Dr. Topol Provides Answers About Boosters, Vaccination for Kids, and Antiviral Treatments

John Whyte, MD; Eric Topol, MD


October 07, 2021

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JOHN WHYTE: Welcome, everyone. You're watching Coronavirus in Context. I'm Dr. John White, the chief medical officer at WebMD.

So who exactly needs boosters, and when? When are we actually going to see a vaccine for kids? And should you wait as a parent for a little while once they're available?

And then, what's the timeline for antivirals? When are we going to get more effective treatments? Well, joining me today to answer all these questions that I know are on your mind, you've been writing in, is my good friend and the editor-in-chief of Medscape, Dr. Eric Topol. Dr. Topol, it's great to see you again.

ERIC TOPOL: Great to be with you, John.

JOHN WHYTE: I want to start off with boosters. And can you break it down for our audience in terms of who really needs them: Is it 8 months? Is it 6 months? We've heard different things. What's the science that can guide listeners to say, “Hey, I need to get a booster”?

ERIC TOPOL: All right. Well, there's hard data, there's only one place and one vaccine, which is Israel. It's over 1.1 million Israelis over age 60, 60 or above, and they had unequivocal benefit from the booster, or the third shot. The waning of the benefit of the vaccine started around 4½, 5 months.

Clearly, it was there at 6 months and just kept growing. So that group, 60 and older, irrespective of whether there's other health issues, deserves to get a third shot of Pfizer. Now, the question is, both other vaccines, like Moderna or J&J, and also other age groups and other indications beyond just 60 and above.

We have several pieces of data about Moderna and J&J that shows that that's going to need a booster at some point. And in fact, the problem is there's no Israel out there to give us the data. So we should have it in the U.S., and we don't. And that's a problem. And we have so many people with Moderna and J&J vaccines.

There was, as you know, John, a MMWR [Morbidity and Mortality Weekly Report] that showed the J&J antibodies after just a matter of weeks from the vaccine. And they were really quite low, compared to the Moderna and Pfizer. So I would think we should have called out for the people who got the one-and-done to get the second shot, whether it's either Pfizer or Moderna.

We have these purists that want to wait for this data that we're not going to have for such a long time. The problem here is we're leaving people vulnerable.


ERIC TOPOL: All of this was a third-shot story from the beginning. The only question was, when would the third shot be necessary?


ERIC TOPOL: That I think it's becoming increasingly clear that all these vaccines, whether it's 5 months, 7 or 8 months, a third shot is going to be part of the program to get the full vaccine effectiveness. I think that's where we're head --

JOHN WHYTE: Yeah, but is there going to be a fourth shot, a fifth shot, a sixth shot? I mean, does it stop at three?

ERIC TOPOL: I hope not. But I think the reality is that we're relying too much on neutralizing antibodies to carry us through, particularly this Delta period where it's so hyper-infectious. So it's a perfect storm. You have both the waning of time, then you have this hyper-transmissible variant.

Now once we get down to low circulating levels of virus, which I hope we'll get in the near term, then this won't be as significant a problem. Now, that also will have an influence on subsequent boosters. If we achieve containment, the utility of boosters, once a year let's say, will be of less significance.

Plus, there's a possibility that we get a much better memory. That is because the spacing in the U.S. was so limited. That is, 3 weeks for Pfizer, 4 weeks for Moderna. It should have been at least 6 to 8 weeks. So if we start the idea that we're going to get a far better memory of B and T cells, that might help prevent the need for fourth and fifth shots subsequently.

JOHN WHYTE: All right. Well, let's talk about what other people are talking about. And what they're talking about is, I got Moderna, I got J&J, so can I get Pfizer in San Francisco? Some other studies have allowed it. Some experts are suggesting it actually might be a good idea if you got Moderna and J&J to actually get a different vaccine.

And as you point out, there are the purists out there saying, “Oh, no, we have to wait for the data. No mixing and matching.” What's your advice to folks that are listening and that are worried?

ERIC TOPOL: I wish we had more and better data. So we do have for AstraZeneca, which is a close cousin to the Johnson and Johnson. And there, if you had that vaccine, the adenoviral vector, and then you've got an mRNA vaccine, either Moderna or Pfizer, the immune response was the best we could get from any combinations of vaccines, including two mRNA vaccines or two AstraZeneca. So if you extrapolate that, I do agree that if you had J&J, you really -- it would be wise to get a Pfizer or Moderna as your second shot.

JOHN WHYTE: What about if you got Moderna?

ERIC TOPOL: Yeah, if you got Moderna, I think, it doesn't probably matter. I mean, remember, you're well aware of the dose of the mRNA is triple in the Moderna as compared to Pfizer.


ERIC TOPOL: Are actually a little bit more than that. So if you get Pfizer, except for that dose and the spacing, it's pretty close to interchangeable. I can't imagine getting the shot that doesn't follow the lane of Moderna or Pfizer makes that big a deal. But the booster that Moderna has applied for when it formally is EU aid is for 50, half the dose of what it used --

JOHN WHYTE: A lower dose, right.

ERIC TOPOL: Yeah. So that may reduce the side effects, which initially, there was somewhat increased side effects with Moderna as compared to Pfizer.

JOHN WHYTE: But here's where the confusion that I hope you can help clarify for folks: So we're saying folks need boosters. Then we have the CDC director say walk, not run, to get a booster, because you're protected from severe disease. And some will argue that's what vaccinations really are supposed to do.

So how important is it to get it at 6 months? Can you wait 9 months, a year? I mean, it should it be on your priority list to do this fall and winter.

ERIC TOPOL: If you're 60 and over, I would say it should be on your priority list to do as you approach 6 months. Because the longer you wait, the more vulnerable. That is, if you're out and about, you're going to have some exposure. The more exposures you have, ultimately, it's cumulative in terms of the risk of the infection.

The point here is that this is the ultimate, that is, prevention of hospitalizations. This is not just preventing symptomatic infections, the severe illness. So that's where the older age group, it's really important short of age 60. Then we're talking about infections, symptomatic infection. The chance that you're going to really block hospitalizations, at least from the data we have right now, is not nearly as impressive.

JOHN WHYTE: OK. I want to move to kids 5 to 12. That's what everyone is talking about as well. And I'm not going to ask you when you think it's going to be authorized. What I want to talk about what we know so far, and we don't have all the information.

But we know it's roughly 2,200 kids in that entire age range of 5 to 12. So not a lot of kids studied over 2 months. How concerned are you about do we have enough data in terms of looking at safety and efficacy for kids 5 through 11?

ERIC TOPOL: Yeah, so we're talking about the trial of Pfizer, which used a third of the dose as in adults and teens. So it's instead of 30 micrograms, it's 10 micrograms. Now, it was a 2-to-1 randomization, so two-thirds of the 2,200, or back in 1,500 children, got the vaccine.

So what can you say about that? Well, there was a nice antibody response. So that's good. There were no significant safety problems that were encountered. That's good. You can't really talk about rare side effects. So we saw in teens the myocarditis popped up in one in tens of thousands of kids. And we can't really say that much, because you only have 1,500 as a denominator.

Most likely, though, because these doses are so low, already we started with a vaccine that had much lower dose than Moderna. Now, we've taken one-third of that. So the chances of getting these rare side effects are low.

But we'll know much more once that program gets going, because very quickly, parents are very eager to get their kids vaccinated so they don't have problems with school. And we'll within weeks if there's going to be some rare side effect, if it's going to crop up. I doubt it, but it's possible.

JOHN WHYTE: But what do you do for an 11½-year-old, right? So the 12-year-old is getting the full dose that every adult got as part of the Pfizer. Yet they're getting a third of the dose, in theory, depending upon what happens with authorization or approval, of someone 6 months older than they are?

ERIC TOPOL: Yeah, well, good question. I mean, you go with the plan. The plan is that you get a good immune response, and it's probably good enough. I think, we always learn more. You made a very astute qualifier about the 2 months.

That is, these data are 2 months, just like the initial vaccines for adults. And that we'll only learn about whether that dose is short for the 11½-year-old as we look at data 6 months and a year from now. So it's hard to know.

JOHN WHYTE: But the trial for adults was around 40,000 people around the world, and multiple trials were done. We're talking about 2,200 kids. We were talking before we came on about MMWR, Morbidity and Mortality Weekly Report, that the CDC puts out -- and we'll show it on screen -- where it talks about hospitalizations in kids and adolescents throughout the pandemic. It's been in the news, especially about the increase in the number of hospitalizations for kids through the past couple of months.

But the reality is, when we look at the graph, for 5- to 11-year-olds, they're the group that have the lowest hospitalization rate, including compared to kids younger than 5. So the assessment has been by some people. I want to hear your thoughts on it that, hey, Dr. Topol, this isn't a true public health emergency in where emergency use authorization powers are appropriate.

Sure, we don't want kids to be hospitalized. We don't want kids to die of a disease that could be preventable. But are we moving too fast as we talk about vaccination in kids?

ERIC TOPOL: Well, there's different ways to look at this. To say that the reason to have a broad vaccination program in young kids is to block hospitalizations is probably not the primary motive, but rather, to break the chain of transmission. So if you're trying to break the chain of transmission, you want to get 85%, 90% of the population vaccinated. And so, kids are a part of it, they're a vector in this whole process.

I mean, there's certainly a conduit of getting transmission to other kids and adults, family members, and household contacts, et cetera. So this is an issue. Now, we do know, as you've seen from the Children's Hospitals Association and American Academy of Ped, we just have coming down from the highest children infected and hospitalized in the whole pandemic because of Delta.

And this is the problem: We're not talking about waning of immunity. We're talking about because it had a really hyper-transmissible variant. Now, if, let's say, we get Delta contained really well, which doesn't look particularly sanguine, but let's say it does, in the weeks ahead. Well then, the urgency is different.

But if we are still looking at 90,000 cases a day, high children involvement, and then all of these hospitalizations, did not help to break this chain and to protect kids, because some of them do get hospitalized. And you saw the pediatric hospitals in the Southeast, the ICUs were full. The worst situation we've had in the entire epidemic, and when there's vaccinations galore.

So my sense is that this urgency is where we are now. If we are able to achieve very low levels of cases, it's a different story. It's a circulating virus, not just in the country but in a particular location, is a very important determinant of this decision. The other thing is, if you're a reluctant parent, you're worried about side effects, you could just wait a few weeks to see what's going on out there. We'll know --

JOHN WHYTE: Well, everyone can't wait a few weeks, though. To be fair. If we all as parents say, we're going to wait a few weeks, so --

ERIC TOPOL: There are so many eager parents, you don't have to worry. You don't have to worry. But actually, I think, it's perfectly reasonable to go ahead. But John, I think we could be looking at -- this is going to be probably late October or early November at the best to get the go-ahead. We could be looking at a much -- hopefully, I mean, I'm the optimist as you know -- a more favorable situation where it's not such an urgent issue.

JOHN WHYTE: Yeah. Well, one metric that makes us a little discouraged, Dr. Topol, is the rate of vaccinations over the last couple of months. We have slowed down dramatically, and we know there is a lot of hesitancy. Where are we on antivirals? Where are we on really good treatments in the form of a pill?

I mean, we have injections, subcutaneous infusions, in terms of monoclonal antibodies, we have some benefit of remdesivir, but we really don't have a simple pill. But there's some encouraging news about that. What's your perspective on the availability soon of some type of antiviral to treat most cases of COVID?

ERIC TOPOL: Right. Though, this is really important, because it goes back to the earlier things you were bringing up. It's about how are we going to need fourth boosters, fifth shots, and whatnot? If we had really good antivirals that you could have in your medicine cabinet or carry it around with you when you travel, and an exposure or at the earliest symptoms, possible symptoms, it was perfectly safe. This would be all we need. But there hasn't been a nearly enough emphasis on the drugs’ side effects.

Now, remdesivir is very weak, and the studies are mixed. But there are better direct antivirals. Remember: Remdesivir was a repurposed drug. Now, there are drugs that have very high viral SARS-CoV-2 neutralization that are in clinical trials. So maybe we'll see a pill. But also, we have inhalation interferon preparations that could just take a puff of that, and that would be at the earliest possible time. There are going to be some more drugs down the --

JOHN WHYTE: But when? People want to know when.

ERIC TOPOL: Yeah. Well, you know what? I'll tell you, it would happen a lot sooner if we'd given it as much attention. Ultimately, it's not going to be just a vaccine story. It's going to involve medications and rapid test, and that's how we'll eventually live with this virus for the years to come. And it won't really interfere with our lives as it is right now.

JOHN WHYTE: As folks know, you've been one of the leading voices throughout this pandemic. Your Twitter handle -- and we'll show it on screen -- is a must-read for anyone that wants to know the latest going on on COVID. I have no idea how you have time to make all these graphs and descriptions and summaries. But I want to ask you, Dr. Topol, since you've been involved in this throughout: What's the one thing you might have changed in the communication strategy on the rollout of these vaccines?

ERIC TOPOL: Well, that's a tough one. Thanks, John, by the way. That's very kind of you. I think, there's just so many. It's hard to just pick one.

But, I think, the problem we had is we didn't take on the anti-science vigorously before even the vaccines started to go out. It is nuke it, you know? That you're going to hear this or that, or this or that. In fact, we couldn't even imagine what people were going to make up. That you'll become infertile, that you would be impotent --

JOHN WHYTE: Magnetized.

ERIC TOPOL: -- magnetized. Who would even dream this stuff up? But what I would have done is basically prepare the public -- knowing once the vaccines, the first trials came in 95% efficacy -- what I would have been doing is taking on all these entities. This is what you'll hear from so and so, so and so, and so and so, and then calling them out.

And unfortunately, this is the state we're in, because that large proportion of the country, we're talking about a very substantial 30%-plus, they are basically transfixed. They've been -- their minds have been inculcated with this complete cockamamie stuff. And now, how do you reverse it? Because they're entrenched. So, I think, that would have been the thing that if we had done that -- and we still haven't done it, by the way -- we still have not called these sources out at the highest levels.

JOHN WHYTE: And then, finally, are we still going to be talking about COVID in May? I mean, we'll still talk but, hopefully, talk about other things. But are we going to be talking about COVID in May?

ERIC TOPOL: Of 2022?

JOHN WHYTE: Hopefully, not 2023. In 2022.

ERIC TOPOL: Yeah, no, I actually think we won't be talking about it like we are now. The only caveat would be we've got to get this containment, so we don't get something worse than Delta. But if we don't get something worse than Delta, which is what I'm certainly hoping for, we will be good. We will be good much sooner than that.

This idea that we have to wait till spring to achieve containment, that's what I think that's overly pessimistic. We can do better than that.

JOHN WHYTE: Well, Dr. Topol, I want to thank you for taking the time today. Always providing your insight. Everyone needs to check out your Twitter feed, and we'll check in with you obviously before May. For sure.

ERIC TOPOL: I hope so. John, it's always a delight to talk to you. I guess, I should be calling you Dr. White, since you called me Dr. Topol.


ERIC TOPOL: But, really, always enjoy it. Thank you.

JOHN WHYTE: Thank you.

This interview originally appeared on WebMD on October 7, 2021

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