Have We Set Unrealistic Goals for the End of the Pandemic?

John Whyte, MD; Celine Gounder, MD

Disclosures

September 09, 2021

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JOHN WHYTE: Welcome, everyone. We thought a few months ago we might be seeing the end of the pandemic, or at least it was on the road to the end of the pandemic. But today, we're concerned about how this pandemic’s going to end and when is it going to end.

There is a great piece in The Atlantic a few days ago entitled “Americans Are Losing Sight of the Pandemic Endgame.” And my guest today is the author of that essay, Dr. Celine Gounder, an infectious disease specialist and epidemiologist at NYU Grossman School of Medicine and Bellevue Hospital and host of the Epidemic podcast. Dr. Gounder, thanks for joining me.

CELINE GOUNDER: It's a pleasure to be here, John.

JOHN WHYTE: You know I really was struck by your messaging in this piece. And I want to read a quote if I may. You say, "in a scenario in which some people might still become infected but very few get seriously ill or hospitalized or die, We can move from a public health emergency to a more normal life." Have we set unrealistic goals in terms of how this pandemic can end?

CELINE GOUNDER: I think unfortunately, John, we have. I think we have set unrealistic goals in terms of it's only reopening the economy or it's only eliminating all transmission and infection. I think we've also had unrealistic goals or expectations of the tools that we have at our disposal.

I think many people figured that once we had vaccines, everyone would get vaccinated and then the pandemic would end. And if prior pandemics, epidemics are any lesson, any guide here, we know that that is not likely to be the case. Not everybody is vaccinated all at once. And even if you could accomplish that, there are limitations to what vaccines can do.

JOHN WHYTE: You referenced that when you kind of allude to the fact that we got it wrong from the very beginning, when we talked about what the data are for vaccines and what we use them for, and now it's kind of come around again in the context of boosters. And you point out how vaccines aren't designed to eliminate all infections and that we're too focused on all infections, even mild cases. What should the messaging be to our listeners who quite honestly are getting confused? Who needs boosters? When needs booster?

We seem to be ahead of the science. Some people look at the information and say, “Hey, Dr. Gounder, I told you vaccines don't work. That's why we need boosters.”

Others are looking at it and saying, “I need a booster now.” Is it 6 months? Is it 8 months? Is it 3 months? What is your advice? You've been involved with the pandemic from the very beginning in terms of how should people think about vaccines and how should they think about boosters.

CELINE GOUNDER: Well, I think one really important message about vaccines is vaccines work best at a community level. It's really an ecosystem of people in which the virus is spreading, and you need to get community immunity, not necessarily herd immunity, but some level of community immunity to really curb the spread. And so vaccinating other people around you will help protect you.

I think it's also important to understand that vaccines work best at inducing what we call systemic immunity. So that's immunity in your internal organs and your bloodstream, not so much on mucosal surfaces, so like the inside of your nose your throat, your mouth. And so that means that you could still get an infection in your upper airway, but it doesn't necessarily go down into your lungs and into other internal organs.

And that's where people get really sick. When SARS-CoV-2 infects the lungs and other organs, when their oxygen levels drop where they end up on a ventilator, that is true COVID disease. That is what puts you in the hospital and may cause you to die.

And so I think those are a couple of things that really people need to understand and realize that vaccines are not going, number one, to stop all transmission. However, number two, the vaccines are working really well. They are working as injectable vaccines do, in that they are inducing very good immunity to prevent disease, hospitalization, and death.

Some of the recent data out of the CDC, for example, show that in New York state, the vaccines remain 95% effective in preventing hospitalization. So that is excellent. But it also makes me think all of this about sort of those yearly conversations we have with patients in the clinic about getting their flu shot.

Flu shots are a great example. They don't prevent all infection, but they do a good job of preventing people from landing in the hospital really sick. And I think this is going to be an ongoing slog of sorts where, just like we have those very difficult discussions every year with patients about getting a flu shot, I think getting the remainder of people who have not yet gotten a COVID vaccine vaccinated is going to be an ongoing challenge.

JOHN WHYTE: So is that the priority, and then we focus on boosters? The data on boosters, the media and some scientists tend to aggregate the data, meaning they're lumping all infections. And you kind of have to dig in a little deeper to break out mild, moderate cases versus severe.

So we're in the midst now of thinking about boosters. What do you advise our listeners, our physicians on Medscape: How should they think about boosters for a population other than that that's immunocompromised? We have good data on immunocompromised in terms of mounting an immune response. But now we're in the midst of talking about the general population. What's your framework for evaluating it?

CELINE GOUNDER: Yeah, so you want to look really at severe disease, hospitalization, and death. That is the most critical outcome to be looking at here. And with respect to the immunocompromised, the reason that they need an additional dose is because they don't respond very well to the vaccines from the beginning. It's not that they necessarily have waning immunity. It's that they don't have immunity from the beginning after vaccination.

And so you're giving them an additional opportunity to at least get some of them to become immune. And even then, to be clear, not everybody who gets three doses of vaccine, who's immunocompromised is then immune. And so they still need to be taking additional precautions.

To a slightly lesser degree, you see a similar effect in the elderly, where they have what we call immune senescence, where their immune systems just aren't what they were at the age of 20. When you're 80, everything is sort of getting old and tired and falling apart, including your immune system. And so people who are elderly may benefit from an additional dose, not necessarily because of waning immunity, but because they may not have responded as well in the first place.

And then finally, the other group where we have clear evidence that people would benefit from an additional dose of vaccine is in nursing homes. And that's the setting in which we have seen breakthrough infections turn bad, so to speak, where breakthrough infections progress on to severe disease, hospitalization, and death. And that's for a couple of reasons.

One, nursing homes do have a concentration of elderly people, people with underlying chronic medical conditions, including immunocompromising conditions. And then also the setup of a nursing home, you have a lot of people close together. And what we've seen in those settings is it's typically unvaccinated caregivers or visitors who are getting infected in the community and who are then bringing the virus in to these nursing homes. And so on the one hand, would nursing home residents benefit from an additional dose?

Yes, probably. That's a good step to be taking. But even more important is making sure that their caregivers are vaccinated, their visitors are vaccinated, and that their caregivers and visitors are also masking up to really protect them further.

JOHN WHYTE: You talk about the endgame. What's the conversation we're going to have 6 months from now?

CELINE GOUNDER: So we're not going to be able to eliminate COVID. And I think people were hoping this is just going to go away and then we can get back to life the way it was before. What we've seen with other coronaviruses that have become endemic, and a great example of this is coronavirus OC-43, also known as the Russian flu, which emerged into human populations in the 1800s. That eventually became endemic, meaning it's spreading at some low level in the community really all the time, perhaps more during the cough and cold/flu season.

The question is: How can you convert this into something that is milder, that is not killing people? And that is what we saw with OC-43, is that eventually, you have populations develop immunity. In that case, it was natural immunity over time where a lot of people died. And that was before we had sophisticated hospitals, that was before we had ventilators.

And we don't have the kinds of data on those deaths and that morbidity from the 1800s that we do about what's happening today. But that said, we have tools today that can help us fast-forward that process and prevent people from dying in the process where you are creating that community immunity, where eventually there will be a stabilization. And yeah, people may still get cough, colds from COVID, but they won't be ending up in the hospital, they won't be dying, and that's really what's critical here is getting us to that point.

JOHN WHYTE: You know, you wrote this piece in The Atlantic, in some ways to reframe the debate, and clearly you're an excellent communicator. I want to ask you to grade our public health agencies in terms of how well they've been communicating around the pandemic. We'd all agree well-intentioned, want to protect people. What grade would you give them?

CELINE GOUNDER: I think that's a really tough one because frankly, I don't think anyone would have gotten an A-plus in this situation. I think it is impossible to balance all of the different interests, the politics, and the shifting science perfectly at all times. So I think that is really important to understand, and I think there's been a bit too much, frankly; in particular, CDC-bashing and FDA-bashing.

I think people have had really unreasonable expectations about the FDA. The FDA knows the importance of the COVID vaccines. They know that this is something that needs to be -- that the vaccines need to be approved as quickly as possible.

Right now, there's a lot of pressure on the FDA to issue emergency use authorization, for example, for vaccines for children under 12. But then if you do that too quickly and the process is compromised, that will backfire, and then people won't get vaccinated. So you really need to make sure that these processes are done properly, that the science is vetted properly.

And that frankly takes time. You can't, for example, get 6 months of follow-up or 3 months of follow-up in shorter than that period of time. It's what the science mandates.

With respect to the CDC, I think it's been similarly complicated to balance what has been pressure from certain politicians saying you're not reopening, you're not relaxing on certain mitigation measures quickly enough. But then, when the science or the epidemiology, the situation on the ground really mandates tightening up again, people don't want to go back. And so then, what do you do? Do you just say, “You know what, we can anticipate things are going to get worse again, we should just continue remaining tight on things like masking and social distancing for example indefinitely until things really do subside, or are we able, as a society, to tighten and loosen with the epidemiology”? And I think that's more of a sociological question than it is truly a question about how the CDC communicates.

JOHN WHYTE: Are you still going to be hosting your podcast 6 months from now?

CELINE GOUNDER: We will be releasing a different season, at that point in time, that is more of a historical season focused on smallpox eradication. And so this is the only human disease that's ever been eradicated, and looking really at some of the lessons that can be learned from that prior program and applied to the present day. And unfortunately, we find ourselves learning and relearning and forgetting and then having to rediscover some of these same lessons.

JOHN WHYTE: Tell our viewers where they can find your podcast.

CELINE GOUNDER: Yes. Epidemic is available on Apple, Google, Spotify, all the usual places where you find your podcasts.

JOHN WHYTE: Dr. Gounder, I want to thank you for being a voice throughout this pandemic, trying to help educate our physician colleagues as well as the public on what they need to do to protect themselves, protect their family, and protect their community.

CELINE GOUNDER: It's my pleasure.

This interview originally appeared on WebMD on September 9, 2021

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