MedPage Today Editor-in-Chief Marty Makary, MD, MPH, of Johns Hopkins in Baltimore, discusses vaccine hesitancy, child vaccination, and the recent surge in India with Joshua M. Sharfstein, MD, vice dean for public health practice and community engagement at Johns Hopkins Bloomberg School of Public Health.
Following is a transcript of their remarks; note that errors are possible.
Makary: Hi, I’m Marty Makary and I’m here with Dr. Josh Sharfstein. He is vice dean of the Johns Hopkins Bloomberg School of Public Health and former deputy commissioner of the FDA and former Maryland health secretary. Josh, great to have you with us.
Sharfstein: Thanks for having me, Marty.
Makary: Josh, I always love picking your brain, and you’ve got so much wisdom on so many issues that relate to the pandemic right now. You had an article that just came out in JAMA that I want to get to. But what are your thoughts on this broader issue right now of vaccine hesitancy?
Sharfstein: Well, what we’re seeing is, initially there was much more demand than there was supply. So people were scouring the internet for doses. They were lining up outside vaccine sites, and a lot of that excess demand has been met. And now we’re getting to the point where supply and demand are more in balance. And pretty soon we’ll be at a point where there’s more supply than demand in the United States because the people who are left are more hesitant.
And we’re going to have to now shift strategies. If the first strategy was, let’s set up the football stadium, let’s create an easy way for people to sign up, now, we’re going to be thinking about how do we message to people, how do we put ourselves in a position to answer their questions, how do we work with people’s doctors who they trust more than anyone else to talk to them about vaccines?
Makary: Are we moving to walk-in clinics fast enough?
Sharfstein: I think we’re definitely seeing that shift. But I think probably we have to go even beyond walk-in clinics. I think it’s important to get the vaccine to the extent possible to people’s physicians. Because the people that are left will have questions and they’ll be in the doctor’s office. And the doctor may be able to say, here we go, we could do it right now. We could protect you right now and inspire people in the moment. And I think we have to take advantage of those opportunities.
Makary: You’ve yourself gone to the vaccine clinic in our area. And you had some pretty interesting experiences there. Can you share a little bit about that?
Sharfstein: It is the most fun thing I’ve done in the last 16 months. You know, mainly I’m in my basement here talking to people or writing about the pandemic. And I’ve been going out since the vaccines became available to volunteer with the Baltimore City Health Department. And it’s first of all, just fun to be around other people.
And then it’s great to be around people who are excited and positive, and it feels like you’re really fighting the virus one person at a time.
But it also gives me a sense of what people are thinking about why people are getting vaccinated. I get to talk to people while they’re getting screened in the observation area. And now we’re hearing from people who were somewhat hesitant before, but they’ve come around because they’ve seen their friends get vaccinated, but often it’s someone in their life.
The last time I went, someone was telling me, my mom said I really needed to get vaccinated. The person who was talking to me was like 65 years old. But she said, her mom told her to get vaccinated. And she said, okay, I’ll do it for you, mom. And so there she was.
Makary: That’s pretty cool of all the people that you see in the vaccine clinic get vaccinated, for what percent is it a deeply emotional moment?
Sharfstein: I think it’s important for a lot of people. A lot of people, they don’t go to the doctor that much. I was a health commissioner of the city of Baltimore and I always wondered, who are the people that we don’t see in our clinics? And they’re coming in to be vaccinated.
And sometimes they get anxious, so then I spend extra time with them as the physician. And I talk to them and they say, I’m really anxious because I haven’t been to the doctor in 10 years. And so these are people who really can be brought into the system and they’ve really thought about getting vaccinated before they come. And it is a big deal for them. And it’s an opportunity to capitalize on, to help them think about other care that they can get.
Makary: It seems like the urgency to get kids vaccinated depends a little bit on whether or not one thinks that we’re close to herd immunity — that we’re far off from herd immunity, whether or not natural immunity is part of the equation, it looks like there’s going to be a vaccine available very soon for kids age 12 to 15.
What are your thoughts on child vaccination in general?
Sharfstein: Well first of all, it’s great that there were studies for kids 12 to 15 and we’ll be able to see those studies; the evidence should be released so everyone can see it — the doctors, the patients, the parents — and talk over what it means. There’s obviously going to need to be a lot of surveillance of any unforeseen side effects — very closely with any new population of patients.
But in general, I think it’s a very positive development because we know that kids in that age group can really pass it along and we’re seeing some of them get sick and some of them of course have this post-inflammatory syndrome. So hopefully it will really help with both of those things.
Makary: Josh, what I really appreciate when I’ve talked to you and get your thoughts on issues is that you’re a pediatrician and a lot of folks have a perspective on this based on their background in virology statistics, clinical medicine — you’ve got a bunch of those backgrounds. How has your role as a pediatrician influenced your outlook and your recommendations on what’s happening?
Sharfstein: Pediatrics has very much the attitude that it is always better to prevent than to treat. You know, we’re constantly thinking in kids, how do we prevent? And we’re willing to do extra work to prevent in kids. Typically with a risk of 1-3% of sepsis, everybody’s getting blood cultures in kids; we’re just worried. We want to get ahead of it.
We have the understanding that when you prevent, then you have just amazing opportunities for kids to thrive. And so, it’s a very naturally consistent way of looking at the world as with public health.
And so, I see the pandemic and I think it’s great that we have an amazing healthcare system. We have so many ICUs we were able to scale the ICUs. We were able to bring people in to manage ventilators. But I see the failures in the prevention, that we weren’t able to get testing to the right places at the right scale and do contact tracing and scale, and really support people in isolation and quarantine.
And I think when we look back on this pandemic, we’re going to be very proud of the medical response — and I am proud of the medical response and have so much respect for people who are just jumping into even clinical environments they weren’t used to.
But I think we have a ways to go to have that prevention component as strong as it needs to be, to keep people out of those intensive care units.
Makary: You’ve got a great article in [JAMA] with Ruth [Karron, MD, and Nigel Key, MD] and you talk about the J&J vaccine, and that whole process — what we can learn from it, what people should take away as their take-home messages. How would you summarize that article for the listeners out there?
Sharfstein: Sure. Well, we’re talking about this very rare thrombosis with thrombocytopenia syndrome, which is occurring with the Johnson & Johnson vaccine, as well as with the AstraZeneca vaccine, both of them adenovirus vectors.
So in general, the first thing is it looks like it’s caused by the vaccine. And the evidence for causality includes a much higher rate among people who are just vaccinated than the baseline rate, as well as this consistency across these two vaccines. It looks a lot like heparin-induced thrombocytopenia, which is a very serious condition. And there’s a lot we don’t know about it. We don’t know a lot about the pathogenesis or how common it is. We just have some evidence from reporting. So there’s a lot of work that has to be done on it.
I would say from a policy perspective, there are two major points. One is that even with this risk, which is very rare, the benefits of vaccination outweigh no vaccination. But at the same time, if the alternative is a vaccine that is not associated with this risk, like the mRNA vaccine, that may make the most sense for people at high risk for this complication, which right now for the J&J vaccine looks like women under 50.
So we say in the editorial that clinicians should consider advising women under 50 to do the mRNA rather than the adenovirus vector vaccines, if there is an alternative. But if the comparison is no vaccine, still use the vaccine.
Makary: You know, I really appreciated that article, Josh, because it does seem like the recommendation as to whether or not to get the vaccine, the J&J adenoviral vector vaccine, is not a recommendation that’s in a vacuum. It’s dependent really on the alternatives, and when you’re severely supply-constrained and a lot of people are dying from the infection, that might yield a different recommendation than when you have the alternative mRNA vaccines at your disposal, and there’s a lower background rate of infection. Is that … am I understanding that correctly?
Sharfstein: It’s true. I teach about regulation at the School of Public Health, and usually I start a class by saying, there’s a medication that we use that’s coming before the FDA and it kills two out of every 10 people — should the FDA approve it? Nobody raises their hand. Then I go, oh, well it’s against a disease that’s otherwise fatal 100% of the time. Then everyone raises their hand. And then I go, but there’s an alternative that we’re about to approve that isn’t fatal at all. Then nobody raises their hand.
So I mean, it is really true that benefit and risk are relative concepts. And you just have to be able to understand the context, and that can be hard particularly in a pandemic, but those are definitely the principles that you have to bring to assessing benefit and risk.
Makary: Why did India get hit so late? I was surprised by that. I had always thought that India was prime to get hit hard, especially given the additional oral fecal transmission route in addition to the respiratory route. But why did they get hit so late? I was surprised by that.
Sharfstein: Well, India moved pretty aggressively initially to impose non-pharmaceutical interventions, and reduce movement. So the initial surge didn’t really happen in India, and then they prepared a huge amount for a fall wave. They built hospitals, extra hospitals, they started to manufacture oxygen, and it just wasn’t that bad. I think everybody was so worried about it, and they took precautions.
And then it passed, and at that point, I think the voices of people saying maybe this was never going to be that bad took over. And the leadership in the country really acted like it was over. They didn’t convene their committee that was governing the COVID response, I think for a couple of months, by reports. And there were massive political rallies, tens of thousands, hundreds of thousands of people. Mask wearing really wasn’t happening.
So it was sort of baiting the virus, and the virus will take the bait.
Makary: Marc Lipsitch, MD, from Harvard, an epidemiologist, and several others wrote a piece in Nature, sort of talking about what they call dose-sparing strategies. Is that something you think in India they should be considering right now?
Sharfstein: You mean for the vaccine?
Makary: Yeah, for the vaccine. That’s right. So everything from delaying the second dose to maybe half the first dose to all sorts of different … what they call sort of collectively dose-sparing strategies.
Sharfstein: Oh, I see. I think that sure, everything should always be considered, and it really will depend on what the data shows. I think the concern is obviously with the variants that you may not be buying enough time if you’re just doing one dose, because it may give some room for the variance to spread. So I think if you consider all of those factors, then you can make a good decision. So I don’t have an opinion on exactly what India should do.
Last Updated May 05, 2021
Source: MedicalNewsToday.com
