COVID Vaccines for the Under 5's: The 'Finish Line' We Need

; Abraham Verghese, MD; Katelyn K. Jetelina, MPH, PhD


February 17, 2022

This transcript has been edited for clarity.

Eric J. Topol, MD: Hello. I'm Eric Topol. I'm with my colleague, Abraham Verghese, co-host for the Medicine and the Machine podcast. Today we welcome Professor Katelyn Jetelina, who is a phenomenal epidemiologist from the University of Texas at Houston and who is going to enlighten us about her role as "your local epidemiologist" in the pandemic. Welcome, Katelyn.

Katelyn K. Jetelina, PhD, MPH: Thanks for having me. I'm excited to be here.

Topol: Can you tell us a bit about your background and how you landed as one of our guiding lights for explaining the pandemic and providing insights for everyone?

Jetelina: It's been a very organic journey and something I would never have dreamed of doing. I used to work at the World Health Organization, so at the beginning of the pandemic, I was following the raw data closely. My colleagues asked if I could give them daily updates, just a few sentences on what the heck was going on. This was not just my faculty but also staff and students because there was a lot of confusion and anxiety. So I started sending an email to about 30 people. I called them my "Daily Data-driven Updates" and I signed them "Love, Your Local Epidemiologist" because I was their local epidemiologist.

A few days later, one of my students asked me if I could start sharing it on Facebook so she could share it with her friends and family. So I started a Facebook page called Your Local Epidemiologist. In the beginning, I was updating it every day. These were primary data analyses as I was following what was going on. It ended up growing and growing; last time I pulled the data, I had reached about 130 million people in 2 years. It's been a wild journey and a lot of fun.

Abraham Verghese, MD: In your nonepidemiologist life, you're a busy mom with two very young kids. I believe our listeners are always curious — how do you get this done? How do you juggle all these things to write such a beautiful newsletter and keep up with Twitter and do all of the things you do?

Jetelina: I couldn't do it without my support system. We have our grandparents down the street who help babysit. My husband is completely supportive, and I do it in my free time. Once the girls go to sleep, I read up. I write a post in about an hour and then it goes live in the morning. As I said, it's very off-the-cuff and organic, just going with the flow and what I'm thinking in my head as we go. I think people appreciate that it's not too curated. I now have a copy editor because everyone got annoyed with my spelling mistakes. So I've been learning over time. I would be doing this inside my brain whether I had a newsletter or not, so I figured I'd just put my thoughts to paper and see how it goes.

Topol: Recently, there was this major disappointment regarding the inability to go forward with vaccinations for kids under the age of 5. Can you tell us about your reaction?

Jetelina: I think we all were incredibly shocked. This entire process for the under 5's has been completely unprecedented. If Pfizer and the FDA had enough data to move forward with submitting an Emergency Use Authorization (EUA) application, I felt like this was pretty much in the bag. They were going to have that scientific external committee meeting the following week, but they canceled it at the last minute. We were all shocked. As a mom, I was incredibly disappointed. As an epidemiologist, I was confused and I am still confused about what was going on.

As a scientific communicator, my biggest concern is losing parents' confidence in the process. We know already that kids aren't getting vaccinated. Only about 30% of 5- to 11-year-olds are vaccinated. We need to be as transparent as possible and explain and communicate what's going on carefully and diligently. Unfortunately, I haven't seen that happen yet.

Topol: You're appropriately emphasizing that we have done a very poor job of getting children aged 5-11 vaccinated with a vaccine that has been available to them for months. This is far lower than what would be expected, especially when the concerns about myocarditis are not there. The last review I saw found 12 cases total out of several million doses, and those cases were all very self-limited. That's an incredibly low rate of the only really feared side effect in those kids.

The dose was lowered even more to promote safety, and my understanding is that this was unprecedented. They were going to give a green light for an emergency authorization for the two-shot data that didn't show enough efficacy, with a third dose — because they had to go ahead with this third dose — still pending. Now that seems really odd. The option would have been to reload with a different dose and do a two-shot trial. Who wants to give kids three shots if they can get two? Or wait till you have the data. The whole thing was bizarre, and I agree with you about what this is going to do when the vaccines are eventually rolled out to these younger children. It's really unfortunate.

Jetelina: Speaking with my parent hat on, in December, when we got the news that the clinical trial failed, we were all disappointed, but I felt like we had a new goalpost. We knew then that the EUA wouldn't come through until next summer. We thought we'll make it through to next summer. Then, a month later to hear, "Oh, we may actually have the data." Maybe the goalpost has changed but it's been a very confusing ride, and I am someone who is well versed in clinical trials. I couldn't even imagine how the parents out there feel. I feel pretty hopeless right now and very confused.

Verghese: One of your lovely quotes is that "reality is not binary." I love that. I think you've done a great job helping the public to understand that. And I imagine that you also get a lot of pushback from folks who believe that reality is binary. How do you personally handle that? I mean, that must have been a shock that came along with your prominence and your celebrity status.

Jetelina: I don't know if I handle it well. It's the reality of being a public-facing person and being an epidemiologist or a public health official. You're smack in the middle of the conversation. I never thought this newsletter was going to become as big as it is so I certainly didn't expect the negative that comes with the positive. I have developed a pretty tough skin. There are crazy people out there, but I believe the majority of people truly appreciate some level of communication to tell them what's going on because that gap isn't being filled well at all in the United States or across the world. I try to focus on the silent majority who keep opening up those emails and I try to give myself some grace along the way. It's tough. Right now, I'm in a holding pattern with my newsletter. I gave myself a week or two break; it was time.

Topol: That brings me to that very interesting closing you have in your newsletters. In a world of social media with all sorts of viciousness, each time, you sign "Love, Your Local Epidemiologist." There's not a lot of love out there. I wonder if you could comment on that because I don't see anybody signing "with love" anymore.

Jetelina: I never thought twice about it until I went on Andy Slavitt's podcast, and he brought that up. I guess it's something I've always just done. I want people to know that I care. I care enough to do this in my off time, I try to digest the tsunami of information. It goes back to the roots of doing this for my friends and family, but it keeps getting bigger and bigger, which I love. I hope that closing makes it more personal. I hope it puts a face to the words and to public health, so people have a trusted messenger and someone to turn to for the scientific perspective. Other than that, I haven't thought about it. I just continue to do it. I feel like I need some sort of closure on the post.

Verghese: Reading your newsletter, I'm struck by how much it contrasts with the sort of official stuff that comes from the CDC and elsewhere. Presumably, they have to use very carefully vetted kind of speaking but, as a result, they wind up sowing more and more confusion. Your newsletter is quite gratifying to read because it not only conveys the love, it's also very simply put in a way that all of us can understand. It brings me to a question that I want to ask both of you because it's very much on our minds again, in that nonbinary area. What is the effect of prior COVID infection in our calculations on where we're heading? I know Eric's been writing a lot about this and you've thought about it too, Katelyn. Where do you think that fits in?

Jetelina: Eric, you just had an amazing post about this in your own newsletter with a lot of the data.

Topol: Yes, and there's a lot more coming out today on that, both from Israel and the United Kingdom. I believe it's unequivocal that prior infection provides a level of immunity. We wouldn't want anybody to go out and get COVID. We're not talking about chickenpox parties. With COVID, it would be reckless. But if you happen to have proof of a confirmed infection, it seems that should be good for credit. I believe the "one and done" that we used to say with the J&J vaccine (which isn't true, of course) does apply to prior COVID or natural immunity plus a shot. If we could just convert those resistant people who have had COVID to get one shot, they would have the same protective level, even with Omicron, as they would with three shots. Katelyn, I'm interested in your thoughts. You look at data; I love how data-driven you are. Is that sound? We are held up in this country by reasonable thinking against a mandate. A lot of these people who are questioning mandates say, I had COVID, I have some immunity. Why don't I get recognized for that? The CDC has tunnel vision and does not recognize that there is such a thing as natural immunity. What do you think?

Jetelina: I agree that the data are showing that some level of infection-induced immunity is protective. If we're talking about policy, it would be difficult in the United States because we don't have a health system that documents all of that. If you're going to a concert, do you count a previous positive test as the same as vaccination? We don't necessarily have proof unless people print out their test results. It's a little messier in the United States compared with Israel or the United Kingdom. But it is what it is.

I think this question of how much Omicron infection helps is critical for where this pandemic will go in the next waves. We think Omicron has touched about 40% of Americans. This level of immunity combined with vaccinations will no doubt help build that immunity wall. An interesting study came out a few days ago from South Africa showing how an Omicron infection without vaccination protects really well against Omicron, but not so well against other variants of concern. So another piece of the important puzzle is if and how this virus will continue to mutate. A lot of viral evolutionary scientists — and I know one is in Eric Topol's lab — say it looks like the mutations have been very random. They're not a ladder as we would expect. If this virus continues to mutate off of Omicron, that's great news because that means those 40% of Americans who were infected will be protected. Or are we going to get some random mutation, as we did with Omicron and Delta? I don't know. No one knows, but that's certainly something I'll be paying attention to because it has major implications for where this pandemic goes.

Topol: To get back to your point about the messiness of our health system, In August, I lobbied the CDC to recognize prior COVID as being equivalent to one vaccine dose, and their response was: How are we going to prove it? Well, if people want to get credit, they can come up with their test results. I'm not suggesting in any way that natural immunity alone is adequate. I'm saying that people need to have at least one shot. The point here is that we have a 64% two-shot vaccinated rate in this country. If we could get a lot of those people who have had confirmed prior COVID get one shot, that has to help. The other thing is that having prior COVID doesn't protect from long COVID, obviously, but the vaccines do to some degree. What are your thoughts on all of the data about vaccination protecting from long COVID? Do you have the sense that this is real protection?

Jetelina: I think it is. Some four or five solid studies have shown significant — I mean, it's not 100% reduction in long COVID — but we're talking about 0.5% compared with 30% or something. So vaccines provide a lot of protection. I don't know, and I'm sure I could have missed it, but I haven't seen many studies that ask the question of whether infection-induced immunity protects against long COVID. I believe that's an important question to be asking.

Topol: I don't believe there are any data so far. The other issue that Abraham was getting at and you touched on is that we don't know much about Omicron and long COVID either. This whole idea about prior infection-induced immunity as a function of different strains of the virus, especially the one we are going through now, seems like that's still up in the air.

Jetelina: Especially since Omicron induces a very different disease pathology than Delta. So the effect it may have on long COVID and on how long that immunity lasts on B cells and T cells could be very different — not necessarily worse, but different. Those implications are crucial for whether we get a next wave or this just burns out.

Verghese: I want to circle back to something that makes you quite unique — you are the mother of two young children. What is your sense of the level of wariness or acceptance of a vaccine in that age group in general? What was your own thought process? Let's assume that we do get a vaccine that is safe and effective for this group. How well do you think it will be received by parents?

Jetelina: It's going to be very well received by me. It's something I've been looking forward to. As with a lot of parents, it feels like it's the finish line, and that's why it hurts so much when it's pushed back. As a parent and an epidemiologist, I very much recognize that we got lucky that kids having milder disease than adults. But still, kids aren't supposed to go to the hospital and they aren't supposed to die. It continues to be one of the top 10 causes of death in children. If I can protect my child from that, then I want to do that. It's going to be more difficult for parents as a whole. Maybe 20%-25% of parents will line up for it just as we saw with the 5- to 11-year-olds. A lot of the hesitancy is because of misinformation and thinking that the virus is milder for kids. I look forward to seeing the data that we haven't seen yet from Pfizer.

Topol: You and I had a chance to collaborate on a piece in Substack about the pan-coronavirus vaccine, and I wanted to get your updated thoughts about that. Is it important? Should we push harder on it? Is it possible? What could it do for us?

Jetelina: That's one of the more exciting, innovative biomedical technologies that's come out of this pandemic. A variant-proof vaccine is very cool and would solve a lot of our problems right now. It's going to take time before we see that effectiveness data, though. It may be the next generation of vaccines. I believe that vaccine is still in a phase 2 trial at Walter Reed. But that means that results should be coming in the next few months, and I'll be very curious to see what they show.

Topol: There are a lot of candidates out there. The one you just mentioned from Walter Reed is the first one out with a phase 2 trial with a different nanoparticle. But of course, many others are trying to stimulate very broad neutralizing antibodies. It is an exciting area. I hope by later this year this will help get us to a state where we don't have to keep using the original vaccines that were directed to different virus from the one we are dealing with right now.

Jetelina: I believe that type of vaccine will get us out of this reactive response into a much more proactive mindset. Right now, the discussion is whether we need an Omicron-specific vaccine. The Omicron wave is almost over. Is this the direction it's going to mutate? We don't know. So we keep having a reactive response. A pan-coronavirus vaccine would help get us out of that rut. One of the silver linings of this pandemic is how much team science has gone on, how much advancement has occurred in medicine and science. It's absolutely incredible and really cool to watch in real time.

Verghese: I was struck by one of the tables in your newsletter that gives guidance on how to decide about whether to mask indoors or outdoors, based on testing prevalence. As I read it, I thought, This is useful to people who read it, but there's a huge segment of the public who have made up their minds on things like that. They already have decided. In public health, in your academic life, are the science doubters, the naysayers being treated as a public health problem? Is that being addressed with the same tools that we bring to everything else? In a way, that's been the biggest issue in the epidemic, at least in America.

Jetelina: I would argue that it's the biggest problem we have in our response to this pandemic. And not enough has been directed to fix it. Last summer, the Biden administration and the Office of Science and Technology Policy put out a plan for a pandemic preparedness and communication. The disinformation campaign was one little line in a plan that was pages and pages long. I believe it has to be at the core of how we prepare as a country for the next pandemic, or any of our other health problems. If there was clear and proactive communication, we wouldn't be in such a bad place. Our science and our message wouldn't have been as polarized. I believe a whole lot more people would be alive today. We need a lot more advancement in that area.

Verghese: It's more than communication. It requires a study of how people think and react under stress. I don't see enough of that, unless I'm missing it.

Jetelina: Scientists, especially social and behavioral scientists, have been studying vaccine hesitancy for decades. It continues to amaze me that everyone was surprised when people didn't want this new vaccine and we didn't leverage those tools or the science we had before to get people educated about this new vaccine before it was even rolled out. So again, we were reactive rather than proactive. I wish that the social sciences had been leveraged more strongly during this pandemic.

Topol: Speaking of science, let's turn to epidemiology as a science. It's been somewhat frustrating for me because epidemiology is the study of populations, whereas now we have the ability to study things at the individual level. As you know, since the early weeks of the pandemic, we've had the ability to take data from smartwatches and fitness bands — no matter what company manufactured it — and identify where there's a cluster of cases, whether there are predictors of long COVID, or vaccination responses that the body is churning even though the person has zero symptoms. But we haven't taken advantage of that. We don't provide for each person, on their smartphone, to do individualized real-time risk assessment. To me, that's upending epidemiology. It's like reverse epidemiology; it's at the individual, granular level. Why don't we push for that? Why does this idea of digital surveillance get dismissed?

Jetelina: I don't know. We have some incredible technology that we could use to get ahead of this but we haven't leveraged it. I don't know if it's because we have a serious trust issue in this country about surveillance or if it's because of privacy concerns. I do know that science is happening. It just hasn't been widely disseminated or implemented. And again, this could be part of our preparedness going forward. But I haven't seen that conversation come to the table.

Verghese: There's a lot of talk about the end of the epidemic. I think it's a little naive because, if anything, the epidemic has shown us that it's not going to simply end. You've written eloquently about that concept. I'm curious about how you answer that question when you're faced with predicting what the next 6 months might look like or what next winter will look like.

Jetelina: One thing I've learned during this pandemic is to approach the virus with humility. We don't know where this is going to go. We all have a lot of great hypotheses, but at the end of the day, we need to prepare for the worst and hope for the best. That's typically how I answer in the short form. I believe this virus is going to be a part of our lives. It's not going to burn out and we need to learn what that means and try to do all we can to lose fewer lives going forward.

Topol: Getting back to the disinformation and misinformation issue, we've just gone through the Joe Rogan and Spotify, Robert Malone stuff and you write your newsletter on Substack, which also shares authors on that platform. Robert Malone calls himself the inventor of the mRNA vaccines, which obviously is a fraud. Other people, like Alex Berenson and countless others, who are the proponents of the largest conduits of misinformation and seemingly purposeful disinformation are there. Could you comment on that? Should a platform have censorship when it comes to public health matters like this, where we're putting people at risk?

Jetelina: This has been a tough internal battle that I have been going through. Substack is a platform I use and they've been incredibly supportive of my work and echoing that work. I believe their solution, which is to not censor, is a risky one. It not only risks people's health and lives, it also risks my personal safety because a lot of those followers are behind the death threats I'm getting and why I need security at my office and all of that. I think it's risky. I will say, though, that I do not like complaining without a solution, and I don't know what the solution is. I hear that if Spotify or Substack closes someone down, they'll just go to another platform. So how do you stop this spiraling out? I don't have a solution. So I am open to them trying this out. But I was clear to them that it was very risky.

Topol: I implored the founders of Substack to draw the line on the medical matters and not have censorship otherwise. I know you've had death threats. So have I. Yesterday I got an email saying, "You will die soon." It was a great way to start off my morning, and I had to refer that to the local FBI; it actually had the person's name and was easily traceable. My family gets very scared. How do you deal with these death threats? This is so sick — we are trying to help people and we get death threats.

Jetelina: My university is incredibly supportive, so I have security at my front door and they scan all the packages that come into our fifth-floor building because of me. I have a lot of support that way. I have been doxed, which means that all of my personal information was published on Infowars or a disinformation online system. Thankfully, it was just my work stuff. It hasn't been my personal stuff yet. It's incredibly scary. I've had a friend in this same space who had to move houses because these people started showing up at her door. One of these days, someone's going to get hurt. I don't know who that will be, but it is scary and a very real threat and it takes a toll. There is a point where you ask yourself, is it worth it? To me, it's still worth it, but maybe tomorrow it won't be. I don't know. It's taxing, and a lot of scientists are experiencing this; something like 15% of scientists said they were experiencing this kind of stuff throughout the pandemic, and it's just unacceptable.

Verghese: As someone who's not in the public eye on this issue as much as you both are, I'm in awe of both of you and of all the people who put themselves out there and speak frankly. Whenever I delve back into COVID by reading Eric's tweets and your newsletter, I'm always struck in the interval how far we have come. I have a wonderful sense that, for all the uncertainties, we have many vaccine candidates, we have pan-vaccine candidates, we have many therapeutics, nucleotides and protease inhibitors in addition to monoclonal antibodies. So despite everything, we're in a much better place than we might have been, a tribute to science and to people like you. So thanks to both of you for being courageous and speaking out.

Jetelina: It's a team effort, right? Everyone's playing their role and helping get us through this pandemic. Because of that, we've gotten really far. I think that when we're responding in a crisis, we neglect to communicate how far we've come, especially with public health, because when public health works, it's invisible. It's important to recognize that we've saved one million lives in the United States with our vaccines. That is just insane, and fantastic, and something we really, truly still need to celebrate, because it was a team effort.

Topol: The other thing that's a miracle is not only the high level of efficacy of these vaccines but also how they've held up so well to the evolution of the virus.

What a pleasure to have this conversation with you. We could easily go on for many hours, but we covered a lot of ground. We're cheering for your continued extraordinary success. You, like few other people in the field of epidemiology, are great at simplifying the message so that anyone can understand it even while being data-driven and getting the latest data out there. We admire you and your efforts. Hopefully things will calm down and the love you close your newsletter with will dominate over the negativity and hate that we see out there right now. Thank you so much for joining us today.

This podcast is intended for US healthcare professionals only.

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