Published on May 13, 2021

Video Transcript

[MUSIC PLAYING] JOHN WHYTE: Hi, everyone. I'm Dr. John Whyte, Chief Medical Officer at WebMD, and you're watching Coronavirus in Context. A lot has been happening over the past few weeks, so to help break down the latest data, provide insights on the recent guidelines, I've asked Dr. Amesh Adalja. He's a senior scholar at Johns Hopkins Center for Health Security. Dr. Adalja, thanks for joining me.

AMESH ADALJA: Thanks for having me.

JOHN WHYTE: Let's start off with, how concerned do we need to be about what's happening in India?

AMESH ADALJA: What's happening in India, I do think, is something that everybody should be concerned about. Because when you're talking about an infectious disease outbreak, one with a highly contagious virus, if the outbreak is not controlled in all corners of the globe, the rest of the globe will remain at risk, the world will remain disrupted, and we will really not have control of this pandemic.

It's even more important that this is happening in India, because India is a place where they export vaccines, where they are part of major global efforts to vaccinate the developing world. So the fact that India now has to turn its attention to its domestic problem is going to, also, cause a supply constraint for the developing world which was relying on Indian made vaccines, such as the AstraZeneca vaccine, to vaccinate their population. So this is going to be something that will delay the control of the pandemic and have a ripple effect outside of India to the rest of the world.

JOHN WHYTE: On a practical basis, in the United States, is it an issue that if the virus isn't controlled there's going to be additional mutations, more variants that, perhaps, can evade the current vaccines? Is that a major issue going on here that then could require more boosters?

AMESH ADALJA: Any time the virus is spreading in an unchecked fashion, you're going to have the generation of new variants. Most of those variants are going to really not have much consequence, and some of those variants are going to be concerning because maybe they're more contagious, such as the variant that is spreading right now in India. It's very hard, however, for a variant to completely evade a vaccine. Although people talk about vaccine escape variants, it still appears that our vaccines, from the variants that we've seen, have the ability to stop what matters, serious disease, hospitalization, and death.

So while it's very important to think about immunizations, I also don't want to go too far on the other side and kind of envision a super virus that's able to evade our vaccines completely. But the point is, we don't want more contagious variants, we don't want to deal with variants. We don't even want to be in conversation about boosters. So the quicker we can get spread contained, the quicker we can get the population of India vaccinated, the less will even have to think about these hypothetical possibilities.

JOHN WHYTE: And you've been talking about herd immunity, what it means. Some people are saying it's 80%, other people say it's 70%. How do we factor into those people who have gotten COVID, which is probably an underestimate. Does anyone really know what the right percentage of vaccinated needs to be to get this virus under control?

AMESH ADALJA: Not exactly. So herd immunity is a mathematical formula, and you can come up with the number of 70%, 80%, but there's a lot of assumptions in that number. One is that the population is homogeneous, meaning that everybody is at equal risk for getting infected and spreading it, and that's not true. We've seen in other types of mathematical studies where a herd immunity threshold can be lower if the people who actually spread the virus in the community are the ones who have immunity through a combination of vaccination or prior infection.

And if you look at countries like Israel, they had a precipitous decline in cases when they got to about 40% of their population fully vaccinated. So I do think herd immunity is an important milestone to cross, but I think we'll still see benefits even before we get to herd immunity, probably around that 40% fully vaccinated range. And the other point is that herd immunity isn't everything. What we were trying to do with the vaccine program was not to induce herd immunity rapidly, but to remove the ability of the virus to cause serious disease, hospitalization, and death.

And that's why we vaccinated in the United States, not the people who are spreading the virus first, but the people who were at most risk for requiring hospitalization. And I think we've been successful in that regard. Just walk through a hospital now in April or May of 2021 versus January of 2021, and you can see what these vaccines have done. So I think that the primary objective of the vaccines was to remove the ability of this virus to threaten hospital capacity, and that's largely been achieved in the United States.

JOHN WHYTE: So it's a success of the vaccination program, particularly in the elderly, where 85% have received at least one dose, nearly three out of four have received both doses and been fully vaccinated. I want to ask you what everyone else wants to know, get your best predictions. How is the summer of 2021 going to be different? Is it going to be more like the summer 2020 last year or is it going to be more like pre-pandemic summer of 2019?

AMESH ADALJA: The summer of 2021 is going to look more like the summer of 2019 than it did the summer of 2020. We have a substantial proportion of the population vaccinated. We do not have concerns about hospital capacity. Anybody, really, who wants to have a vaccine that's eligible is able to schedule themselves to get a vaccine and usually can get that vaccine pretty readily. So I think that you're going to see more activities being able to be partaking in. We've got a lot of epidemiological data on outdoor spread so those types of activities are going to probably be very close to normal, I would assume.

It's all going to also depend upon which state you live in. Certain states have certain restrictions, other ones do not. But as I think we get into the summer, I think we're going to be in a point where a lot of pre-pandemic life is going to come back. They're still likely will be some concerns in certain states with mass gatherings because not enough people have been vaccinated.

And we will still hear about cases, we will still hear about people getting exposures and getting quarantined, but they're going to be of a lower cadence. They're not going to be at the same level as they were in the past summer or at any time during this pandemic because of the power of the vaccines and because of the knowledge we have of the epidemiology of what spreads infection and what doesn't. But the key to making the summer as close to 2019 as possible is to have as many people as possible vaccinated.

JOHN WHYTE: Say we have 25% of people that aren't willing to get vaccinated. Do you think we're going to start to see immunity passports? And I don't love that term, but do you think we'll start seeing there will be a requirement for travel to get on a plane, to get into a concert. We're starting to see the requirement to come back to college. If you want to come in person, you're going to have to be vaccinated and prove it. Do you expect more of that in the private sector?

AMESH ADALJA: I definitely do. We're already seeing it, for example, with sporting venues having vaccinated-only sections. We're hearing about parties for vaccinated-only people. And I think this is a natural thing because the vaccine does improve your life. It does allow you to reclaim your pre-pandemic activities in a way that you couldn't prior to the vaccine. And remember, if you're a vaccinated person, the virus is going to treat you differently. So you should expect other people to treat you differently because you're no longer a threat to them.

So I think this is something that's going to happen. It's going to be temporary until more people are vaccinated or we have more control of this virus, but it is something I expect the private sector to do. And I think it's a good thing because I do think that vaccinated people are getting vaccinated for a reason. They want to use that immunity, and they want to be able to get back to their lives. So I do think if people are holding out on getting vaccinated, they should get vaccinated, but they shouldn't expect the rest of the world to wait for them.

JOHN WHYTE: When do you expect businesses to more fully reopen? And is there going to be the physical distancing within offices? Are people still going to be wearing masks? Is everyone going to have a temperature check still? What's your sense of where that may be by the fall?

AMESH ADALJA: By the fall, I suspect most businesses will be open. There still will be flexibility for telecommuting. And some places may like telecommuting because it might be cheaper, it might be easier for them to do that than having people fly to Chicago for a meeting on Friday afternoon every week. So there will be some changes, but most businesses, I suspect, will have the ability to open fully by fall because enough people will be vaccinated, enough of this public health emergency will be over by that time.

There may still be a lot more policies regarding coming to work sick, I think that's going to go away. It should have went way long before this pandemic. There will be much more attunement to that. Social distancing, I think, will be in place until enough of a office is vaccinated or enough people that interact in that office are vaccinated.

JOHN WHYTE: What if 10% of your employee workforce refuse to get vaccinated, and you don't have a mandatory policy? Do you still need to have those physical distancing requirements?

AMESH ADALJA: What I would do is if it's only 10% of your population, your workforce population, you may Institute differential policies and say, if you're not vaccinated, then you need to wear a mask when you're in any situation where you can't social distance. And that's something hospitals used to do before with influenza vaccine. So some hospitals, if an employee wasn't vaccinated for influenza, they would have to wear a mask throughout the influenza season.

So I do think they might there may be ways to come up with differential policies if it's a small proportion of your workforce population that's not vaccinated. If it's a large proportion, then I think it's very hard to do that because you're going to get a lot of mixing of unvaccinated people, and it's going to make it much more challenging to do. This is something that's evolving now, I advise businesses on this. And a lot of this hinges on how much of your population gets vaccinated and what their job function are and what your office setup is and can you social distance those people.

Remember, COVID isn't going to go to zero. We're not going to get to a point where there's no cases. What we're trying to do is really remove the ability of the virus to cause serious disease. And then I think it's going to become a little bit different based on each company's risk tolerance of what type of risk they tolerate, what type of business they're in all. Of that's going to condition how people think about COVID-19 when it's no longer the same deadly threat that it has been for over a year.

JOHN WHYTE: You've been involved in this from the very beginning. What are the lessons learned?

AMESH ADALJA: The lessons learned are, no matter how prepared you think you are as a country, if you don't have the political leadership to execute the appropriate pandemic response, you will end up in a very, very dark place, and that's what happened here. We were ranked the most prepared country in the world for a pandemic. We had plans, we knew exactly what to do. All of these subject matter experts were telling people what to do, but yet January, February, half of March basically passed without any action taken. And when the actions were taken, they were the wrong action.

So the lesson, to me, is that pandemic preparedness really needs to be fortified, not just in funding because, obviously, our public health infrastructure has gone decade after decade with neglect.

JOHN WHYTE: Absolutely.

AMESH ADALJA: But it's also political leadership needs to understand the risk of pandemics and that there is a way to do this correctly. And I think that if you go back and look at it, most of the mistakes that were made were political in nature. And there were a lot of us on television everywhere saying this is the correct action to take. This is what's in these reports that we've been writing for decade after decade, but that was really ignored. And I think that's what we have to fix, is this has to become a national security priority to get this right so that the United States can perform more like Taiwan than the way that it did.

JOHN WHYTE: But in fairness, one could make the argument that there was not adequate surveillance in terms of the pandemic, that there were some signs earlier in December. That wasn't a political issue, that was more of an epidemiological and public health issue. We could say there were issues, as you may recall, with the testing that the CDC first started in terms of the tests were not accurate and could not be used. So that was a misstep as well. Those weren't political in nature, Dr. Adalja, were they? They really scientific ones in terms of the public health infrastructure.

AMESH ADALJA: I completely disagree. Those were completely political decisions. The CDC and the US government decided not to take the World Health Organization test. They wanted a homegrown American made test. The CDC also refused the South Korean test that was available. In the very beginning, because there was a public health emergency declared, there was an emergency use authorization apparatus, which basically prohibited private labs, university labs from making their own tests.

So the private sector was basically cut out of the ability to test, and we had to rely on a CDC test that was flawed, that was only available at public health labs, and we had very strict testing criteria from the CDC that was all political in nature because this was being viewed as a China problem. So you can only test people if they came from China. You could only test people with lower respiratory symptoms, not upper respiratory symptoms, because this was being viewed as something that was in China. We were quarantining people on Air Force bases when they came back from China, but the virus was already spreading outside those gates.

JOHN WHYTE: Dr. Adalja.

AMESH ADALJA: Those were all political decisions.

JOHN WHYTE: But in fairness, on the lab tests, when the FDA loosened the requirement on lab tests through the private sector, we saw a flood of inaccurate tests come to the market that lacked sensitivity, that lacked specificity, that did not have the precision that we needed in detection. So to be fair, when the requirements were loosened under the emergency use authorization, which is, as you know, in FDA, devices have a different process. There is a whole bunch of inaccurate tests.

AMESH ADALJA: There were some inaccurate tests, but I think--

JOHN WHYTE: There were a lot of inaccurate tests.

AMESH ADALJA: Not PCR molecular-based tests.

JOHN WHYTE: No, no, no.

AMESH ADALJA: You're conflating antibody tests with PCR based testing. And I think what the issue was is if you-- then, it's not either or. It's not a false alternative. You can have organizations like the American College of Pathologists rating tests. But we do know that companies, like Quest and LabCorp plus university lab tests, they were basically had their hands cuffed. They were unable to do those tests until the fix was made in the emergency use authorization apparatus.

So we were stuck with one test that couldn't work and wasn't working. So I don't think that this system made any sense to do this. And it was actually foretold. People warned them that emergency use authorization pathway and moving away from laboratory developed tests was going to hamper us. And I think this is something that's one of the original sins of the pandemic. And the fact was we could have used the WHO test. We could have used South Korean tests that had already proved their mettle before that. So even that part of it was a problem.

JOHN WHYTE: Where did we succeed?

AMESH ADALJA: The biggest success story is likely Operation Warp Speed where there were pre-market commitments to make vaccines, where there was a portfolio approach looking at different types of technology not knowing which vaccine would cross the finish line first. I think that is clearly a success where we were able to really push forward certain technologies that had been and burgeoning before but really hadn't been able to cross the finish line yet. And I think that's really something where the United States stands apart is that Operation Warp Speed was able to deliver vaccines in record speed with multiple different technologies, multiple candidates all crossing the finish line.

JOHN WHYTE: Well, Dr. Adalja, I want to thank you for providing your insights today for an engaging intellectual discussion about some of the issues around the pandemic and really providing us the insight that we need to put all of this into context, so thank you.

AMESH ADALJA: Thank you.