How Do We End the Pandemic? Experts Discuss the Path Forward.

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There is finally a light at the end of the COVID-19 pandemic tunnel, thanks to a historic vaccine development effort. What will it take to bring us out of this pandemic, and how can we do it as rapidly and smoothly as possible? 

Last week, we convened experts for a panel discussion where they detailed the devastating nature of this pandemic, moving vaccines out of production facilities and into arms, New York’s vaccination efforts, ensuring equitable distribution, and charting a path back to ‘normalcy.’ Watch the full video below and read on for highlights!

The discussion featured viral immunologist, physician-researcher, and Pulitzer Prize winner Siddhartha Mukherjee, MD, DPhil, epidemiologist, global health expert, and MacArthur Fellow Wafaa El-Sadr, MD, MPH, MPA, New York Governor Cuomo’s COVID-19 Response Task Force member Gareth Rhodes, JD, and NYSCF CEO and Founder Susan L. Solomon, JD.

What makes the COVID-19 pandemic so uniquely devastating?

This pandemic has been especially brutal in part because our public health systems were not prepared for an emergency of this magnitude.

“I think one [challenge] is that unfortunately we did not learn the lessons of the past and we were not ready to respond to what many of us knew would inevitably come along, which is another pandemic caused by a virus,” explained Dr. El-Sadr. “We had essentially dismantled some of the structures and the workforce that has traditionally been very involved in terms of trying to predict these pandemics as well as trying to respond to them.” 

“Another aspect is the underfunding, and almost a deterioration, of our public health systems,” she continued. “We have let them wither over the past decades for a very simple reason: people often don’t appreciate what public health does. Public health is largely about prevention, and nobody appreciates prevention. There’s much more of a sense of appreciation for healthcare in general, rather than public health. I think also at the same time, there’s been a huge gap in our capabilities to implement a variety of different interventions, whether it be in testing or now the rollout of the vaccine.”

What steps must be taken to get a vaccine out of production facilities and into arms?

“We do have some bright lights,” said Ms. Solomon. “The first two vaccines are pretty fabulous; I think better than the expectations of the companies themselves. But the last mile is getting those vaccines into people and making sure we have enough. Fortunately, we are going to have an incoming administration that believes in science and that is committed to public health. So how do we get from where we are to where we need to be?”

Dr. Mukherjee, who serves on the Governor’s Reimagine New York Commission, noted that the first hurdle to overcome is a vaccine production limitation – an obstacle Dr. El-Sadr recently wrote about in a New York Times op-ed arguing that President Biden should leverage federal resources to manufacture more vaccines, as President George W. Bush did to help supply the world with HIV medication. 

“We don’t have enough [vaccines] for a lot of reasons, but one of the reasons is that we didn’t invest in the infrastructure that is required to produce these vaccines at a level of 200–300 million people, and potentially, as Dr. El-Sadr pointed out in her op-ed in the case of HIV, for the world,” explained Dr. Mukherjee. “And now we are scrambling backwards to invest in the infrastructure to produce the vaccine.”

“Step two is the movement of the vaccine from the factory to the delivery sites,” he continued. “Because we are a federal system, the movement of the vaccine to the states has been delegated to ‘Operation Warp Speed’ for the most part, which is the federal aspect of the system and is being controlled by subcontractors to move the vaccine to the various sites. Thus far, that does not seem to be the bottleneck.”

“Step three is the most complex. Step three is a state responsibility. Once the vaccine arrives, it is now the responsibility of the county and the state to dispense the vaccine. If we had full capacity — in other words, if we had no limitations on the number of vaccines available — we would do what was done during the smallpox pandemic or other pandemics of the past. We would say, ‘Come one, come all: Here’s a kiosk in Chelsea. Here’s a kiosk in Chicago. Wherever the vaccine is, you could come get it and you’re done.’”

The limitations in current COVID-19 vaccine availability are exacerbated by their more complicated administration process than previous vaccines.

“For each vaccination, there is a 15-minute observation period that you need to go through to ensure that you don’t have an allergic reaction (30 minutes if you’ve had a prior vaccine allergy),” said Dr. Mukherjee. “So the vaccination is no longer a two-minute job, but rather at least a 20-minute job. And you can imagine that is a tenfold change in the total amount of time [the process typically takes].”

Where is New York in the vaccination process?

New York is currently in Phase 1 of the vaccination, which includes frontline healthcare workers as well as people over 65, first responders, and public transit workers (for the latest on New York, see here). Mr. Rhodes, who works on Governor Cuomo’s COVID-19 Response Task Force, emphasized that his team is working hard to ensure that as many people are receiving the vaccine as possible, especially after initial reports of institutions having to discard leftover vaccines.

“The conversation has shifted, properly and rightfully so, over a period of weeks to ask: why are there still doses and inventory when they could be going into arms? On December 14th here in New York, 2.1 million people were eligible [to receive the vaccine]. Today, over 7 million people are eligible,” said Mr. Rhodes. “And that’s not even including the recommendations that were made this past week about adults under 65 with underlying health conditions.”

“If you look at the [New York] state population of those 16 and older, it’s 15 million people,” he continued. “[Since December 14th], we only received 1 million doses for first doses, of which we have administered approximately 700,000…What we’re looking at is between 200,000 and 300,000 doses coming into New York a week right now.”

“Assuming we had all of the vaccines that we needed, how many people could we, in fact, vaccinate?” asked Ms. Solomon.

“At the Javits center alone [a convention center in New York City converted into a mass vaccination site], we think we could do 25,000 people a day if we ran it 24/7,” said Mr. Rhodes.

“In terms of capacity, in New York state, about 10 million people get the flu vaccine over five months every single flu season,” Mr. Rhodes said. “If you do the math, that’s 500,000 shots a week. We did 300,000 of the COVID-19 vaccine last week. And then we have these massive centers. We don’t use the Javits to do flu vaccines. We can build [the infrastructure]. It can happen. It’s also the geographic reach: going into the communities, churches, community centers, etc.”

He also stressed that the process could have been aided by more federal support earlier on.

“Our existing healthcare infrastructure has been pushed to its max for the last eight months. We’re asking the same infrastructure to take on a logistical and operational challenge that is as challenging as testing and building emergency hospitals. There was an enormous opportunity for the federal government to play a much larger role here. Instead, a lot of it was left to the states and local governments, which I think is partly to blame for what you’ve seen the last couple of weeks nationwide, in terms of the number of doses that are going into arms.”

However, the ramp-up in distribution efforts is a promising sign.

“I remember in late March setting up the Javits Center as a temporary hospital and seeing the USS Comfort come up the Hudson river,” recalled Mr. Rhodes. “Now seeing [it used to put] those shots in arms is emotional, just seeing how that transformation has happened. And, at least for me, that’s a real sign of hope for what’s ahead.”

How do we ensure equitable distribution of the vaccine to the communities most affected?

To help prioritize the vaccine rollout across different groups, a National Academies of Sciences, Engineering, and Medicine (NASEM) committee developed a framework released in October for who should get vaccinated when. That framework was then used by the CDC to develop more specific guidelines, which states are now implementing on their own to vaccinate the population in tiers (for more on the ethics and economics behind rollout guidelines, see highlights of our previous panel).

“The priority groups are based on very good intentions, and the intentions were to preserve equity,” said Dr. El-Sadr. “It is really important that those who may have been most severely impacted by this pandemic should be at the front of the line, and also to try to prevent disease and deaths. The problem is that reality clashed with the principles, and it became clear that while these are really very great motivations for doing it right, it is just very hard to deliver on this.”

In addition to fostering equity through the tier system, the panelists discussed opportunities to address it by increasing the accessibility of sites.

“Maybe what we can do is try to get at equity by where we situate vaccination centers. And then you can maybe have decreasing age bands so that we go down different ages and let geography guide equity,” posited Dr. El-Sadr. “Or not just geography, but maybe even different workforces, like setting up something at the bus depot or things like that.”

“How do we address the disproportionality of deaths among African-Americans and Latinx and other communities which have suffered disproportionate amounts of death? I think one solution is to increase vaccination,” Dr. Mukherjee said. “What if we could have a neighborhood kiosk, not Walgreens necessarily, but a neighborhood kiosk that is a vaccination site with clear information available in all languages, particularly languages that are local, where people can get vaccinated.” 

This is a two-dose vaccine. How effective is the first dose?

Early data from Israel, which currently has the highest vaccination rate in the world, suggests that just the first dose of the vaccine can help curb infection rates.

“We also asked both Pfizer and Moderna to actualize the level of protection given by the first dose itself,” noted Dr. Mukherjee. “That data is available in the New England Journal of Medicine. So, it turns out that after 14 to 21 days of the first dose of both Pfizer and Moderna, you get pretty reasonable levels of protection from the virus. But it’s not as if you get a vaccine and magically, you’re immediately protected from the virus. It takes some time for your immune system to respond. Very early data (unpublished) from Israel would suggest that the transmission also decreases.”

When will we get back to normal?

We are now closer than ever to a return to ‘normal,’ but the panel stressed the importance of maintaining social distancing, wearing your mask, and other safety measures, especially as the virus continues to mutate.

“Not only are we losing 2,000-4,000 people a day, but there are new viral variants popping up that are worrisome,” said Dr. Mukherjee.

“The B117 strain, which is the strain that’s impacting London, is probably vaccine sensitive, which means that it will be prevented by the vaccine,” he continued. “The E6 strain, which is from South Africa and in Brazil, is still in evaluation. The B116 strain, which we have in the United States, has a greater level of infectivity, but it doesn’t seem to cause worse disease. The E6 strain from South Africa and from Brazil may be less sensitive to the vaccine, although we don’t know that yet for sure.”

“I always think that in order to achieve the desired impact of vaccines, you have to optimize two things,” said Dr. El-Sadr. “You have to optimize the uptake of the vaccine by the population, and you need to optimize the efficacy of the vaccine itself. We have covered one of those factors: the efficacy piece. So now the challenge is how do we get to very high uptake in our communities. And that’s really what’s going to determine our ability to gain the benefits of these vaccines.”

“The concern is that if you keep on getting transmission, that you will have a mutation and that mutation may be associated with more severe disease and may actually be able to escape the vaccine,” she continued. “So that’s why it’s really important to use the vaccine to our best ability. Now we must achieve the highest coverage, because with 95% efficacy, if we can get to 80% coverage, 90% coverage of our population, I think we would be in good shape. We would hopefully stop the development of COVID-19 and hopefully be able to then go back to normal. But even after you get a vaccine, you must continue to observe the current protective measures that we know that face covering in particular, the masking and the distancing.”

“I don’t want people to think that they get vaccinated and it’s a get-out-of-jail-free card and they can rip off their masks and fly where they want,” added Ms. Solomon. “We don’t know if you are still able to transmit the disease once you are vaccinated.”

“There are many vaccine pessimists and there are many people who have raised doubts about our capacity to vaccinate, given the pace of infection,” said Dr. Mukherjee. “But if we do a good job with vaccination — in other words, if we can vaccinate 250 million people on the order of 25-30 million per month, we could potentially see the end of this by April or May. That will be an enormous success. If we don’t do it properly, we stretch out into the next summer or potentially into the winter.”

What should you keep in mind as the vaccination process plays out?

“I would just ask for patience,” said Mr. Rhodes. “We went from 2.1 million people eligible to 7.1 million people eligible in a matter of 48 hours. We’re not going to have any vaccines left on the shelf at the end of the week, and they’re going to be getting into arms. And the moment that we can get more vaccines out there when more supply comes, then we certainly will.”

“I totally understand and appreciate the frustration. People are exhausted from what we’ve been going through, but I always tell everybody, please, this is not the time to let down your guard,” added Dr. El-Sadr. “I think most importantly, we do have tools at our fingertips. I call them the non-pharmaceutical vaccines. We know that the masks and distancing works really well. So, as we are waiting to get access to the vaccine and hopefully that access will increase incrementally over the next several days and weeks, let’s hold onto our non-pharmaceutical vaccines.”

“Be safe, wear your mask, and be patient. Keep refreshing to look for your appointments as you become eligible,” agreed Ms. Solomon.

Dr. Mukherjee’s mantra is just three words:

“Patience. Science. April.”

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