Allen Alter:
Welcome, everybody. Thanks for joining us on this special Class of '71 panel discussion. We have some distinguished speakers from our class who are going to be part of this. They'll be introduced shortly. I just wanted to say that we're grateful for your presence today and just to remind you about a few things that are coming down the pike.
Allen Alter:
Of course, our virtual 50th reunion, most significantly, will be June 11th through 13th during alumni weekend. There'll be lots of events and two special class of '71 events of this nature where we'll be gathering just for our classmates virtually. Those programs are in development. Then over the next year, in anticipation of seeing one another in person for alumni weekend 2022, June 10th through 12th in 2022, that's when we'll be able to hug one another and really celebrate our 50th in person.
Allen Alter:
In the coming months you'll hear, if you haven't seen already, some outreach about a virtual yearbook that we ask everybody to contribute to in some form or another with text and pictures and there are instructions about how to do that. If you haven't received it, let us know. Ashley in alumni affairs or Susan Jay or myself would be happy to pass that along.
Allen Alter:
The other thing that we're asking everybody to take note of and, hopefully, participate in is our class gift. Susan knows a lot about that and has been instrumental in it. We've already raised considerable money towards the class of '71 scholarship and towards a Brandeis fund. I turn it over to the co-chair of the class fund of '71, 50th reunion committee, Susan Jay.
Susan Jay:
Thank you, Allen. Welcome, everyone. This is wonderful. The first in a series of webinars that we're going to be having. I am delighted to introduce our classmate and my friend since freshman year, Dr. Arthur L. Caplan. Arthur is currently the Drs. William F. and Virginia Connolly Mitty professor of bioethics, department of population health, and the founding head of the division of medical ethics at the NYU Grossman School of Medicine in New York City. Prior to joining NYU, Art was the Sidney D. Caplan professor of bioethics at U Penn where he created the Center for Bioethics and the Department of Medical Ethics.
Susan Jay:
As you can all imagine, Arthur has a very extensive bio. He's the author or editor of 35 books and over 800 papers and peer-reviewed journals, one of the most recent of which is relevant, Vaccination Ethics and Policy. He served in a variety of national presidential and international committees. He holds seven honorary degrees from colleges and medical schools. He's the recipient of many awards and honors, including being one of the most influential people in the world in a variety of health arenas.
Susan Jay:
I don't think there's anyone on this webinar who has not heard or seen Art speak in a local, national, or international media outlet. He advises and speaks on a wide range of bioethical issues such as human cloning, human experimentation on vulnerable subjects, trafficking and organ body parts, and genetics and gene therapy.
Susan Jay:
During the pandemic, he has been co-directing an advisory group on sports and recreation for the US Conference of Mayors and for NCAA Sports. He has also been developing an ethical framework for distributing drugs and vaccines for J&J and helping develop rationing policies for health systems.
Susan Jay:
We are all appreciative of Arthur sharing his time with us. Welcome.
Art Caplan:
Well, thank you, Susan. If my mom was still alive, she passed away maybe a year ago now from COVID, she would be thrilled at that introduction.
Susan Jay:
That was the point.
Art Caplan:
Yeah. For those of you who don't recognize that person from the class of '71, I am Artie. That was the moniker that I went by at that time. In case you were confused, it's still me just transformed into a graying ancient.
Art Caplan:
Other than that, welcome, everybody. It's really a pleasure to have you at this event. As Susan said, we're going to do more of these and we have a series of events that I think over the next year or so will attract many of you and we can tell our classmates to participate.
Art Caplan:
Today, we have outstanding expertise from our class in COVID. It's amazing how strong the people are that we've got from our class on the panel. We have Steven Berk, who is a dean down at Texas Tech, an executive vice president there of the medical school, Susan Weiss, who is a distinguished microbiologist and probably knows more about the virology of SARS, COVID-2, and has worked on MERS, and cousin coronaviruses. I don't know that anybody is more expert than she is in microbiology. She is at the University of Pennsylvania.
Art Caplan:
Deborah Cotton, who I've had the pleasure of dealing with, not always pleasurable, sometimes she turns down articles that I try to get published but mainly pleasurable. She's at BU where she's a professor of medicine and epidemiology in the school of public health there and knows the field, both from her own expertise and from having the opportunity to track and see what people are writing in one of the most distinguished journals in all of internal medicine that is out there.
Art Caplan:
These are three. We could have had many more. I'm just thrilled to have these people with us. Here's the march, we're going to let each of our panelists give some opening remarks. I'll probably lead off with Susan, partly because she is this year's recipient of the Brandeis Alumni Achievement Award so that ought to get her some priority. I'm sure it's moved up very high on her resume now of the distinguished awards that she has received.
Art Caplan:
We'll lead with her and then I'll let Deborah take the floor for a few minutes and then we will go to Steve and then I will ask them some questions that I think they're well prepared to answer from different angles of our SARS, COVID outbreak. Then we will open the floor to you all. The way we'll do that is the chat box. You can't ask a question on this particular webinar. It would be confusing and hard to manage. I'm watching the chat box. You may ask a question at any time in the chat box. As we go along, I'll keep an eye on that. I'll try to direct questions there.
Art Caplan:
Hopefully, if we don't get to all the questions, we may be able to ask Ashley, who's done a great job putting this together, from Brandeis to compile them and maybe we'll be able to answer them after the panel ends. We'll post or reach out and try to address things we didn't answer. Hopefully, we'll have a solid hour, learn a lot, engage in dialog, and really take advantage of the expertise that our class has in the space.
Art Caplan:
With that, Susan, I'm going to turn to you. If you could just get us a little bit oriented to what you think are some of the key aspects of this outbreak that maybe people are properly understanding, not understanding, from your expertise.
Susan Weiss:
Okay. When I left Brandeis, I went and I got a PHD in virology. I then went to California where I was a post-doc working on retroviruses with Harold Varmus and Mike Bishop. At the end of that time, I decided I wanted to do something different so I looked for an interesting virus system to work on and I found coronaviruses. We're talking 1978 or so when really the only coronaviruses we knew about were caused the common cold or caused infections in just about every animal species you can imagine. There were serious pathogens of animals for which people were doing a lot of vaccine research at the time.
Susan Weiss:
Anyway, from that time on until about 2002 when we had the first SARS epidemic, there was a small group of people studying these coronaviruses as animal models. We worked a lot with mouse hepatitis virus and we learned a lot about how these viruses replicate. They have a really unusual mechanism, which, of course, we won't get into now.
Susan Weiss:
We really knew a lot so that when SARS emerged in southern China in 2002, very quickly identified as a coronavirus and we knew how it replicated, we knew its immune response. We knew a lot about it.
Susan Weiss:
Then that epidemic only lasted about eight months, if you can believe it. It went away because SARS didn't spread asymptomatically. People kind of forgot about it I think because it was fast and it was in Asia. It was like over there.
Susan Weiss:
Things were quiet in coronavirus land until 2012 when MERS, Middle East Respiratory Syndrome Virus, emerged in Saudi Arabia causing an epidemic that's still going on. Both of these viruses originated in bats. MERS has a reservoir in camels and still infects people.
Susan Weiss:
Then fast forward to 2019, we already had had two epidemics but we kind of ignored them. We really forgot about them. We got hit with the big one, obviously, in December of 2019 when SARS-2 emerged from Wuhan. Really, everyone's behaving like this is something really new. These viruses are not new. We know a lot about the basic stuff about how they work. This virus is just so perplexing because it's able to spread asymptomatically or pre-symptomatically and it's just spread all over the world in a way the other coronaviruses haven't.
Susan Weiss:
I just hope we've learned a good lesson from this one and we don't stop working on understanding the basic biology of these viruses as well as continuing to look for their precursors in bats and other species.
Susan Weiss:
I guess my thoughts about it are just the virus itself is not so unusual. We know how it reacts. We know how to look for antivirals against it. Obviously, we've learned how to make vaccines. We have to not drop the ball in keeping on top of these viruses. I think I'll stop there.
Art Caplan:
Thank you, Susan. One quick question. Do you think the knowledge that you and others had about this category of coronaviruses was partly responsible for the speed with which vaccines were able to be produced?
Susan Weiss:
Well, I mean, we knew about the spike protein in 1978. Yes. I mean, we're talking a long gap. Warp speed was the development of the virus. We have to give Drew Weissman, another Brandeis alum, a lot of credit for developing the MRNA vaccine. Knowing which protein to target ... I mean, we knew that a long time ago. Yeah. That comes out of basic science for sure.
Art Caplan:
All right. Thank you very much. We will move onto let Deborah offer us a little bit, maybe some history, and then over to where we are now in your view with some of the key COVID issues.
Deborah Cotton:
Sure. Well, first, I don't think we can thank Susan enough for her work in the last 40 years. What amazes me about her is that ... I have many memories with Susan. We were suite mates. One of my most intense memories is discussing the Iliad with Susan.
Susan Weiss:
Really?
Deborah Cotton:
She's so brilliant. That's Susan. Anyway, after Brandeis, I went to medical school and decided along the way to become an infectious disease doctor. I went to the NIH. Probably the most important thing I did at the NIH was turn down an offer from Tony Fauci to train in his lab. That is probably the most historic thing I did.
Deborah Cotton:
I, ultimately, decided that I was more interested in clinical epidemiology, clinical medicine, got an MPH at Hopkins and then returned to Boston where I've been ever since, practicing, focusing on AIDS, especially AIDS in women, and all sorts of infectious diseases, doing some administrative roles along the way.
Deborah Cotton:
Most of my time now I am a deputy editor at the Annals of Internal Medicine, as Art mentioned. I can tell you that in this year, past year, we have had twice as many submissions as we normally do because of COVID. We're all working quite overtime.
Deborah Cotton:
I'm quite immersed in the disease and happy to talk about the disease itself if that is helpful to anyone. It is an extraordinary thing. Having spent my career in AIDS, many people ask me what is this like? Was it like this in AIDS? What I try to say is that really AIDS is being compressed from a decade of work into a year of work. I mean, remember that it was literally three and a half, four years, before we knew what HIV was. It was another decade before we had effective therapies. After 40 years, we have no vaccine. Very different disease but a great challenge to all of us. I'm very interested in your questions.
Deborah Cotton:
I also want to bring greetings. Some of you remember my husband, Roger Lipsett, also a member of our class. He says hello to you all.
Art Caplan:
Thank you. Steve?
Steven Berk:
Yes. I'm Steve Berk. I'm the dean of the Texas Tech Health Science Center School of Medicine. I've actually been doing that for 15 years. I went to Boston U Medical School, I did my residency in infectious disease fellowship at Boston City. Also, became trained in geriatric medicine. I spent my entire career in academics teaching medical students, doing research, mostly on infections in the elderly, and taking care of patients.
Steven Berk:
This pandemic, for me, has been the challenge of trying to navigate a health science center. We have multiple campuses, Lubbock, Amarillo, Midland, Odessa, El Paso is its own school now, but trying to navigate us through the pandemic, trying to keep the medical students safe and still optimizing their education, evaluating some of the potential therapies we had, most of which didn't work, convalescent serum and Remdesivir.
Steven Berk:
I have a particular interest in what happened to nursing homes in COVID-19. Dr. Verghese and I wrote an early editorial in the Washington Post warning that nursing homes would be the tinderbox for SARS-CoV-2 and really now trying to reevaluate nursing homes post-COVID to start over with a new model.
Steven Berk:
I spent a lot of time with students in their voluntary activities, medical students have been really worked very hard to support fighting against this pandemic in every way, particularly, right now, working with a great group of medical students, not only at Texas Tech but across Texas to try to guarantee that the disparities in vaccine distribution won't be as severe as they've started out to be.
Steven Berk:
Also, maybe lastly, as we have more medical students applying to medical school now than ever before around the country, even reevaluating based on resilience and character, what students we should really be taking for the next generation of medical school and ... I don't want to offend anybody but to say it's probably not about organic chemistry or even about the MCATs but I think we have to take a deeper dive in who we want the next generation of medical students to be. Those are some of the things that I've dealt with in the pandemic as the dean of a medical school.
Art Caplan:
Very good. Those are great introductions. You can see the kind of expertise I was talking about in the class, some of whom worked here ... I'm laughing about organic chemistry, which I took with Fred Alton, another one of our classmates, one of my roommates, as a matter of fact. I would be thrilled to find out that organic chemistry is less important than we thought it was at the time as pre-meds.
Art Caplan:
Anyway, let me go back to Susan. I have a question. I know it's on the minds of many people. It's in the news every day. In the past couple of weeks, I've seen more news about genetic mutations. The virus is mutating. Some people almost take the view in the media that it's got a brain of its own. What's your view about the threats of variations and mutations and what do we make of that?
Susan Weiss:
First, I'll unmute myself. Well, first of all, let me explain where they come from. Viruses that have RNA genomes, they don't have any DNA. These are RNA viruses and they replicate and as they replicate, they make errors. It's just the way their enzymes work as they replicate.
Susan Weiss:
Most of these, many of these, have no effect at all but some of these changes in sequence in the RNA genome, they're kind of mutations but they're really just normal variations. If they should give the virus an advantage to replicate or to spread then they're selected for it and that virus with that change in it is going to become a more dominant virus.
Susan Weiss:
It doesn't necessarily mean they're going to become more virulent or more pathogenic. In fact, often times they're not. A virus in order to survive wants to be able to spread. It's not particularly invested in killing its host. It really just wants to spread a lot. The more it replicates and spreads, the more successful it is.
Susan Weiss:
I think most of these mutations are simply a selection for viruses that are spreading better and that's what we hear about the UK virus, that first one, and actually as sort of evidence of that, these viruses are popping up all over the place because they give the virus an advantage to replicate most likely. It's not like the virus in Britain ... It is showing up here but we're getting independent ones as well. We've been looking here at the University of Pennsylvania and there are certainly so-called Philadelphia variants. Some of them have very similar mutations because these are the sequences that make the virus replicate better.
Susan Weiss:
For example, the UK variant, that's sort of the most talked about one I think, it's clear that the response to the Moderna and the Pfizer vaccines are able to neutralize that virus. They're not really threatening in that sense.
Susan Weiss:
The virus from South Africa seems to be a little bit more worrisome because one of them mutations in that virus does seem to make neutralization by serum from convalescing patients less effective. It doesn't mean it's not effective. It'd be less effective.
Susan Weiss:
Again, when people are testing these variants, they're often just looking at whether an antibody can neutralize them but there are other parts of the immune response that are not measured in these assays. We really don't know how worrisome it is. I mean, so far, I think it's not that worrisome. I mean, if it becomes a dominant ... If there are any dominant mutations that really do compromise the vaccine efficacy, new vaccines can be designed. Remember, these vaccines are just against the spike protein and that protein can be the messenger RNA vaccines can be reprogrammed quite easily. Producing them will be a big deal but actually designing them is really very simple.
Susan Weiss:
At this point, I'm not that concerned about these. I think we should watch them and we should see at some point ... These viruses come from bats and they have to adapt to humans. A lot of this may just be adaptation. I think we have to wait until we see some steady state of the sequence and maybe then that's the time to think about boosters or other vaccines.
Art Caplan:
Yeah. I was going to ask you, I'm going to followup in two directions here but let me just ask, I think many of us on the call and myself have heard about different vaccine platforms. We have the MRNA vaccines and then there are the old style J&J vaccines with attenuated virus. Is that going to make any difference in terms of efficacy? People ask me these days, "Does it matter what vaccine I get? Should I seek out one?"
Susan Weiss:
Let's back up for a moment. There's no attenuated vaccine here. Everybody is afraid of using an attenuated SARS. Although, I think actually it would be a good approach but that would take a long time to develop, safety, and all that.
Susan Weiss:
The most common vaccines we have now, the MRNA vaccines and the adenovirus ... They're not even Adenovirus. They're adenoviral vector vaccines. Both of these vaccines present either a messenger RNA or a DNA, both programmed to make the same spike proteins. They're essentially giving the same antigen.
Susan Weiss:
I'm not an immunologist. I don't know ... I can't tell you whether presenting them one way or the other is going to be better. It does look like I think so far that the MRNA vaccines show better protection in the trials that have been done. Really, theoretically, they're all giving you the same antigen. There's no virus. Adenovirus is a vector. It's just giving you nucleic acid to allow you to make your own protein. They're very clever.
Art Caplan:
You mentioned from bats. A lot of people, former presidents, others, have other suggestions. The virus started in a lab, a virus was an error in a biological lab in Wuhan, China and so on. You seem to be convinced that there's some zoonotic connection from bats. Why are you of that view?
Susan Weiss:
Several reasons. First of all, there are certainly viruses in bats. Bats have hundreds and hundreds and hundreds of viruses. There are viruses that resemble this one in bats. In fact, for SARS-1 there are even viruses that have spike proteins close enough to the human virus that they could infect humans. They could go directly from a bat to a human. There's certainly reasons to believe ... We don't know the precursor virus to this one yet, the bat virus, but it took a really long time with SARS to figure it out too. There's most likely a bat precursor virus.
Susan Weiss:
The other reason that I think it's ... We can't rule out that there was a virus in a lab that somehow escaped, which I think it's unlikely but you can't really prove a negative. What we can be really sure of, at least in my mind, is that this virus was not synthetically made by some evil scientist because to make a recumbent virus, which you can do, you always have to start with a base of another virus. This virus doesn't resemble anything we know. It's not like it's got a piece of SARS and a piece of MERS and a piece of this and a piece of that.
Susan Weiss:
You make these virus with a bat bone. There would be no way that anyone could ever, ever figure out how to make a virus with these properties. It's just humanely impossible. I'm 100% convinced it's not a synthetic virus. I think it's most likely from bats.
Art Caplan:
Let me jump over, Deborah. I got a question for you that sort of follows on here. What about herd immunity from an epidemiological point of view? Are we ever going to get in a position where we could say that our either getting naturally infected or from vaccines or however it gets built will build up in our country, let's say, enough immunity to attenuate the epidemic?
Deborah Cotton:
Well, I think we're all hopeful that we eventually have about 80%, 85% of the population vaccinated and some of that percentage will be people who were naturally infected. We think that's roughly the level we'd have to be at before we basically see the epidemic collapse. It's going to depend on a lot of things and I think that there's no secret here that we really are behind in rolling out the vaccine.
Deborah Cotton:
Our goal should be to get the vaccine into as many people as possible. Viruses can't mutate unless they're replicating. We need to drive down the epidemic. We certainly need to protect those most vulnerable in terms of what would happen to them if they got infected. We also need to try to drive it down in young people who won't feel the effect themselves necessarily but who can infect others.
Deborah Cotton:
I think that the concept of herd immunity is a very old one in infectious disease. This is not something that people talked about just with SARS-CoV-2. It's a well known concept. What it needs to be varies by the virus but we believe that it's probably going to have to be pretty high.
Deborah Cotton:
Now we are seeing some reduction now and part of that has got to be that we've, unfortunately, seen natural infection beyond what we would have liked to have seen. We don't think it's due to the vaccine yet because the vaccine hasn't rolled out enough. We do have some herd immunity that's natural but not enough to end the epidemic.
Art Caplan:
Yeah. That old strategy of relying on natural infection, that some espouse, doesn't seem to have taken us...
Deborah Cotton:
It would have had a much bigger toll in terms of lives lost. I think that's what we have to say. This was not a situation where it would have been a reasonable thing to do to just allow people to get infected.
Art Caplan:
Let me ask you a followup question on this. Today, I happened to get a paper accepted in the distinguished journal the Annals of Internal Medicine. It's about risk behavior.
Deborah Cotton:
I wasn't the editor. I just want to...
Art Caplan:
I know that. I know that.
Art Caplan:
That's why I thought I'd let you know... Anyway, that particular paper tries to explore the phenomena of risk reduction and when people get vaccinated, they may feel that they can just go out and do anything they want, throw off their masks, have a good time, go to parties, whatever. Are you worried about that phenomena? Are you worried about people in a sense taking false confidence? Either that the vaccine is 100% effective or that they won't necessarily infect others.
Deborah Cotton:
Well, I think that one of the concepts we like to stress is risk reduction. I think it's going to be a tough few months for people to understand that until we really do have a large, large percentage of the population vaccinated, that we have to, as good citizens, even if we are immunized ourselves, continue to do everything. Wear masks, avoid big crowds, avoid high risk situations.
Deborah Cotton:
The issue of whether or not you can become infected once you're fully immunized and perhaps, more importantly, whether you can transmit is up in the air right now. There's no question in most people's minds that once we're vaccinated, the risk of transmission to others should be greatly lowered.
Deborah Cotton:
Until we get the vaccine rolled out, far greater than we have, it would be very premature to give everything up.
Art Caplan:
If I said I'm going down to Miami to take Susan to a dinner in a restaurant, should I go to a restaurant indoors?
Deborah Cotton:
I would not go to a restaurant indoors in Miami. Now, here's what's getting harder to parse out. What do you do if you're with a group of people, a small group of people, who have all been fully immunized? That's a tough one. I think that it is a matter of risk reduction. What risk are you willing to take for yourself but also what risk are you willing to potentially pose to other people?
Deborah Cotton:
I can't answer it for any one given person. Personally, I want to keep the number of people in my circle, I continue to keep it very small, because both of my daughters are in healthcare, one, a nurse, one, a doctor, both have been fully immunized, I have been fully immunized, I spent time together with them. I can tell you that we ventured out for one dinner and were so appalled at the behavior of the people in the restaurant that, even though, we were not really posing in any way a greater risk than they were posing to themselves, I don't think we can see that again. It was upsetting that people even now were not wearing masks while they sat there waiting to order their food.
Deborah Cotton:
I think for most of us, life is not going to get back to normal. I think it's a calculus each person has to do.
Art Caplan:
Just a quick reminder, questions into the chat box. I'm seeing them growing there, not ignoring them, I will get to them. Steven, a question for you. We heard reference to the fact that as long as viruses are out there replicating, they're also potentially mutating. This brings us to a question about the vaccine supply and how we distribute it.
Art Caplan:
I wanted to get your view. Some people say we should vaccinate people in our own country, complete that, get the United States under control, and then worry about other nations. I sometimes think of this as advice you get on airplanes about put on your own oxygen mask first before you help others.
Art Caplan:
Then there's some who would argue that you've got to really think globally because anywhere that the virus is spreading, it's dangerous to us. It could come back in a different form. What's your thinking about what I'll call vaccine nationalism?
Steven Berk:
As a Brandeis graduate, of course, I like to think globally. I will say right now what's more on my mind is the fact that minority populations are not getting the vaccine and they're not getting the vaccine for complex reasons. One, a lot of them distrust the idea of getting a vaccine at this point. We need a lot of work in that regard.
Steven Berk:
Then we have to get equal access. In Texas, if you want the vaccine, you're 65 years of age or over, you get it at a big civic center, you've got to go in and register with your computer to get the vaccine.
Steven Berk:
As Deborah said, if we're really dealing with herd immunity, 70%, 80%, we're really far from that because we have a higher percentage in the country than that that, at least, for right now don't even want the vaccine. That's what needs to be done first.
Steven Berk:
Of course, global thinking is really important. We've learned that ... Again, we don't want to worry about the South African or UK variants but it reminds us that we're in a very small world and viruses go from one place to another very quickly. We're not going to do well if the rest of the world does poorly.
Steven Berk:
Like I say, for right now, trying to reach herd immunity and trying to convince our population that they need to be vaccinated. I can tell you coming from Texas, where it was extremely difficult to talk people into wearing a mask and where vaccines and masks have become politicized so that it's not even about the science, it's about party line, I think we've got a long way to go in our own county. I would concentrate on that first.
Art Caplan:
I'm sure there's no magic bullet to this but what do you think are the steps necessary to overcome vaccine resistance. I keep thinking now ... I get asked all the time these days who should go first and why is the system unfair and why is the rollout bad. Those are important questions. Hopefully, in four or five or six months, we'll have much more supply and we'll start to think about people who don't want to take the vaccine and what to do about them and it's not, as you point out, an insignificant number. Do you have any thoughts about what we should be thinking about now to handle that issue? Which I think will be with us soon enough, sadly.
Steven Berk:
One of the things we found out ... We have a group of students called The Barbershop Hypertension Students. They're able to go into barbershops and convince clients that they should have their blood pressure checked better than doctors do on TV. We're really enthusiastic. We have the Student National Medical Association that is going to work with African American population, the Latino Medical Society is going to work with Hispanic population, and I think they have the ability to ...
Steven Berk:
People from their own communities will have the ability to move this thing away from vaccine hesitancy and I'm looking forward to my medical students and medical students around the state of Texas to help us do that. The students can also do the vaccines themselves and help get individuals signed up for the vaccine as well. Those are some of the issues.
Steven Berk:
Another problem I think probably everybody has heard about, as we were doing better on vaccination, the truth is that the second dose of both Pfizer and Moderna can be pretty tough. There's a lot of new concern about getting that second dose of a vaccine. Talking to some people who actually were pretty sick, not as sick as if they got COVID-19 but pretty sick.
Steven Berk:
I think there's a lot of challenges to get the vaccine utilization up to where we could even talk about herd immunity.
Art Caplan:
A question for anybody who wants to jump at this, I see it in the chat box, a number of your classmates are asking how long before there's a vaccine for children? Is that an important area to try and expand evidence so that we could move into that group? Are they low risk to the point where it's not a priority?
Deborah Cotton:
Well, we know that the trials are starting in children or scheduled to start. I know I heard Tony Fauci say he thought perhaps by next fall we might have some licensed vaccines in children.
Deborah Cotton:
The very good news, as we know, about SARS-CoV-2 is that children do not seem to get as sick with the exception that there is a sort of multi-inflammatory system disorder miss that unfortunately does occur. It seems to be quite rare. There is concern, however, that it's more common in children of color. It tends to be older kids. It tends to be boys.
Deborah Cotton:
I don't think we should dismiss pediatric COVID-19. I mean, it's something that we need to think about. I think it's a good thing that we're starting to do these trials. Also, even though very young children don't seem to transmit as much, we know the transmission is extremely common in teenagers, young adults, they really are creating, if you will, part of the issue here. We need to get our younger people immunized and those trials are starting.
Art Caplan:
How long do you think they'll take? I mean, recruiting teenagers to trials has never been, I don't know.
Deborah Cotton:
I don't know. I think it will take ... We all were children during the last polio epidemics and when the polio vaccine was licensed. I remember talking to my mother because my brother, who is a year and a half older than I am, was in the trial. He was one of the polio pioneer kids. I remember my mother telling me that some parents were very opposed to their children being in the trials, others were not. She was not. She and my father were very pro-trial.
Deborah Cotton:
I think it's going to depend a little bit on parental views because kids are going to have to get permission to be in these trials. I think that it's a very wise decision to go ahead and do them. We don't know. It'll depend on the number of kids and what are the endpoints? What are the endpoints that we're looking for in a trial in kids?
Art Caplan:
What do you mean by that? Endpoints means?
Deborah Cotton:
Well, kids don't tend to get sick so what are we looking for? I have not seen the trials, I haven't seen the protocols but I think those are important decisions.
Art Caplan:
They might be surrogates for disease?
Deborah Cotton:
Right. Whether or not they, in fact, show that they get infected, whether or not they mount antibodies. It's going to be more of a lab endpoint I think than a sickness and, certainly, gratefully, not a mortality endpoint as we had in the adult trials.
Art Caplan:
Susan, there's a lot of talk that one hindrance to vaccine development in the past or into the future is, basically, patenting, equity, privatization, commodification of ... That there's a business model and that many pharmaceutical companies, biotech companies will not release, say, information about how to make vaccines to other potential manufacturers, I don't know, India, Vietnam, whoever you want. What do you think about the, if you will, intellectual property, commercial environment with respect to vaccine development? Do we need to change it? Has it produced, in fact, good things?
Susan Weiss:
I don't know if that's a good question for me. I've been in this ivory tower my whole life. Can I just comment on something Debbie said for a moment? Figuring out whether people are going to be able to be infected and passage the virus after they're vaccinated is really tough because, as we know, just to these sort of nasal sample tests ... The virus is very transient. You'd really have to follow people like, I don't know, twice a week or something to really find out whether they have any virus in their nose and even if they do have virus in their nose, it may be not enough, very unlikely not enough to spread.
Susan Weiss:
I guess maybe you could followup with antibody tests, which would be more concrete I think over time but either one of those is a really labor-intensive process. I don't know that it's been done with the other vaccines. The endpoint has been disease, right?
Art Caplan:
Yeah. Let me followup the question I asked about the environment of vaccines in a slightly different way. There are Chinese vaccines, there are Russian vaccines, they're being given out. Many countries are saying they can't get anything else. Are they wise? Is that prudent?
Susan Weiss:
I mean, I think that conceptually, the Sputnik vaccine from what I understand is basically an adenoviruses vector and it's probably ... I don't know the clinical trial data but, theoretically, it's the same...
Art Caplan:
By the way, I don't think anybody does.
Susan Weiss:
Okay. Even the Russians. We have a Russian cousin who actually said he got the vaccine. Actually, they did something clever. They have two different serotypes, which means ... Sometimes with an adenovirus vector, you can develop an antibody response so that a second vaccine with that same vector, you might have a response against the vector and it might not be very effective.
Susan Weiss:
Theoretically, that vaccine is really the same thing as Astrazeneca or J&J. I think that's okay. I've been involved a little bit with a company making a vaccine in India. It's a kill virus. Those vaccines are going to be much easier to use in developing countries because they don't require the -80 storage. I think we need those vaccines for places that aren't going to have -80 freezers around the corner.
Art Caplan:
And two shots.
Susan Weiss:
Yeah. I think it's not a bad thing for all these different countries to be developing their own vaccines.
Art Caplan:
You want to jump in there?
Steven Berk:
Yeah. Actually this is more of a question for you but I heard one expert suggesting that maybe the Astrazeneca vaccine, which isn't that effective but still might be very useful in some underdeveloped countries. I think that's a problem that we could be headed for.
Art Caplan:
There's an issue about when you have to decide that a vaccine or a drug is good enough. This isn't the first time that that question has come up. I was involved in cholera and developed a policy for India for one shot, even though it was a two shot vaccine, but to try and get more, if you will, utilization. That was done. We've seen some people with the HPV vaccine. Those of you know it as the cervical cancer prevention vaccine, three shots down to two. Maybe in some instances, you might go to one.
Art Caplan:
To me, tough ethics policy decision. We've even seen and anybody can comment on this, the suggestion that the US go to one shot for Moderna and Pfizer vaccine just to get initial protection out there. Anybody want to comment on the wisdom of that?
Susan Weiss:
I think it hasn't been tested. I think we just don't know. As a non-clinician, I'd be a little bit leery of that.
Deborah Cotton:
We actually published three papers in the Annals on this topic, two modeling papers and one sort of editorial on the issue. I think it is a very complex issue. It is something that you have to think about when you're in a pandemic, as we are, and when the vaccine is not rolling out quickly. The supplies have been very constrained.
Deborah Cotton:
Right now, it seems like we would not be in a position, which we looked like we were going to be in, in December where we were going to really run out of vaccine. There are strategies that would make some sense, if we were, and one of them would be to give the first dose and not necessarily give the second dose right away. I don't think anybody is saying give it up. I think they're saying there's some latitude in the second dose. Given the exigencies of the epidemic, we were concerned, many people were concerned that that would have to be considered.
Deborah Cotton:
The good news is we've got the models out there. They've been published. People can play with those models. They can put in different variables if we come to that.
Art Caplan:
You mean by modeling what the impact would be of a first...
Deborah Cotton:
... the impact would be. Exactly. What would the impact be? Most of the modeling suggested that we would not end up with more lives lost if we had a policy of delaying the second dose. Again, it looks like we're not going to have to really come up against that. There are advantages to having a one dose vaccine. We know that some people don't come back for the second dose. We don't know why that is. It may be that they had some side effects.
Deborah Cotton:
As Steve said, people seem to have more side effects to the second dose. I think we want, certainly, for people to understand that these really are not serious side effects. It's unpleasant. You don't feel well. As Steve said, it's a lot less than actually having COVID.
Deborah Cotton:
What I do say is a practical thing. If a couple or people who live together go and get the first dose together, you have some leeway on when you get that second dose. It doesn't have to be the same exact day. I say stagger it. At least, by 24 hours. Have one of you get it and then wait and the other one gets it in 24 hours or 48 so you can take care of each other if you're not feeling well.
Deborah Cotton:
I do hope that people pay attention and come back and get that second dose but we know it's an issue. For some people, one dose is good. Also, even though it is less effective in terms of 70% or whatever for the J&&, remember that if we hadn't had these two 95% efficacy vaccines, we would be cheering for an efficacy of 77% reduction and the reduction in serious disease and death is complete. Even with J&J it appears.
Deborah Cotton:
I think basically the advice I give to patients and friends is whatever vaccine you're able to get, get it and don't worry about what it is. We're hearing rumors about some people saying Pfizer is better than Moderna, that's ridiculous. Just get what you can. As soon as you can get it.
Susan Weiss:
Can I make one observation? It seems like the people that have the most side effects from the first vaccine are people that have already had the infection. It could be that those people actually don't need a second dose whereas naïve people should have a second dose.
Susan Weiss:
I don't think anyone's ever ... They've tested different distances between the two doses, right? I'm assuming it was just setup at three weeks or four weeks and that was it. We don't really know.
Deborah Cotton:
We don't really know. There are arguments to be made, as I understand it, and I'm not an immunologist but I have heard some immunologists say there is an argument to be made for waiting a little longer.
Art Caplan:
There's some data that appeared that seemed to make even better impact if you waited a little longer. The UK is having a natural experiment. They're delaying way past what the trials were done as long as 12 weeks for the second shot. Hopefully, we'll have a followup there, which leads me to another question.
Art Caplan:
Now we have some vaccines out there. We're all talking vaccines on this call. We haven't really discussed testing. Haven't even discussed things like access to hospitalization, when you need that, which I'm going to get to in a second.
Art Caplan:
For vaccine work, is there any room for mandating the vaccine? Is there any room for saying, "You have to get this. We don't care about your choice, your resistance. We're in the middle of a plague"? If an employer wants to say you've got to have a vaccine to come to work or to get on a cruise ship or to show up at school, should we be thinking mandates and stop trying to just noodle around all day long with persuasion and education and choice?
Steven Berk:
I can jump in on that because I was either ahead of my time or behind my time when I told our faculty that the COVID-19 vaccine would be mandatory because we've made the influenza vaccine mandatory for a decade. We didn't want our physicians giving influenza to our patients. It seemed pretty straightforward. Very rarely did anybody argue about it.
Steven Berk:
Now that is totally out of the question now. I understand that because this is an emergency use authorization and that's the big difference.
Art Caplan:
That means it's approved but not licensed?
Deborah Cotton:
Correct.
Steven Berk:
Right but, theoretically, everyone agrees from Dr. Fauci on that that's a big deal and that we shouldn't make this vaccine mandatory at this point. I think your question is critical because people are going to eventually want to ... We certainly will add this vaccine to all the other vaccines that medical students have to have when they start medical school and I figure other employers may do the same.
Steven Berk:
Then as far as schools, I guess that ... I don't know that I want to get involved in that one but that will definitely be an issue of the day also. Will the schools make it mandatory once we...
Art Caplan:
Add it to the list of mandatory vaccines that kids already need to take.
Steven Berk:
Right. Once we have a safe vaccine for children.
Art Caplan:
Deborah, are you in favor of persuasion?
Deborah Cotton:
Yeah. I mean, Steve's absolutely right. Right now everybody's tabling it because it's under an EUA. Legally, as I understand it, you could not enforce it.
Art Caplan:
By the way, I'm going to jump in there. You could.
Deborah Cotton:
You could?
Art Caplan:
Yeah. You could. You'd be fighting perhaps. The EEOC put out an opinion a month ago saying, "Yeah. You can do it if you're an employer." We'll see.
Deborah Cotton:
Yeah. I mean, the people need to understand there's vaccine hesitancy among healthcare workers too. We've experienced that forever with influenza and not being able to get people to be vaccinated. We can require and have required hospitals, that people who will not be vaccinated for flu wear a mask, some just make it very unpleasant in the workplace.
Deborah Cotton:
It is a very difficult question. I think that right now with the anti-vaxxers, it's going to be very difficult to mandate it for schools. I'm grateful that I don't have to try to make those decisions.
Art Caplan:
By the way, as somebody who was involved early in getting the flu mandate through, both at Penn.
Deborah Cotton:
We published a paper together, Art, on this.
Art Caplan:
Yes. Yes. It got states to pass laws here that mandate flu vaccine for healthcare workers. NYU has a vaccine rate of 99.3%. The only people out are medically excluded, no objections, and we're about to get sued, by the way, by the people we fired so we can watch to see how that goes. I know they filed some of the people we let go for refusing. That may set a precedent for mandates there. We'll see.
Deborah Cotton:
Very interesting.
Art Caplan:
Testing. Did we under-test? Should we have done more rapid test development? Did we not pay attention enough in the whole outbreak in the US and elsewhere to get a test? I see this in sports. They're testing frequently. They're going to run these events by testing every other day, they have a quarantine plan. That's what the NCAA is going to do with the basketball tournament that's coming. Obviously, the NBA tried it with its ... There are many sports that are proceeding with testing as their protection. Did we not use that enough? Should we now have rapid testing out there that would get the schools open and so on? Anybody can go at that.
Deborah Cotton:
Well, personally, I think yes. I mean, I've been a proponent for rapid tests. I think we need to use them more. We need to help people understand what they can and cannot do. There's no question that the private colleges have been doing it and doing it rather successfully.
Deborah Cotton:
It really comes down to money. It comes down to an issue, again, of privilege. What does it mean if you test positive? Are you able to stay out of work? We go into this with a lot of assumptions about what would happen if we used it widely, everybody tested themselves at home every day, but we also know, as we usually do with an epidemic, that nothing has been fair and equitable about this epidemic. I'm afraid that rapid testing, while I think it's a tool we should be using more, is not going to address the inequities that we have and that we're even more aware of after this pandemic.
Art Caplan:
Let me wrap up ... Oh, go ahead, Steve.
Steven Berk:
I'm just quickly going to say in Texas, we did a lot of testing, especially in west Texas.
Art Caplan:
Don't die for this webinar.
Susan Weiss:
I'm sure it's not real.
Steven Berk:
In West Texas, there was a period of time, we were in the top 10% of infectivity. We did a lot of testing but we didn't do adequate contact tracing and those are the two that have to be together. You can do all kinds of laboratory testing but you've got to find where your focus of infection is and then act on it. That's actually very difficult. I can tell you in the college population, which was probably our doing, 40,000 Texas Tech students, there wasn't enough contact tracing to find out what fraternity had to be isolated and all of that.
Art Caplan:
Well, I'm sensitive to the time here. I also want to let Susan and Allen and Ashley, if she chooses, to have a last word before we go. I found this really educational and I'm very grateful that you took the time to teach us more about the many dimensions of the pandemic. I see lots of questions came in. As I threatened, we may accumulate a couple of them and ask you to answer them outside this webinar context.
Art Caplan:
Again, can't thank you enough for doing this. It was really great to have the chance to see our class fire up questions and get so engaged with your presentations and I'm very proud to be in this class with these kinds of experts and people who have had so much of a contribution to make to battle this pandemic. Thank you.
Art Caplan:
Susan, Allen, you want to say anything before I let everybody out of here?
Susan Jay:
I want to thank everyone, each panelist, for your participation. As Art said, we are so fortunate to be classmates and to have you as resources for all of us. I am thrilled and delighted and, hopefully, within the next year, because we're not going to meet in person until a year from June, we'll have an opportunity to get together for another kind of a health panel and, hopefully, we will have your input in that as well. Thank you, Artie, for doing this.
Allen Alter:
I echo Susan.
Susan Jay:
You gave me license.
Art Caplan:
I did. I did.
Allen Alter:
I echo Susan's sentiments and extend my thanks too and congratulations, especially, to Susan Weiss on her Alumni Achievement Award and for the great work that you're all doing through this epidemic and in science in general. I think we're ready to sign off. If possible, we'll try to get some of the questions answered and some answers circulated to our class as well.
Allen Alter:
Thanks to everybody who tuned in. Keep us informed of your email in case there are any changes so we can keep you informed of what's going on at Brandeis and reunion-wise for our 50th. Thank you. Ashley, thanks for making this happen, and to Daniel as well at Alumni Relations for the technical support today.
Art Caplan:
Thanks, everybody. Thank you. Great to see you.