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COVID surges and vaccination rates. Are the two inextricably linked?
Vaccination rates continue to increase as many states have opened availability to all adults. But also increasing? COVID-19 surges, apparently resulting from a combination of eager travelers, relaxed distancing and mask mandates, and new variants that are more transmissible and perhaps more dangerous. What does that mean for vaccines and the ability to stop this pandemic?
Nahid Bhadelia, MD, MALD, the medical director for Boston Medical Center Special Pathogens Unit and associate professor of infectious diseases at Boston University School of Medicine, joins “Track the Vax” host Serena Marshall on this week’s episode to discuss whether we can vaccinate our way out of the pandemic.
Following is a transcript:
Marshall: I want to ask you, now that we’re seeing vaccines become more available than ever before, we’re still seeing these surges. So let’s start there. In Michigan, for example, they’re canceling surgeries because of an influx in COVID cases. You would think vaccines would stop the surges.
Bhadelia: That’s right, Serena. I think the trouble, though, is that the majority of us still are not vaccinated. So what you’re seeing is a shift that was very similar to what was in Israel and other places that potentially are slightly ahead of us in vaccinations. There are two examples: one is Chile and the other is Israel.
So, if you take Israel, they rolled out their vaccinations and initially it was by decades [of age]. What they start to see after … in February and March, as people who are older, who are vaccinated, as they got vaccinated the overall … mortality went down. However, the people who ended up sticking out as those who needed to be hospitalized or who were getting severely ill were people who are younger. One hypothesis for why this is happening is that the B.1.1.7, one of the variants, which is thought to be more transmissible, and thought to potentially be more lethal, is spreading with greater frequency.
And so it’s not just that somehow the virus said “alright, I’m going to ignore the people who are vulnerable, who are older, who have been vaccinated, and then go after the young.” It’s just that the young are left as the vulnerable populations and this particular strain causes more severe disease, we think, and causes potentially more lethality.
What’s happening in Michigan is similar to what’s happening in Chile. Right now in Michigan, what you’re seeing is this shift in the age of hospitalizations has gone down to the 30s and 40s. And because the variant that’s there is more lethal, you’re seeing potentially more severe disease than what you would have a few months ago.
And so it’s just a race between the vaccines and the variants. And right now in Michigan, the variants there are winning out.
Marshall: So it’s not really so much that it’s the vaccines that aren’t doing their jobs. It’s the fact that as the pandemic has progressed, we’ve seen a change in the virus itself?
Bhadelia: That’s right. And so, the thing is that viruses mutate. Right. All living things mutate every time they replicate. In fact, your own cells as they’re building, over the days and minutes and seconds that you were living, you are making copies of yourself. And every time you do, there might be small mistakes, which are these mutations. That’s exactly what’s happening with the virus.
Sometimes these mutations can be advantageous and they confer an advantage to the virus. And so that’s what these variants are — as we call them, variants of concern, are those that we think are changing the way that this virus is causing disease and how it’s transmitting.
There’re homegrown variants here in the U.S. as well, but the three main ones that we’ve been tracking, that we know the most about, is the variant that was discovered in the U.K., the B.1.1.7 that’s thought to sort of have mutations that allows it to hang on tighter to human cells. And so it’s easier to get the disease and get sick from it. It looks like people who have that virus, the virus sticks around and has higher amounts of concentrations for longer, so they’re able to transmit it to other people. And, like I said, there is now growing evidence that it can be more lethal.
The good news is in Michigan, you know, to your point of is this the vaccines failing versus the virus, the good news is the B.1.1.7 does not seem to evade your immune memory of either its natural immune memory or the one that’s from the vaccines. The vaccine efficacy does not seem to be affected by B.1.1.7. It does seem to be affected a little bit by the other two variants, the P.1 and the B.1.351, which are also present in the U.S. But of course, the one that’s really spreading and this week according to the CDC director has become the predominant variant, which is the B.1.1.7, thankfully is not affected by the vaccines.
And hence, it is the fact that the vaccinated are changing their behaviors, which is okay, because it does look like the vaccinated probably don’t transmit with the same frequency, thankfully, to other people and don’t get infected with the same frequency. But it’s also that the unvaccinated are changing their behavior because restrictions are down, mask mandates have gone away and that’s what’s putting people at greater risk in the setting of these variants.
Marshall: So is it psychological then? People think, oh, I heard we vaccinated 2 million people today. And so that’s a good thing. And we’re sort of letting our guard down too much because they think that we can vaccinate our way out of this. When in reality, those variants exist, spread still exists, and it’s just maybe exhaustion from the pandemic?
Bhadelia: Yeah, I think the best way I’ve heard it described is like you’re running a marathon, and at like mile 21, you stopped to get a hot dog. That’s what we’re really doing. We are so close. If we just held on tight for a little bit longer until more of us were vaccinated so that we couldn’t be a good host for these viruses, then the B.1.1.7 would not have had a foothold. You know, it wouldn’t have found this vulnerable population that it could really sort of transmit with higher frequency among. And so it’s pandemic fatigue. I think it’s this thought that’s like: “Well, the people who are vulnerable are already vaccinated and I’m younger.” But of course, you know, what’s happening now is people over 65 sort of make up the greatest amount of mortality with this disease.
But the virus has changed. And so the virus is in the young. It is because they are the vulnerable compared to life months ago. These variants are likely causing more severe disease and potentially have a greater lethality because that’s what we know they do at baseline.
Marshall: So is there over-reliance on these vaccines to get us out of the pandemic mean that we’re going backwards, that we’re regressing from the gains that we made?
Bhadelia: I think the vaccines are the way out of this. That’s how we eventually get out of this, but right now they are not enough. Partly because, you know, what we’re all trying to aim towards, right, is this term that many have heard, which is his idea of vaccine-induced herd immunity. The idea that enough of us get vaccinated so the virus cannot find enough vulnerable people in the community to keep transmitting.
And we just let our guard down a little too early before we got to a point where enough of us stopped being vulnerable. So right now, I mean, Michigan is an interesting scenario because I think that the idea of sending places like Michigan more vaccine is a good one. We want to surge those areas with vaccines, but vaccines themselves will not be enough because if you don’t do the hard work of bringing the community’s transmission down, you kind of leave a hole in your bucket. Because the kind of things that might stop it is if you stop indoor capacity, if you keep those masks on until more of the Michigan’s population is vaccinated.
There was a study that Rochelle Walensky, actually before she became the CDC director, published, if you remember a few months ago, that said that vaccines make a smaller impact when there’s huge amounts of community transmission. And so I think it needs to be a combination of sending them more vaccines, but also putting into place some of those public health restrictions again, and then doing other strategies, right? I mean, really surging testing in there. If you could get tons of people tested and encourage people to get tested, they find out their status. They’re more likely to change their behavior. Then surging those areas with more treatments like monoclonal antibodies.
Marshall: Dr. Bhadelia, that’s interesting that you mentioned testing. It’s something we heard so much about previously and as vaccines came out we haven’t really heard anything about it. I was going to ask if we should be pushing up the vaccines to allow more people to get vaccinated faster, but it sounds like even if we did that we would still need that added element of more testing again?
Bhadelia: That’s right. I mean, I think throughout this pandemic this is true, right? That we can’t rely on any one strategy. It’s all about layering mitigation and it’s the same thing with response. You can’t rely on any one response strategy. You have to layer all the response strategies. And right now you have to do the testing. You have to get the therapies in there and you have to do the vaccines.
The interesting thing about just surging the vaccines, though, just a caution that I have, is if you just surged the vaccine, because I think it is a good idea, and we should do that, it’s a zero sum equation right now where you, when you give Michigan more vaccines, you’re taking that away from other places.
So keep in mind that testing and variant screening is not the same state to state. So are you potentially, because other states are not testing there, they don’t have the same level of testing. So they’re not identifying as many cases or they’re not identifying as many strains. Are you potentially, you know, creating greater inequity by taking away more vaccines from other states.
That’s one part, but the other part is, is it unfair because Michigan is not taking the rest of the measures such as non-pharmaceutical interventions? I still think that they should do all of those things. Like testing the non-pharmaceutical measures. If you really want to bring an end to the surges that we’re seeing there, we need to do all those things, including the vaccines. The only thing that I will say is that just because you’re not seeing a B.1.1.7 surge in other states right now does not mean that it could not occur.
Marshall: It could come.
Bhadelia: Exactly. Right. Because Illinois, if you look at all the states around Michigan, they all opened up around the same time, but you’re not seeing surges there. And that’s just a matter of timing and luck. I mean, it only takes a few, you know, a few chains of strong transmission and outbreaks in one of those states for B.1.1.7 to start increasing in those states, as well.
Marshall: I want to talk about something you mentioned a moment ago, that the vulnerable population is now younger because the older population is vaccinated. Is that a ripple effect we’re going to see continue? You mentioned that viruses continued to mutate. So as we vaccinate down to 18, will children now become the ones that are carriers and are actually being impacted by the virus in a way we haven’t yet seen?
And could that be a factor of continued mutations? Are we essentially putting kids at risk in the pandemic as we vaccinate older Americans?
Bhadelia: Yeah. So I think, I know what you’re saying, but I think that that’s giving the virus too much credit. There’s nothing intellectual sort of… there’s no intellectual gaming going on. There is just who the hosts are that aren’t protected yet.
But it does raise an interesting question of, are these variants having a selectively different outcome in the young. Like right now, if the older people were not vaccinated, would it still affect the younger people? And I don’t think that’s the case. Right. And so I think what you’re seeing is that in general, these are viruses that are becoming better at transmitting and potentially causing more severe disease. And so you’re seeing, you would have seen this in all ages, and you’re just ending up seeing it in younger ages because they’re the ones that are not vaccinated.
Marshall: But to that point, it became better at transmitting and causing severe illness. So if it continued to mutate, theoretically, one version of that mutation could become better at transmitting and the population that would then not be vaccinated would be children.
Bhadelia: That’s right. Exactly. So if the only people who are left where the virus can continue to transmit is the young, then that’s where it will transmit. And particularly if all of society lets down their guard, right, the behavior is going to change in children as much as it does in adults.
And so you could potentially see more opportunities of kids getting, potentially getting infected as well. So I think it’s important for us to include children in that vaccination eventually. Risk-wise they’re lower than everybody else. But eventually I think we need to include them if we want to achieve herd immunity.
The only thing I’ll say is that it’s not just children. I think we think of us only in this country, but it’s actually adult transmission all over the world. Unless we achieve global equity in vaccinations you’re going to see a continued transmission, continued evolution and new variants develop in other parts of the world. You know, maybe it’ll take a long time before they can impact, completely change or impact the efficacy of the current vaccines. But that continued transmission anywhere in the world is a threat to all of us.
Marshall: That brings me to something I wanted to ask you, which is that we talk about getting everyone vaccinated here in the U.S., but it’s a global pandemic. And as we’ve talked about, can change and adapt. And so at what point do we talk about global vaccination efforts and getting rid of this title “global pandemic”?
Bhadelia: Now. Yesterday.
Marshall: Last week.
Bhadelia: Yeah. Right. It’s already happening. Right? I mean, you saw that there was a concern that there was a variant identified in India that had a couple of mutations and that variant was found here in California. I mean, the variants are happening continuously. Anywhere there’s a transmission there is nothing geographically that’s specific to developing the new variants, except for the fact that there’s high levels of transmission. So anywhere there’s high levels of transmission you’re going to see that.
Here’s the selfish reason to vaccinate the world. And I’ll talk about then why there is also the right reason. The selfish reasons to vaccinate the rest of the world are: if the transmission continues in other places, even if we vaccinate all of us, eventually there might be variants that can come back and reduce the efficacy of our vaccines. And so we may leave more of our population vulnerable.
The other is, not vaccinating, well, there was a study from RAND in Europe that said that if we don’t have vaccine equity, it could cost us $1 trillion annually, in terms of the fact that we’re all economically dependent on each other. The way corporations now sort of operate with staff everywhere, supply chains everywhere, you know, we’re all dependent on each other as far as money, economic perspective as well.
The reasons why to do this, the non-selfish reasons why to do it, is because it’s the right thing to do. Not only that. There are places in this world where even the healthcare workers have not been vaccinated, which means that if there’s a whole percentage of healthcare workers who, if they pass away or can no longer work from having been infected from COVID-19, then you are affecting the health of that entire population.
It also delays all those communities going back to normal and operating. Running their healthcare systems normally, running their economy normally, having their public come back to normal. All the gains in development, economic development and education and health. We’re already going to see a huge impact. We’ve had our heads stuck in the sand, but as we walk out of this and start opening up our society, I think we’re in for a really rude awakening of the impact this has had on the rest of the world. And we need to do everything possible to mitigate that from here on out.
Marshall: Already though we’re seeing summer travel pick up. We’re seeing record pandemic travel, in fact. And so if globally vaccines aren’t even close to where they are in industrialized nations, what does that mean for the coming months? The CDC has put out guidelines for, you know, if you can travel this summer, if you’re vaccinated. Is that realistic?
Bhadelia: So there’s two parts to this. The impact it has on us and the impact it has on the rest of the world. So the impact it has on us, I think that even if all of us get vaccinated, right, it is likely that international travel will take a little bit longer to come back. Particularly in areas of the world where there isn’t a high level of vaccination, because there might just be hesitation, you know, in terms of, do I want to travel in that area particularly if there’s continued transmission. The good thing is that we are protected in those scenarios, right? Unless, unfortunately, you come across a variant that might reduce the efficacy of the vaccine that you took, then that’s different.
Marshall: And then you could bring that variant back even if you’re vaccinated?
Bhadelia: That’s right. Yeah, exactly. Yeah. But I mean, I think that people may just be more hesitant internationally, which I think is, I don’t know, I think the world is so connected it doesn’t really make a difference. I mean, every place in the world is two flights away. Two flights and a bus ride away in my experience.
So the thing that I’m concerned about for the rest of the world is that, you know, what you’re hearing is that the one way to return travel to normal is vaccine passports. And we have, we’ve done these, right? We have yellow fever vaccination cards that we use when we travel internationally. What I’m afraid of is that by doing that and making it a requirement, you are potentially creating global inequity. For example, academics, people I work with in Uganda and in Liberia who would come here for conferences, all of a sudden, if they don’t have access to vaccines in their own country they can’t come to the U.S.
And so you’re sort of creating more inequity, right? The populations in those countries just don’t have access to those vaccines. And then now you’re sort of adding additional burden on them. So how do you create that equity I think is going to be an interesting point.
Marshall: We’ve talked a lot so far about how these strands can mutate and how vaccines have worked and some of their shortfalls. I just want to look at this big picture here for a second, Dr. Bhadelia. Are vaccines the clear game changer in this pandemic if we can’t get them into the arms of everyone in a timely manner? Ultimately, what will it take to no longer call this a public health emergency or a pandemic?
Bhadelia: So good question. And I don’t think there are clear answers yet. There are suggestions that I’m seeing on the horizon. So are we going to get enough people? I think we will, you know, and good news that I’ve seen in the last week, there was a study from Kaiser Health News that said that people, the number of people who said they were not going to get the vaccine has remained the same; but the number of people who said they wanted to wait and see went from 39% to 17% between December and now. And so you’re moving people who are waiting and seeing in to people who wanted to get vaccinated. Thirty percent of the country’s already been vaccinated. Another 30% says they can’t wait. They’re going to get the dose as soon as they get it. Right. And it’s 17% they’re waiting and seeing. And so with those numbers, you already might get to a point where you have high amounts of vaccinations.
And then you have people who may, at least in the short-term, may have natural immunity from having had the virus before. I mean, the trouble with natural immunity is that we know that then some of the variants you may have higher rates of reinfection. Although I think overall the rates of the reinfection may be pretty low to begin with, but also we don’t know how long. It is likely that natural immunity does not last as long as the immunity from vaccines. We know that because looking in the laboratory, we see the amounts of antibodies that are created, even though that’s not the only thing that gives you immunity. We know that with vaccines it’s much higher levels and it’s likely to last for longer and protect you from those variants.
So what does it take? I heard an interesting proposition. I’ve heard propositions about getting to a point where there’s fewer hospitalizations and fewer cases. Dr. Fauci over the summer had said, you know, if right now we are at 60,000 cases a day, we could get to like 5,000 or 10,000 cases then maybe that means that we start opening up again.
What it takes? Vaccines are the absolute game changer of how we get out of this for the most part. But I think that we’re going to be aided by seasons, hopefully by summer, hopefully the cases will start going down. The concern is going to be in the summer, like cases go down and we open up.
Should there be a concern that next fall, if the virus comes back because you know, if there is seasonality to it, are you going to see the cases go up again, despite vaccinations? And that’s where a lot of people will differ. I’m optimistic. I’m optimistic that if we get majority of the people vaccinated, you’ll have some level of baseline immunity that even if the virus comes back, we’ll be closer to something like the flu, you know, rather than….
Marshall: But a majority of people in America vaccinated?
Bhadelia: Majority of the people in America vaccinated. Exactly. Although, you know what I’m going to say, sorry, what I’m imagining, unfortunately, is what we saw with measles. Which is we get the majority of the people in America vaccinated, but vaccine hesitancy often tends to travel within communities. You see entire, you know, towns or neighborhoods where people are sharing the same disinformation and misinformation. I see that potentially happening with COVID. Where all we get all of us vaccinated, but there are clusters, communities, where vaccine hesitancy is greater. And so they don’t reach that immunity. And so all next year you might still see outbreaks in those communities.
Marshall: Outside of the U.S, though, it’s a global pandemic. At what point will it no longer be? Is that ever a realistic threshold to reach or will it always be hovering right at the surface somewhere?
Bhadelia: It is hard to tell. I’m going to be very cynical in what I say next. I think it’s going to stop being a global emergency when it stops affecting well-resourced countries. And unfortunately it’ll become a continued struggle for resource-limited and middle and low-middle income countries until they can get the majority of them vaccinated. The good news is, you know, with a younger population, with the weather, some of those countries have not seen the same impact. It may just be that they have, they haven’t been able to get a handle on their excess mortality.
But what’s going to end it is that vaccination, getting that vaccination everywhere out there. I don’t think we’re going to eradicate this virus in the short term, not in the next five years. I think there’s too much transmission.
Look at things like yellow fever. We were just talking about yellow fever. Look at things like typhoid. There are still outbreaks of all these infections that we have treatment and vaccines for. It’s partly because vaccines are the right answer if your health systems are well-resourced. If your health systems are not well-resourced, it’s going to be much harder to get those outbreaks under control. There may be more regionalized, more localized, but I think that it’s going to be awhile before we get rid of this as a threat.
Last Updated April 14, 2021