番茄社区

In this video, 番茄社区 Editor-in-Chief Jeremy Faust, MD, of Brigham and Women's Hospital in Boston, sits down with two experts in the field of infectious diseases, Luciana Borio, MD, and Rick Bright, PhD, to talk about COVID-19 policy, vaccines, and the future of mandates.

The following is a transcript of their remarks:

Faust: It's a great pleasure for me to be joined by Dr. Luciana Borio and Dr. Rick Bright. Rick Bright is the CEO of the Pandemic Prevention Institute at the Rockefeller Foundation. He has also served as the director of the Biomedical Advanced Research and Development Authority (BARDA) and the deputy assistant secretary for preparedness and response at the U.S. Department of Health and Human Services.

Dr. Luciana Borio is a Venture Partner at ARCH Venture Partners and a Senior Fellow for Global Health at the Council on Foreign Relations. Dr. Borio is an infectious diseases physician, specializing in biodefense and emerging infectious diseases.

Dr. Borio, Dr. Bright, it's so great to have you join us here on 番茄社区. Let's get started. Welcome to you both.

So for the first question, I just want to talk about these that you had out [on Jan. 6]. Huge impact already, people talking about what needs to happen now, what needs to happen in the future. But I want to just kind of go through and point out a few areas. We'll touch on vaccines. We'll touch on therapeutics and a little bit on testing, and let's start with a first little excerpt, which I'm going to read so I get it right.

as when we are no higher than what typically occurred in most severe influenza years before the current pandemic. So that's a really great platform and a way to think about this, because "old normal" would be great. We would love to get back to old normal. So if the new normal can be like the old, I think that's a win.

My question is how do we define what that is? Is the "new normal" flu plus coronavirus season and now we're going to have double the deaths as before, or is it more indistinguishable from the past? I'll start with Dr. Borio.

Borio: Yeah. I mean, that's a great question. And I think that it really is about less disruption, right? During a seasonal flu epidemic, we are used to some disruption, but it's something that we can actually, you know, live with. And we know how -- you know, we implement vaccination programs, people get prescriptions for antiviral drugs, if they have symptoms, their diagnostic tests, we'd like to be able to see that for it as well.

And also, the papers highlight the importance of thinking about more than just flu. That it's really this aggregate of respiratory viruses that we have actually not focused on so much over the years with a lot of focus on flu, but that we should think about this as all these viruses that are causing sickness and illness – especially in the winter season in the Northern hemisphere.

Faust: I think that we all feel that the best way out of this is by maximally protecting the population with vaccines. I think the hot button topic is mandates. I think I certainly support most mandates in most situations. And I believe you both do too -- correct me if I'm wrong. I am curious though, I'll start with Dr. Bright, about the definition of the idea of three doses being "fully vaccinated."

And I'll read from the Viewpoint. , "In addition, when the definition of 'fully vaccinated' shifts to three doses or perhaps more doses of mRNA vaccines, the U.S. will lack a reliable way of identifying who has received only the first two doses and who has received a third dose."

So my question is: why does everybody need a third dose? What's the outcome we're looking for? Because I think a lot of people would say, if we're trying to get to a new flu, then is two not enough for, say, young males or even young people in general, who may not have any risks.

Bright: Well, Jeremy, I think we have to acknowledge that we're still learning a lot. I mean, it's important to remember that 18 months ago, we didn't even have a COVID-19 vaccine. Now we have three vaccines that are safe and highly effective, and we're learning how to use those most effectively. And we're learning how to use those in different populations, similar to an influenza vaccine.

We know at the first exposure to influenza vaccine in newborns or very young children, it takes two doses of vaccine to really prime that immune system with the SARS-CoV-2 vaccines or the COVID-19 vaccines. You know, initially we saw data sets of the general population that showed that two doses should be pretty safe and should be pretty effective against the variants that were circulating at the time. Now, we're actually learning the science about the duration of immunity and how long the antibody titers might last and when they start to wane. We're also seeing the virus start to shift and change as we go through the pandemic.

Is there a generic way of vaccinating everyone with the same number of doses? We know the answer to that is no. However, in the context of a pandemic, where we're trying to simplify as much as possible, it's almost easier to make a practice or a policy that everyone gets boosted while we're learning. Because we know that's going to give you more protection against the variants in terms of an antibody response until we have time to take a step back and really understand the proper regimen of vaccine dosing for this virus going forward.

Faust: Let me get Dr. Borio to chime in on this, because I wonder what you think in terms of mandating a third dose, for example, if the outcome is infection versus severe disease, or maybe it's just really all about transmission, because at the end of the day, the mandates are really about protecting each other, not about personal risk. What do you think about that?

Borio: I think the issue of mandates is so complicated, right? I think that no one likes to be in a position to say that mandates are the way to go, because it really isn't.

Who really is high on the idea of mandates? I think that early on it became clear that the uptake was not what it should have been given the incredibly safe and effective vaccines that were developed. And there was a real importance of vaccinating the population because the vaccines truly not only protected the individual but also had a really significant impact in diminishing transmission.

I think now you have to take a step back and say, what are the purposes of these mandates, in addition to keeping people out of the hospital to keep a critical workforce in place, right?

Because there is less, you know, duration of illness. I think it most likely also contributes to decreased transmission, but just not as much as we saw early on. So there's still a reason to support mandates, but we need to take a step back and think about things like, what is the reason that we're doing that?

And I do share some concern about the idea, for example, of mandating boosters for young college students that are going back to school, where the benefit is not as clear as it is for an older individual, with immunocompromising conditions – especially in light of an outbreak that is impacting so many people already. There are so many recent infections. What is a scientific rationale for exposing that young person to a mandated booster even after they had a primary series and were recently infected?

I think we have to begin to consider those before making broad mandates. I understand that they complicate implementation, but we need to be able to maintain, you know, science-based policies to be able to maintain credibility and the trust of the American people.

Faust: Let's stay on this for a second. Dr. Bright, you were involved with Operation Warp Speed. We have to thank for your work and getting us all these vaccines. But now with these mandates, we know that they work in a number of ways; there's a lot of research on this. It really comes down to two things, and this is what my colleague ... calls the "nudge" and the "sludge."

The nudge is where something that you wanted to do, maybe you were thinking about doing it, and a mandate provides that sort of nudge, that deadline.

The sludge is the opposite. It's the sort of, well, I can't go to this thing that I want to go to. I can't board this plane or go to this country or attend this event unless I'm vaccinated. That sludge is something that's kind of making your life a little bit more challenging to navigate.

Which one do you think is the more effective one? And my follow-up question would be: when you were involved in this whole process, did you ever imagine how political this would become?

Bright: Okay, I'll do the first one first. You know, I think it takes a little bit of a nudge and a sludge, and I think it depends on the environment and the setting that you're in. I think overall in a general population, we need to nudge, but we need to make sure that we're nudging with the right messages and the right messengers.

I think there's a difference between nudging and shaming. And I think we have to understand there's a lot of reasons why people aren't vaccinated or can't be vaccinated. There's a lot of lack of education, there's a lot of misinformation, and sometimes it's just still not even convenient to get vaccinated. So we need to make sure that we are not using shame as a tactic.

And if we do not, we need to nudge in a way that people understand and we need to get into the community-based organizations and meet people and meet Americans where they are in our great country so we can nudge them appropriately.

And I think that will have some benefit. In other cases, I do think we need to sludge if it's a workplace environment, if it's a travel sector industry, where it's really incumbent to try to ensure you have that workforce in place that isn't going to wipe out your industry or the sector, because everyone is severely ill and they're hospitalized and the duration of their illness is long and extended, or maybe they're dying.

Then, for the sake of that office or for that company or that industry, there might be a really good need and reason for those companies to mandate vaccination in their employees or in schools to make sure that the environment is as safe and as secure and robust as possible to get us through this pandemic.

Now I'll talk about politics. You know, Lu and I are both in the government. We both spent years in the government and we've been through many exercises. And we always know that government policy is important, and important to get right in the pandemic, and it's difficult to get right in the pandemic actually, but we never experienced political interference.

So there's a difference between politics -- and pandemics are political -- but there's a difference in political interference and that political denialism that we saw at the start of this pandemic, where we had, you know, the political party and leadership and administration basically denying the risk and denying that this was as big of a problem as it was. That affected or impacted policies, policies on testing and mask wearing and even social distancing and the messaging that got out to Americans, and that impacted our response to this.

That political interference influenced policies that impacted the response. And that actually put us on flat footing against this virus that really didn't care what political party was addressing it, but it had a free open run then to take hold and transmit and spread across our country in the way that we've seen it still doing today.

So we need to think about that. Going forward, we cannot say pandemics are not political, because they are, but we have to make sure the politics are helpful in making the right policies that are science-driven, driven by data, and that the best decisions are made to help us control the pandemic as quickly as possible.

Faust: Yeah, and things have gotten so political. People now think it's part of their identity, whether they're pro- or anti-vax or hesitant, and so there's nuts in the sludge. And then there's that small group of people who take up most of the oxygen -- they get all the headlines. These are the people who are really anti-.

And then the question is with mandates, do we have to shove? You know, there is that small portion of people who will not get it. And they try to maybe come up with a reason why they need an exemption, but some of them just -- it's really about their personal freedom, they think.

Should we shove people? I mean, how far should we take this? Dr. Borio, I'll start with you, but I'm sure that Dr. Bright has an opinion on that as well.

Borio: Well, you know, I don't know that I have a great answer for this. I think if there are significant restrictions, people can make their choices. If they're not able to board a plane, a train, or an interstate bus, then they have to take responsibility for the decisions they live with. I don't think that we are in a situation where you can actually hold somebody down and give them a vaccine.

The one thing that I am concerned about, though, that I've seen in my own clinic experience, I've seen an increasing number of people that are more resistant now to the vaccine that otherwise would've been very susceptible to information, discussion, and more open-minded about it to have the discussion. I have patients now that show up and they'll say, "I don't even want to talk about it, I've made up my mind. Let's not waste my time." And that's -- I have never experienced that before.

So I think we have to find a way to understand what's happening, because it's different than before, so that we can take corrective measures.

Faust: Super-fascinating. That concludes Part 1 of our 番茄社区 interview with Dr. Rick Bright and Dr. Luciana Borio. We're going to make this a two-part series because there's so much here, so much expertise, so much insight.

So please join us for Part 2 of what I think is a really interesting conversation with two of our great experts in this field.

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