this virus enters or what we see in South Africa is the likeliest outcome that the vaccine doesn’t work or that its effectiveness goes from 95% to 75%

Dr. Paul Offit

I think the latter. Usually I think that would be what happens but it may eventually move to being less and less effective.

Dr. Bob Wachter 

Speaking of 75, we have a couple of other vaccine prospects out there. First of all, what do you think’s likely to happen with them? And second of all, if they turn out to be less efficacious than the Pfizer and Moderna, how is that going to work in terms of the rollout? Right now, you know, I got mine and happened to be Pfizer day. And if I’d gotten it across town at UCSF, I would have gotten Moderna. And nobody pays any attention because they appear to be essentially the same. But if you start having vaccines out there, that are demonstrably less effective, how’s that gonna play out?

Dr. Paul Offit

So there are two other vaccines that seem to be closest one is Johnson and Johnson’s vaccine, which is this replication defective antivirus type 26 vector, which does the same thing as mRNA, in a sense, except it uses instead of using basically a naked piece of messenger RNA, which codes for that protein that’s by protein, you actually put the genetic material into a virus, which then enters the cell and can make that protein. So your again, your body makes the spike protein, your body makes antibodies to spike protein. If it’s 70% effective or 80% effective. That’s close enough. You know, it seems to me that because at least for example, a Johnson and Johnson’s vaccine, you have some commercial experience.

Dr. Paul Offit  26:06

I mean, that was the vaccine that was used to stop the Ebola epidemic in West Africa. So you’ve been in a lot of people already, at least that type of vaccine, the mRNA vaccines are, you know, this is a novel strategy. There is no commercial equivalent for that, coming into this particular virus. And you know, you don’t know, I mean, you still want to see what the safety issues are, there are, you know, transit, if it’s a single dose of vaccine, which hopefully will be true for the Johnson Johnson vaccine, that’s a significant advantage.

Dr. Paul Offit 

And for the UK vaccine, we’ll see, I doubt that they would be much less than 70% effective, but we’ll see. I mean, time will tell. Also, again, you want it to be effective against moderate to severe disease, I mean, and I want to make sure that when those data are presented to our committee, the FDA vaccine Advisory Committee, that’s the piece of information I want, how effective isn’t at keeping you out of the hospital and keeping you from dying?

Dr. Bob Wachter

So that’s the number you look at more than the overall prevention of cases, it’s how likely is it that you’re going to get really sick and die or go to the ICU? And so you can have a 70% effective vaccine, but one that’s 90% effective in preventing severe cases, and that’s a more meaningful number to you?

Dr. Paul Offit 

Yes.

Dr. Bob Wachter 

Yeah. Okay. You’re thinking about the herd immunity threshold, and your numbers are more optimistic than others I’ve heard, than what Dr. Fauci has been talking about. So take us through what you think that is, maybe a little bit on when you think we will reach it assuming that the vaccine rollout picks up speed a little bit? How do you think about that number?

Dr. Paul Offit 

Right, well, first of all, certain percentage of the population is already immune. And the question is, what percent? You know, we report out that there’s about 20 million people who’ve been affected in the United States, but those are people who’ve just been tested to be infected, if you do antibody surveillance state is that’s a much better way of figuring out how many people have really been infected. And when you do that, you know that that number, that 20 million numbers up by a factor of at least three, and I think it’s 23 million, so it’s probably more like 65-70 million people. So you’re already talking about 20% of the US population that’s already immune, that when they get infected or exposed to this virus, again, they’re unlikely to get serious infection. So you’re building on that.

Dr. Paul Offit  28:05

And then you have a vaccine, at least two vaccines right now that are 95%. Effective, that’s really good. I mean, if you just sort of do the math on what as the formula that you use to figure this out, then you would say that we would need to vaccinate 55% of the population. But that also assumes that it’s protective against contagiousness, which we don’t quite know yet. We know how effective it is against disease, but you can still be asymptomatic, infected and not have symptoms and still shed virus. So we’ll see. But I think if you can get to 60% of the population being immunized, knowing the 20% is already there.

Dr. Paul Offit 

Although Remember, you’re still immunizing at least 20% of the people you’re immunizing or have already been infected. Because we’re not trying to separate out people who have or haven’t been infected. So that sort of knocks it down. But if we can vaccinate 2 million people a day, and I think we can get there, we’re already about it a million people a day, we have a we have an administration that cares, we have two more vaccines that are likely to come onto the market, I think we’re getting better and better at mass immunizing and the weather will get warmer. All of that I think works for you in terms of decreasing this. .

Dr. Paul Offit 

So I think that things are it’s not going to be all at once. I think what will happen is, I think starting by the end of February, I’m going to make a prediction, even knowing this is being recorded. I think that starting by the end of February, you’re going to start to see as weather gets warmer vaccines get out there. And people, some people continue to be infected, but now we’re immune and hopefully still alive, then you’ll see a gradual diminution, in cases, hospitalizations, deaths. And so by summer that we I’m going to predict that we will be largely on top of this pandemic.

Dr. Bob Wachter 

Yeah, a lot of parts are very hopeful, is your sense of the vaccine rollout was part Trump administration and part this is just harder than we thought and that we we’ll get a hand we’ll turn this around in the next month or two?

Dr. Paul Offit 

I think it’s both Yeah. I think that the Trump administration didn’t get much attention to this, it’s too bad and it is hard. It’s not the public health, we’re trying to sort of regenerate a different public health system than the one we have.

Dr. Bob Wachter  30:05

Yeah. Well, as they say on Twitter, I want to put a pin in that last answer, because it’s extraordinarily hopeful. I mean, if you really do believe, first of all these vaccines are miraculously effective. And if you believe that the slow roll out was just a glitch, and maybe the last problems of the Trump administration, we could find ourselves back to a really pretty good place by the summer, early fall, which is terrific news. Paul, thank you for helping to educate all of us about this incredibly important and interesting issue. And it’s nice to leave on that hopeful note. Really appreciate it.

Dr. Paul Offit 

Thank you. I’m just gonna be like a whole day till I see it. Right. And I’ll see you again till tomorrow.

Dr. Bob Wachter

Yeah, that’s right. We have another one tomorrow.

Dr. Paul Offit 

That was terrific segment with Paul, I learned a ton about vaccines. It’s incredibly important issue. And unbelievably interesting, if you think about it. Just as interesting as the ethical dimensions of vaccination. And for that we will hear after the break from Ruth Faden from Johns Hopkins. Look forward to it.

Dr. Paul Offit 

Ruth, I haven’t spoken to you for 30 years.

Dr. Ruth Faden 

It could be, which is really scary, right? We were not like a diaper.

Dr. Bob Wachter

Yeah. The only good part I can tell you now of being this old is that their reaction to the vaccine is pretty benign.

Dr. Ruth Faden 

Yeah, and that being able to get one.

Dr. Bob Wachter 

Right. There’s that too. Exactly.

Dr. Ruth Faden

Let us not undersell that one.

Dr. Bob Wachter 

Yeah.

Dr. Ruth Faden 

Good to see you again. After all these years.

Dr. Bob Wachter 

Thank you. Thrilled you could be on it seems like the ethical issues around COVID are coming fast and furious, but probably faster and furious, or as we’ve gotten into the vaccine stage. So let me start with this. It strikes me as an unusual ethical problem. A little different than figuring out who gets the liver transplant or even who gets the last ICU bed, in that it’s a scarce high demand resource, but one that whose supply is going to open up in the next who knows 2,3,4 months. So, give us your ethical framework for even thinking through this problem.

Dr. Ruth Faden  32:23

Yeah, sure. No, you’re quite right, Bob, it is different, right? There are features in this context is that are relevantly different from other short supply, even in the context of this pandemic. So it is different than the ICU or the ventilator and how we figure that out. And it’s different in high income countries than it is in low- and middle-income countries. So in high income countries, you’re exactly right, I always have to remind people, we are talking about who gets it first, or who gets it now, we are not talking about who gets it ever. Whereas in low-income countries increasingly, and if anybody wants to ask a question about that, I am really happy to talk about it. We are looking like it may be who gets it never.

Dr. Ruth Faden 

So that’s a whole other kind of dynamic, but in the US and in other high-income countries that have managed to secure at least by pre commitment, a substantial amount of vaccine. We are looking at trying to figure out the answer to the question, Who should get it now? Right? Who should get it first was what we did an abstract. Now we’re asking who should get it now. And we’re basically trying to balance the different values that we want to secure through a vaccination program. Obviously, we want to reduce the public health burden of this disease as quickly as possible. So we want to reduce severe disease and death.

Dr. Ruth Faden 

That’s a clearly high priority. We also want to do this in a way that is equitable against a backdrop or in a country that is experiencing profound structural injustice with respect to ethnic minorities, people of color, low-income people and people with disabilities. So we have that problem as well. They are these groups are disproportionately as everybody I’m sure, listening knows, burdened more by this pandemic. How do we distribute the vaccine in a way that it very least, does not make those disparities that are unjust, already worse. And should vaccines be used to reduce the inequities.

Dr. Ruth Faden

And finally, we are also thinking about the people to whom we owe special bits of gratitude because they have taken on risks and burdens because they’ve had no choice but to take on burdens, so that the rest of us could have easier lives, safer lives, a better chance of surviving and living well, and here’s where we talk about our essential workforces. So those are the three things we’re trying to kind of keep in mind as we make these decisions.

Dr. Bob Wachter 

Right. And the fundamental tension is that they don’t all line up in some ways. They’re in conflict with one another. So how do you decide on who comes first?

Dr. Ruth Faden  34:57

Yeah, right. So they can be, right? And the challenges is trying to figure out how to minimize the conflict and to think about where we are in the moment. So it matters a lot. What where we are in the pandemic at the time at which we’re making these allocative decisions, what the supply looks like. And what the pace of vaccination actually is, how good are we at getting vaccines out? So in prospect, before we had vaccine, we were developing the vaccine. But before we had any, we were engaged in numerous planning efforts nationally, at the state level, globally, to set up kind of roadmaps, prioritization roadmaps based on ethics frameworks about who should go first, second, third, and we have all those phases, and everyone is familiar with who has been following, for example, what the CDC has been doing or what your own state has been doing, what phase in mind.

Dr. Ruth Faden 

As we go from in prospect to actual vaccine, we’re beginning to see how some of those fine-grained prioritization schemes are collapsing on their own weight. They’re too complicated. They’re too demanding of a certain sort of system that doesn’t exist and may in fact, become very inequitable in their very implementation because of who can get on these websites. And who can figure out how to not so much game the system is used the system, right? So as we’re putting this all together, the name of the game in my mind right now is to be nimble, to be responsive to the programmatic realities. And to keep those three priorities in mind.

Dr. Ruth Faden  36:35

So I don’t mean to like, sidestep your question, I think we go to kind of concrete examples of where you can try to get to both as best as you can, the equity and the efficiency in your view, like where the equity and the reducing severe disease and death. But the trick now is to answer Where should we go now, given the situation we’re in now, you know, what do we do at this point that is ethically most defensible, which may not have been what we thought was going to make the most ethics good says. A month ago, when we were kind of working at this as an abstract plan.

Dr. Bob Wachter 

Okay, Ruth, we’ve got a lot of listener questions about personal ethics, and particularly the issue of Line Jumping. And so let me ask one, this came from Debbie Ingraham “with no documentation required in my state, there are reports of young healthy people jumping the line, getting vaccinated, while family members of parents in their 80s can’t get appointments, or get the elderly vaccinated, what is being done and what should be done about Line Jumping?”

Dr. Ruth Faden 

Okay, so Line Jumping is, as Debbie describes, it is clearly wrong. Right? If someone is using connections, if someone is using privilege, if someone is using just super great skills at crowdsourcing, that’s wrong, right? Unless you otherwise qualify for a prioritized group that’s been identified and sort of cleared for vaccination by your state’s prioritization schema. So it’s flat out, it’s wrong. I want to just make sure that we distinguish that from the situation that is popping up where people who otherwise don’t qualify are queuing up at the end of the day at places that are basically saying, you know what, we have unused.

Dr. Ruth Faden  38:15

You know, we’re gonna have 5,6,7,8, whatever it is doses unused, maybe at eight, nine o’clock at night, and we stopped vaccinating. And you can come in first come first serve that, of course, makes good public health sets. We don’t want to waste, you know, a single dose of this vaccine right now ever, but we certainly don’t want to do it now. Since that’s not Line Jumping. That’s responding to a practical constraint, right? And being responsive. That’s fine.

Dr. Bob Wachter 

Got it. Yeah. A couple of questions about incentives and fairness. Jane Conrad in Maine said, “Here I am in Maine with among the lowest COVID rates in the country,” and at least her impression was more vaccines are being sent to states with higher rates. I’m not sure that’s true. It may just be that they’re bigger states. But she said “I object to states like and she named a few, I won’t name them. Getting more vaccine than states that have managed the crisis better.” So in other words, is there, are we created an incentive for states that have not done this as well as states that have?

Dr. Ruth Faden 

So I’m not sure that my understanding is that the vaccine is being released, at least formally being released proportional to the population size. So states are supposed to be getting vaccine in relation to the size of their population. I don’t know for sure if that’s how it’s happening. And it’s possible that it’s feeling like something other than that is happening in Maine, I understand the concern. So you’ve got two tensions, right? You’ve got the tension between one sense of fairness that says let’s not in, you know, let’s not punish the places where people have been really good about practicing non pharmaceutical interventions.

Dr. Ruth Faden 

Like mass wearing and physical distancing. And so their rates are down. Let’s not punish those people, right? And give vaccine where the rates are higher. On the other hand, we’re in a public health crisis, we have so many people dying at these extraordinary rates and hospitals closing up. And it does make good public health sense to allocate vaccine, where you have the greatest numbers of deaths, or where you can anticipate the pandemic is going the most badly. So it is attention.

Dr. Bob Wachter  40:23

Is that a legitimate tension that if you’re allocating vaccines to the places with the most deaths? I guess the implication of the question is that people have not been acting, as well as we have been acting in Maine.

Dr. Ruth Faden

Yeah, that’s the implication. But there are all kinds of reasons, right? That can account for why you see more serious disease and death in some parts of the country than others, not the least of which is that not everybody can physically distance not everybody can work from home, not everybody has space. And so that’s a big issue. Also comorbidities and healthier parts of the country, you’re seeing less severe disease and death and parts of the country where there are fewer, proportionally fewer older people, you’re seeing less than, you know, less severe disease and death. So it’s a complicated, it’s a complicated picture. I do think that what is most likely to happen is that the vaccine will go out proportional to population, although good arguments can be made, why that should not happen, it is probably politically, what is most likely to continue to happen.

Dr. Bob Wachter 

One of the most interesting aspects of vaccination to me is we find ourselves now in this position where there’s nowhere near enough supply and tremendous demand. And in a few months, we’ll toggle to this other world where there’s enough supply, and we’re trying to get people to take the vaccine. So let’s talk about a couple of the ethical issues that are sure to arise. And one of them is people have talked about paying people to be vaccinated or otherwise providing incentives. What do you what do you think of that?

Dr. Ruth Faden

Yeah, so I think it’s a very dangerous way to go. There’s a whole literature or world called Conditional Cash Payments, where in various, especially development projects, for example, people are paid to incentivize them to do things like send their children to school, or for that matter, get vaccinated, and it sometimes works. And sometimes it doesn’t. And when it doesn’t, what happens is when it is a couple of things, for one thing, it can there’s an old sort of social psychology, classic kind of aphorism that you can undermine intrinsic motivation with extrinsic motivation. So if you pay somebody to get vaccinated, and they get vaccinated, right? Let’s say you do that for dose one, you do want them to be vaccinated again in dose two.

Dr. Ruth Faden  42:37

But then you say, Alright, we’re not going to pay you again, there’s like, Well, why should I do it, I did it for the money, and now you’re not paying me. So sort of the value of getting vaccinated itself, because you should do it because it could save your life should be incentive enough. Similarly, there is a concern that even if it doesn’t undermine motivation, or you have enough money to pay everybody from both doses, assuming we still keep with two doses, what happens with other vaccinations are people now going to feel like they should be paid for the flu vaccine, and so on. And finally, there is we have enough trouble with distrust, and sort of reservation.

Dr. Ruth Faden 

And so for all of this, we don’t really know for sure, but these are sort of worries. And this related worry is if we are paying people who are already suspicious about why I should take this vaccine, it now starts to take on arguably another sort of nefarious overtone, this must be something that these people want us to do so badly that they’re going to pay us rather than a simple straight message, which is these are great vaccines that can literally save your life and give you a ticket to more joy in your life. At the same time, you know, along the way.

Dr. Bob Wachter

I guess it partly gets at one of the conundrums in in vaccination, which is part of the motivation is to you personally. And part of the motivation is to the community at large. And this quickly comes up in low-risk groups. So if you would say, why would I need to pay someone there? There’s so much intrinsic motivation to get vaccinated, of course, you’re going to want it. But there are other reasons we want a healthy 25-year-old to be vaccinated that they help the community be healthier.

Dr. Ruth Faden  44:13

Yeah. So let’s get there. Right? First, right now I want to focus on everybody for whom it can honestly be said, right? And that’s a lot of people that if you get vaccinated, you are reducing a significant threat to your life. Right? And I’m not supporting the notion of ultimately wanting to go to something like you know, the much-vaunted herd immunity but I think right now we, the focus should be direct protection, we should be able to sell this vaccine to people who are going to be directly benefited on the argument that they will be directly benefited and let me just say too.

Dr. Ruth Faden 

That it’s not just that I’m going to be less likely to get seriously ill. In fact, I’m going to probably not going to get seriously ill at all given the vaccines that we have, which are so amazingly good. But also, I’ll be able to have a little bit of my life back, I’ll be able to be with my friends, I’ll be able to see my family, I’ll be able to, you know, just not live in so much concern. And that’s worth a lot to people too. I hope.

Dr. Bob Wachter 

Can you address the issue of immunity passports and sort of not paying people but making them have a vaccination to get into school, go at an airplane, get into the workplace?

Dr. Ruth Faden 

Yeah. So I think there’s a lot of good conversation and discussion at heart thinking going on right now about, you know, immunity well, so for vaccination passports, I think we’d be clear at this point in how that should work. And certainly for traveling, this is where a lot of it comes up as some sort of first point, there’s a tremendous amount of attention being paid to how vaccination can be used to make it possible for industries like the airline industry to resume and become robust. And economically solvent again, train, travel, tourism, all of that. This is sort of the next step up over the sort of rules that lots of states have that say.

Dr. Ruth Faden  46:07

For example, you need to show that you have tested negative between x and now we have to show that if you’re traveling from abroad, that you have been tested and tested negative and the preceding x days before you can get on a flight to go to the US that kind of thing. So that may be the first place where it shows up. And a lot of people value travel, of course. But let me just close with a deeply about recognizing how that’s gonna land in the context of a global situation in which very few people outside of high-income countries are going to be able to put down that vaccination passport. And that’s a deep, deep worry from the standpoint of global equity, but also from the standpoint of the global economy.

Dr. Bob Wachter 

Yeah, that’s a really good point. Well, thank you, Ruth, I think we covered a lot of ground. There’s such an incredibly interesting and complex issue. And just when you think you’ve gotten your arms around it, you come up with a new wrinkle, and you have to try to grapple with that one.

Dr. Ruth Faden

Pretty much. Thank you for the great questions.

Dr. Bob Wachter 

All right. Appreciate it.

Dr. Ruth Faden 

Take care.

Dr. Bob Wachter 

Thanks to Paul Offit, to Ruth Faden, and to my wife Katie, for a terrific far-ranging episode. We’ve covered a lot of ground as it relates to the vaccines. And as I said, I’m pretty hopeful. I think we’re going to be turning a quarter and get more people vaccinated, more people safe and that will begin bending the curve of the pandemic. A lot of great shows in the works. Don Berwick, probably the leading light in the entire world in the fields of quality and patient safety. He ran Medicare and Medicaid before Andy did. Will give us his perspective, will speak to Julie Gerberding. Julie was head of the CDC for nearly a decade, and then ran the vaccine development process for Merck so she understand some of the key issues and COVID from a couple of different angles.

Dr. Bob Wachter  48:10

And finally, we’ll speak to Atul Gawande. Atul is just finishing service on President Biden’s COVID Task Force. You know, Atul is an amazing surgeon, a prolific author, Atul have many interesting things to talk about. Come back and join us for all of those conversations. Until then, stay safe and look forward to speaking with you soon.

CREDITS

We’re a production of Lemonada Media. Kryssy Pease and Alex McOwen produced our show. Our mix is by Ivan Kuraev. Jessica Cordova Kramer and Stephanie Wittels Wachs executive produced the show. Our theme was composed by Dan Molad and Oliver Hill and additional music by Ivan Kuraev. You can find out more about our show on social media at @InTheBubblePod. Until next time, stay safe and stay sane. Thanks so much for listening.

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