In this episode of The COVID Pod with Dr. Ashish Jha, recorded Tuesday, March 2, Dr. Jha speaks to the importance of equitable vaccine distribution, ventilation over sanitation for public spaces and the promises of the recently authorized Johnson and Johnson vaccine amid the rise of new virus variants. He also provides expert commentary on how to maintain proper testing regimens despite lasting supply chain issues and what to be wary of when cases in a community, like Brown’s, spike.
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Cate Ryan
Hello and welcome back to another episode of The COVID Pod with Dr. Ashish Jha. Today is Tuesday, March 2, 2021, and as we move into another month of the pandemic, we are really grateful to have Dean of the School of Public Health at Brown University Ashish Jha with us once again. In this episode, we reflect on ongoing vaccine developments, including how the U.S. and the rest of the world can equitably distribute new vaccines. We also talk about how we have learned to manage the spread of COVID-19 as new variants arise and testing efforts continue. As always, I’m here with my colleagues at the Brown Daily Herald, Emilija and Rahma.
Emilija Sagaityte
Hello everyone, my name is Emilija Sagaityte, and I am a senior editor at The Herald.
Rahma Ibrahim
And my name is Rahma Ibrahim, and I am a section editor for science and research.
Cate Ryan
And I’m Cate Ryan. Feel free to email us at herald@browndailyherald.com if you have any questions for Dr. Jha.
Cate Ryan
To get started, I wanted to touch on the fact that we’re coming up on a year of this pandemic, and during that time, you've become a really well-known figure. Whenever we turn on our TVs, we see your face, and it's really comforting. But I wanted to ask what your typical week looks like in terms of media appearances, and why you think it's so important to share your expertise in that way?
Ashish Jha
What does my typical week look like? That’s a good question. So I have cut back a lot on media, it may not feel like it, but I try to say yes to about 10 percent of media requests that I get. I still probably end up doing about eight or 10 media things a day. Probably about three or four TV, and the rest of it is podcasts, like this one, but more commonly, like newspapers, The New York Times, The Journal, etc. — Wall Street Journal — or others. And so then the question is, why do I do it? And what's the point, and the point in my mind is this pandemic has been so incredibly difficult for all of us, right? And a big part of the problem is people don't have access to good information. There's so much misinformation and confusion. And much of what I see and have seen throughout the whole year has been either way too pessimistic or way too optimistic but not really grounded in public health science, or not enough of it. And so I started doing media initially because I thought it'd be helpful in the beginning of the pandemic, and ultimately stayed on because the feedback I was getting from people was that it was helpful. It was helpful in people making different decisions; it was helpful in people feeling a sense of where things were going. And I do think it's part of the job of public health leaders to help people get through public health crises, like I just think that's one of the roles of scientists and experts. Not everybody wants to play that role, and that's fine. Not everybody in public health should play that role if they don't want to. But I think it's really important. And by the way, it actually helps with the pandemic because if you can help people behave in ways that are consistent with the science, they're less likely to spread the disease, which helps keep the disease burden down. So it's a public health intervention, as well.
Cate Ryan
Yeah, for sure. Thank you. And going off of that, also, last week, you testified in front of the Ways and Means Committee of the U.S. House of Representatives on the state of vaccination. And I guess that is another way in which you've made your expertise known to the public. And I was wondering if you could speak a little bit about that testimony and sort of what you told them about the hurdles that we've been facing with vaccine rollout.
Ashish Jha
Sure. Yeah. So I testified last Friday. It was a committee that was focused on vaccines and vaccinations and what's been going on, and what I basically did was talk a little bit, not a lot, but a little bit about why our initial vaccine rollout was as poor as it was and where the Trump administration I think dropped the ball. And then I talked about the state of play where we are right now: Some states are doing great, other states are not doing as well. I've spent a lot of time talking to states, both ones that are doing well and ones that are doing badly, to try to understand what's going on and what differentiates. I talked about that a bit.
And then because it's Congress, I spent a lot of time talking about what can Congress do to help? What can the federal government do to help? Because one of the lessons of the last year of the pandemic was that we can't always turn this into every state on its own, 50 different pandemic responses. I mean, we can, and we did, and it doesn't work out very well for us. So part of our job is to make sure we don't do that, and part of Congress's job is to hold the administration accountable. Now, the Biden administration is very, very different than the Trump administration, that's gonna be the most obvious thing that I'm probably going to say the whole time. They do see it (as) their job to help states so I do think that it's going to be much better. But it's still Congress's job to hold the Biden administration accountable.
Cate Ryan
In the testimony, you sort of mentioned equitable vaccine distribution and what that can look like. And I was wondering, what do you think the ideal would be? We've talked about this before, but what is the ideal for vaccine distribution? How can it be more just and equitable?
Ashish Jha
Yeah, one of the things that we're seeing really across the country, and I got into this quite a bit, both in my testimony and in questions, is really large inequities in how these vaccines are being distributed. Despite the best of intentions, despite a lot of states with very good plans for equity, it's actually not working out so well. And in many ways, I think this is predictable. It's predictable because the point is you can make plans however you want. But they're implemented in a society with specific contexts. And what I mean here is, they're implemented in a society that's deeply inequitable. So almost any complex rule you create, those with more privilege and power will figure out how to work those rules. And that's what we're seeing over and over and over again. So there are states who are setting up rules about people with chronic diseases, getting to the front of the line. Clinically, that makes sense, we know that chronic disease burden is much higher in communities of color. So it's motivated by the right reasons.
But then what happens is in order to document chronic diseases, you often need a doctor's note. Well, guess who's much more likely to be uninsured, and even among insured, guess who's much less likely to have a regular primary care doctor? Guess who has jobs that make it hard for them to go see their doctor to get a letter? There's a whole set of things, these policies are not made in a vacuum, and it's interesting because a lot of people who advocate for equity really have put all their eggs in the basket of trying to get the policy right. My push has been, don't worry as much about the policy, do something simple and not so gameable, but get equity through your ground game, set up the vaccination sites in communities of color, engage community-based organizations that actually know people who live in those communities, make it easy for them to sign people up, have hours on evenings and weekends so that people who are working during the regular work hours can actually go get vaccinated. So win equity on the ground, not through your policies that look really good but never seem to work out over and over again.
Rahma Ibrahim
Shifting away from that and talking about the Johnson and Johnson vaccine, the FDA just provided emergency use authorization to it, and obviously we've been talking about it for a while before then. And so we know that the Johnson and Johnson vaccine is a one-dose vaccine, which in itself is a pretty exciting update. And you previously referred to it as a “superb vaccine.” Can you maybe elaborate on why you think that is?
Ashish Jha
So people love comparing the headline efficacy number of these vaccines and say, “Johnson Johnson is only 66 percent effective where Moderna is 95 percent,” and I've made the argument — and I'm going to stand by it even though some people push back — but that's an apples to oranges comparison. It's just not a fair comparison. So let's talk about first that, and then second, why I say this is a superb vaccine.
So why is it not an apples to apples comparison? It's not, because the Johnson and Johnson vaccine was tested in different places. It was tested in South Africa and Brazil, Moderna and Pfizer weren't. So you don't know what the efficacy rates (are) in those places. And by the way, when it was tested in South Africa, the variant that was initially identified in South Africa, B.1.351, was raging in South Africa. That one we know stresses the vaccines a bit, so I am confident that Moderna and Pfizer would have had a lower efficacy number if they had been tested in South Africa.
Second, it was tested at a very different time, even in the United States, where the infection numbers were much, much higher. And if you're testing a vaccine in the setting of a really large outbreak, essentially, you're going to often get lower efficacy numbers because the vaccine is being tested on a much more regular basis. So a vaccinated person may have six or eight or 10 exposures. But if the infection rates are low, they may only have one or two exposures. So a vaccine may look less effective in the context of a large outbreak. So (Johnson and Johnson was) tested in different places, at different times. You get slightly different numbers, or even moderately different numbers? I don't know how to compare them. So I don't think that in any way that I know of J and J is in any way worse.
But let's talk about why I call it a superb vaccine. Even when it was tested in South Africa, not a single person in the J and J vaccine arm ended up getting hospitalized or dying against the South Africa variant. And that's because, to the best that I can tell from all the data we have, the J and J vaccine elicits a very, very strong cellular immunity. So there are two arms of the immune system. There's the humoral immunity, antibodies, we've always talked about antibody levels, and there’s cellular immunity, T cells, is a really important part of that. It seems to generate a really strong T cell response. And that's what prevents you from getting really sick and dying. So the way I think about the J and J vaccine is it’s probably as good at preventing regular infections, but fine, even if it were a little bit worse at preventing regular infections, it prevents you from getting sick and dying at close to 100 percent. That makes it in my mind a superb vaccine, because that's what you care about when you get COVID. You care about not getting super sick, you care about not having to be hospitalized, you care about not dying. And it's really good at that.
Rahma Ibrahim
Definitely. We also just heard that Merck and Johnson and Johnson are partnering for manufacturing the Johnson and Johnson COVID-19 vaccine. So why is that significant?
Ashish Jha
It's great. It's really good for a couple of reasons. First of all, we need a lot more vaccines; we need a lot of vaccines. And the reason we need a lot of vaccines is because we need to vaccinate the world. And I feel very confident that by end of April, certainly by mid-May, we're going to be swimming in vaccines in the United States. I think every adult in America who wants a vaccine will be eligible to get one by mid-May. So that's not that far away. That's a little over two months.
So why am I so fired up about Johnson and Johnson partnering with Merck? Because the world needs billions of doses. We do not have billions of doses. The U.S. and Western Europe have essentially cornered the market on vaccines. They've bought up all the vaccine supplies, and that's a huge problem for the world. And Merck is a particularly good partner because Merck is really terrific at making vaccines. So not every company has experienced making vaccines. Making vaccines is actually really complicated because you're essentially making, if you think about the Johnson and Johnson vaccine, you're making a viral vector-based vaccine. It's complicated stuff. Merck is terrific at this. Merck tried to build its own vaccine for COVID, and it didn't work out. Their vaccine failed. So they are going to use the capacity that they were planning on using for their own vaccine to turn out (the) J and J vaccine. And from a global health point of view and the world’s health point of view, this is absolutely terrific news.
Rahma Ibrahim
Speaking about a global health point of view, one thing that people have been really excited about in terms of the Johnson and Johnson vaccine is it’s temperature-stable, which could make it easier hopefully to distribute it to other countries. So can you maybe talk about what that means for distribution both in the U.S. and also internationally?
Ashish Jha
Absolutely. Yep. So you basically nailed it. It is stable at kind of refrigerated temperatures, so it does not need a freezer. If you remember, the Pfizer vaccine, though this has changed a little bit, but at least initially, needed this super cold storage, minus 96 degrees. Moderna could just be stored in regular freezers, but even that's complicated, and if you're trying to get it out to communities far from population centers, you can do it, it's just hard. Refrigeratable vaccines are terrific because that means they can go out to places, they can stay stable in the refrigerator for weeks. And it'll make it much, much easier to vaccinate the world. It will make it easier in the United States to vaccinate people in rural areas. Also the fact that it can be refrigerated for many weeks means you can get a large supply, keep it stored up and then use it as people come in. I think we'll find that the J and J vaccine ends up being a really useful part of our toolbox.
Emilija Sagaityte
So you've also spoken before about the degree to which the vaccines may prevent the spread of COVID-19, and the research on this is just starting to come out. But we have in fact seen news in recent weeks regarding data from an Israeli study on the Pfizer vaccine, so kind of switching gears a bit. So this study has suggested a near 90 percent efficacy in preventing transmission of the virus, but seeing as these studies, again, are still ongoing, and, as you mentioned, results can depend on the state of the virus in a specific population. So what do you think this early data suggests about the vaccine’s effectiveness in preventing spread? And how accurate or trustworthy do you think the data is at its current stage?
Ashish Jha
Yeah, this is the big question, right? Because if vaccines didn't prevent spread, then that's a very different ballgame than if vaccines do prevent spread. And when you put all the data together, there's good data on this now from J and J, AstraZeneca, the Pfizer stuff you mentioned from Israel, Moderna from the United States, what do we know? Well, I would say we have now a pretty high degree of certainty, not 100 percent, but pretty high degree of certainty that these vaccines reduce transmission. How much do they reduce transmission? 100 percent? No, but like nothing in life is 100 percent. Right? Like, we don't have 100 percent chance of not being hit by lightning but like, small things happen. Again, the risk is not that low, it’s probably not the best analogy. But the point is, so what do we think the best number is? My best guess across all the studies, all the data, is that these vaccines reduce transmission by 70 to 90 percent. That’s a lot, it means you can still spread a little but very little. And it is really remarkable. And it's not shocking because almost every vaccine reduces transmission. There are a couple of vaccines that don't, but almost every vaccine does. I'm not surprised to see that that's where the data on the COVID vaccines are coming out. I'm also not surprised it's not 100 percent. As I said, nothing is. But on transmission, these vaccines end up looking really good at reducing your likelihood, if you're vaccinated, of giving it to somebody who's not vaccinated.
Rahma Ibrahim
Yeah, also, in the last episode, we distinguished between strains and variants, and this obviously remains a topic of concern internationally. So returning to this topic once again, this is a two part question. So first part, are the California and New York City versions of the virus officially considered strains? And the second part is, what do we know about those two?
Ashish Jha
Yeah, we're still learning a lot. I feel like I'm more concerned about the New York one than the California one only because of the data we have. I don't know if we’re ready to yet call them strains. But certainly the New York variant is concerning. It looks like it's more contagious. It looks like it may be a little bit less susceptible to our vaccines. Again, I am not worried that the New York version is going to end up making our vaccines useless. I don't think there's any risk of that, at least in the short-term. But it does look like our vaccines may be a little bit less effective in terms of neutralizing antibodies. So that I think remains a concern. And the California one is still being tested. And we know less about its impact. But the bigger picture point is we're discovering these things because we're finally starting to do genomic sequencing of infections and starting to identify them. These things have been circulating around for a while, and we've been missing a lot of these. I would not be surprised if we see more such variants. And I think we talked about this last time, there's only one way to stop this, which is to stop infections. And the best way to do that is to kind of keep things under control, like not let up on social restrictions, and vaccinate like crazy. And if we do that, we will be in a very different place in two months. Maybe even sooner than two months.
Emilija Sagaityte
So I think definitely from what you said it seems that testing will still be ongoing for the foreseeable future. And so bringing everything back a little closer to home then, last Monday, the testing center at Brown had to close temporarily due to the shortage of supplies that resulted from delays caused by all the winter storms in other parts of the country. And so reflecting on this specific situation, what do you think it suggests about the organization of COVID-19 testing processes? And are there ways to prepare and circumvent such problems in the future, should we be in that situation again sometime in the future?
Ashish Jha
That's a really good question. We are still at a place where our supply chains for these things are still quite vulnerable. We should not be at a point where one set of winter storms can cause this level of testing disruption across the country; obviously, it wasn't just here at Brown, we saw plummeting of testing across the nation. I think, over time, what do I mean over time, over the next three to six months, we're going to get into a different position because I think we're going to move away from all this PCR testing we're doing right now and move towards more antigen-based testing. And antigen-based testing, they have their own supply chain issues, it's not like they don't, but you don't have to go send them off elsewhere, they can all be done right together. And my hope is that we really strengthen our supply chain, certainly before next fall, because one of the things we've learned about this virus is that it does seem pretty seasonal. And what that means to me is, next fall and winter, we're going to see another bump in cases. It may be a small bump, it may be a large bump, depends on how many people are vaccinated. But we're going to be still dealing with some level of testing next year at Brown and elsewhere. And I would really like for us to move away from the way that we do testing now, partly because it's really expensive, partly because it takes 24 hours to come back and partly because it's really vulnerable to these kinds of disruptions. I think we can get better with other types of tests.
Emilija Sagaityte
Specifically, then, also thinking about testing ongoing right now at the University, in terms of positive, asymptomatic COVID-19 cases, cases in our Brown community, we saw those peak for the semester just this past week. And so do you think this is a cause for concern? And do you have any advice for the community on how to bring those numbers back down?
Ashish Jha
Yeah, I saw that spike. It got me, I’m going to be very honest, it got me really worried. And so obviously the University is doing the stuff you're supposed to do in this context. So what do you do? You got to make sure you're doing contact tracing, you got to make sure that you're identifying where people are getting infected. And you got to do isolation of people who've been infected and quarantining of people who've been exposed. All that has happened. And the data that I have seen in the last couple of days suggests that the infection numbers are coming way down. So there was a spike, a peak, and it's on its way down. We have to be very careful and keep watching this because here's what I always worry about in these kinds of situations. Let's say there was a superspreading event, let's say there was a group of people who got together, and it was a superspreading event, you're going to see a spike, and you're gonna see things come down. And then you're going to see the second generation of infections about four or five days later. So there's one of two possibilities right now. Either we've gotten everybody, and we have done a good job on contact tracing, and we’ve really identified everybody who was exposed and quarantined them, in which case, we should just see this kind of peter out and go away. Or, alternatively, we missed people because our contact tracing was not as good as it should have been — and I've been talking to the University, they feel like they're doing the best and really trying to get hold of this — then we're going to see in a few days a second spike, and the second spike will be way bigger than the first one. Because it'll be the second order infections. And so it just depends on how well the contact tracing has gone. I feel pretty confident from everything I've heard from the University, and certainly, they're taking it very seriously, which is all we can expect them to do. So I'm pretty confident that they've gotten folks, but we're going to have to watch this very, very carefully.
Emilija Sagaityte
Yeah, I think we all hope we don't see that second spike, but we will be watching those numbers for sure.
Cate Ryan
And just before we end, I wanted to ask another question about something I saw that you were tweeting about yesterday, I think, which was sort of the distinction between sanitizing services and ventilation. And I know that this has been a thing of discourse over the past few days on Twitter, especially, but I was wondering if you could speak a little bit to that divide and what we should be doing in public spaces, like on campus or elsewhere, restaurants, things like that.
Ashish Jha
Yeah, so let's talk about the mental model of disease spread that leads one to think about sanitizing surfaces versus ventilation. There are, and again, I'm going to take a lot of very complicated scientific debates, and I'm going to simplify it into two buckets. There is the droplet bucket, or there is the aerosol bucket. Droplets, the idea that I speak, little droplets fall out of my mouth, and if you're more than six feet away, you're not going to get hit by them. And what happens is those droplets fall to the ground. That's why they're called droplets: they drop. And so those little droplets have little viruses in them. And the idea is that you've got contaminated surfaces now — tables, chairs, floors. And the notion is, somebody walks by, touches a table, rubs their eyes, rubs their nose, and now they’re infected. That's a lot of how the flu spreads. And so people who have influenza in their mental model for disease spread really think about surface cleaning and think about the importance of that. Masks also work in that context, right, because you're going to prevent a lot of droplets from getting out. So masks work, whether you think of the world in terms of droplets or aerosols. The problem of aerosol mental model, different model, is it's much more micro, much smaller little particles that are coming out when I'm breathing, I don't even have to be talking, I could be breathing. And they don't go six feet, they can go 10, 15, 20 feet, and they linger in the air, they don't drop. And then because they linger in the air, they build up over time. And surface cleaning does relatively little. And what you need is ventilation, you need to dilute it out. So think of that as like cigarette smoke. And when somebody smokes a cigarette, what you want to do is prevent other people from inhaling that secondhand smoke, and the best way to do that is to open up the windows and let fresh air in or ventilate. This is primarily a disease of a second type. There may be a droplet component to it, but it’s primary an airborne aerosolized disease. And we didn't know that a year ago, but we've known that now for like nine months. And therefore, while masks would work under both circumstances, what you really want to do if you want to prevent this infection is you want to open up windows, have good ventilation, obviously keep getting people to wear masks. And so much of the response to this disease has not made that mental switch. So you still have lots of schools that close on Wednesdays for deep cleaning. I’m like, stop deep cleaning, like I don't even know what deep cleaning is, like, just clean but like normal cleaning. And then people come back to me and say well, do you think that surfaces don't matter, and we shouldn't be washing our hands? I'm like no, wash your hands, surfaces still matter a little. Remember, I didn't say there's zero droplets; people still cough, sneeze. But that's not the primary mechanism. So surface cleaning should be kind of pretty standard surface cleaning. We don't have to go nuts. We don't have to do deep cleaning. Just do regular surface cleaning on a normal kind of basis, and get people to wash their hands regularly. But the main thing you got to do is prevent people from breathing in the infection. And that requires a whole different strategy.
Cate Ryan
Thank you so much for defining those two different models and for also really laying out the distinction between why ventilation is so important, because I know that even though it's been a year there still are so many people who don’t know all of that information so thank you.
Before we let you go, is there anything optimistic or anything you are looking forward to in the next few weeks?
Ashish Jha
I am so optimistic about things. I can't wait until more of my colleagues, friends, people get vaccinated. Okay, I understand you guys are like at the bottom of the list on vaccination, so I'm going to give you vaccine envy, and I apologize for this. But like it’s really totally safe. Nothing's 100 percent, but it's pretty safe. Once you have other people who are vaccinated, to start getting together and going out and having a meal with them. I don't know about going out but you can certainly invite people over, you can share meals, you can hang out with other vaccinated people. I think that stuff starts being really pretty safe. And I know that if you're young and you're listening to this and you're feeling, “Oh, my vaccine is going to be so far away.” I'm also really optimistic about how quickly young people are going to be able to get vaccinated. I think if you're an adult, if you're over 18, I guess with Pfizer, over 16, I really think by May, every adult in America who wants a vaccine will have access to one. And so we're not saying like, this is not forever away, right? This is literally around the corner. It's been such a hard year. And we're so close to the finish line. So I am very, very optimistic. And I'm looking forward to hanging out with people and getting together for meals. And I know the last time I had a meal with somebody outside of my wife and my kids indoors, I mean I've done some outdoor dining, was like last March, early March, right? I haven't done it since then. So I'm looking forward to all that. All of that is going to be very, very possible this summer.
Cate Ryan
Yeah, thank you. I think we're all looking forward to that. And also, we realized that the next time that we speak to you, which will be March 12, is going to be the one year anniversary of when Brown announced that they were closing, or that we were closing for COVID. So it's weird coming up on that one year anniversary. And it's nice to hear that there's so much optimism to be had now. So thanks for sharing that.
Ashish Jha
But maybe we can use that as an opportunity to talk about like, what is the fall going to look like at Brown? Or what should it look like? And I've been very open about my advice to the University. But I'm happy to talk through what I think the fall of 2021 ought to look like from a public health point of view, in terms of what will be saved and what will be not. And the preview I'll give you is, I think it's going to be pretty good.
Cate Ryan
Yeah, I'm looking forward to that conversation because we definitely have a lot of reflecting back on this past year, but also looking forward to the next year to do.
Ashish Jha
Thank you for getting together again. And I look forward to meeting up and chatting more.
Cate Ryan
Thank you.
Ashish Jha
Stay safe, be well, talk soon.
This transcript has been edited for length and clarity.
____________________
Produced by: Cate Ryan
Reporting contributed by: Emilija Sagaityte and Rahma Ibrahim
Sound mixing by: Cate Ryan
Music composed by: Katherine Beggs ’22.5
Special thanks to Bilal Ismail Ahmed and Elise Ryan for cover design.
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