Coronavirus (COVID-19): Press Conference with Rebecca Weintraub, 03/04/21
You’re listening to a press conference from the Harvard School of Public Health with Rebecca Weintraub, assistant professor at Harvard Medical School and an associate faculty member at Ariadne Labs, a joint center for health systems innovation at Brigham and Women’s Hospital and Harvard School of Public Health. This call was recorded at 12:30 p.m. Eastern Time on Thursday, March 4th.
Transcript
MODERATOR: Dr. Weintraub, do you have any opening comments?
REBECCA WEINTRAUB: Sure. So I want to just first start us off in kind of my mindset as a provider. So I am both a physician and a vaccinator from the state of Massachusetts and I’ve been very much focused on how do we work upstream, how do we think about the planning involved in this unprecedented vaccine campaign and looking at patterns from past pandemics and past mass vaccination programs and that work early in really a year ago now, when we began articulating that and reminding the general public that we need billions of doses of the vaccine was one which many people weren’t prepared to hear about or thinking that that would be within our arsenal. And so the second part of this message, I think, and I’m sure many of you are also following, is how many of these vaccines are truly home runs, the idea that we can avert death and avert hospitalization is just a tremendous addition to our toolkit. What’s unfortunately been striking is for our state leaders in the United States is that they’ve had such narrow windows to plan and I’m pleased to walk you through anyone who’s interested kind of the changes between the National Academies. A framework for equitable, effective allocation versus ACIP, and that source data set is powered, many of the find your place in the taxi line and several other entities on this call could be able to help and assist. I’m pleased to share that data with those interested. Unfortunately, what we’re finding today is this not only is this window has closed, but many ways the pressure on these state leaders who’ve been so beleaguered is so intense at this point to ensure the vaccine is deployed with scale, speed and equity. And we’ve also been able to detail several enabling factors of why the state has been able to adapt as they can in the midst of this unprecedented time. So we’ve been curating those tactics and sharing the state leaders. And what we’re really thinking about now in many ways is the potential vaccine opportunities ahead. Where are there daily acts in our health care services and how we think about food scarcity or a vaccine could be offered to our most vulnerable. And think of this is the third phase. So the first phase here is that we’re still in low supply, high demand, and we will kind of be in this bull whip fashion where later in May and June, likely supply will be sufficient, but will truly need a much more robust set of delivery channels to serve the most vulnerable. So I’ll stop there. Hopefully that was helpful. And I just will also note we did write about the dangers of vaccine nationalism, and I continue to kind of tag all the tips that are happening between the UK and the EU, the over-ordering that’s really constrained the supply globally that will lead to the persistence of this pandemic.
MODERATOR: Thank you very much. I have a quick request from one of our TV reporters, if you could just tilt your camera down a little bit so there’s less headroom. I think that’s pretty good. All right. First question.
Q: Doctor, thanks for doing this. My question is with the vaccine rollout as its continuing, we seem to be seeing a reduction in people going to get tests, the perception being I got a vaccine, I don’t need to get tested anymore. A, is that true? B, what would you say to people if it’s not true who are taking that attitude?
REBECCA WEINTRAUB: That a great question. And once again, when we think about the vaccine, it’s one element of our toolkit to first protect you, and to decrease transmission, so we absolutely are continuing to ask people to mask, test if they’re concerned about an exposure, practice quarantining, and remind folks that it’s truly two weeks after that second dose, that protection begins.
Q: When you’ve seen what’s going on with our own testing website here in Massachusetts, I would think you would know better than I do, is that pretty typical of what’s happening across the country and around the world, or are we having more problems than others?
REBECCA WEINTRAUB: Just to make sure, Brian, you’re seeing the vaccine website, correct?
Q: Yes. The people going in to try to get appointments. Yes.
REBECCA WEINTRAUB: Yeah. So I share your concern. The software was not built for this type of demand and we had time to prepare an online scheduling service that can manage this type of surge interest. For example, across the state, a new additional million people became eligible for the vaccine. And what you’re seeing right now is there’s changes in the backend happening. It is different state by state. There are certain states have been able to manage the surge differently. It also depends on population size, interest and accessibility. I think many folks are questioning why we deployed a system that was only online to begin with and see other ways to deploy scheduling. And you’re starting to see that happen, especially in metropolitan areas. So I suspect we’re going to see constant iteration to the software and paper based and mobile and other ways that we’re recruiting folks to come in and receive the vaccine who are eligible.
Q: And my last question, as you see what’s going on in Texas and in Mississippi, where the governors are removing an awful lot of the safeguards, how concerned are you?
REBECCA WEINTRAUB: Very. Yes, so I mean, once again, we are in the midst of a pandemic and transmission is happening considering the amount of circulating virus in our communities and we continue to see community transmission. So the vaccine will protect us better if we at the same time mitigate transmission and utilize the playbook that we have masking, testing and practicing physical distancing.
Q: Thank you, doctor, appreciate it.
MODERATOR: Next question.
Q: Hello, doctor, how are you?
REBECCA WEINTRAUB: Very good. Hi, David.
Q: Thank you for talking to us. And I’m going to keep it a little Massachusetts centric for just a bit longer. It’s stampede Thursday here in Massachusetts. We make available tens of thousands of appointments and people spend their morning trying to get one. The governor seems to suggest each week there’s nothing we can do is just supply is not what demand is. Is he right about that? Could we fine tune available appointments to the demand and make it so that people don’t have to spend hours? And what about the cost of that? When I speak with some people who spend hours online, they tell me that they’ve just given up. They’re not going to try to get an appointment for until the supply of vaccine becomes more readily available. And these are people sometimes in their 70s and 80s who have given up on the process. So that’s my question.
REBECCA WEINTRAUB: Yes, no, thank you, David, I share that concern. I wrote about this in January as well. So first to take a step back, it was quite clear in December, and I can share with you the traffic that we’ve done that states were concerned they would not receive the weekly replenishment as requested to operation work speed. And if you remember, in that second week in December, the vaccine supply was proportioned related to your adult population, not necessarily COVID exposure or COVID risk or COVID death across the states. And each week, many of the states did not receive the replenishment for first and second dose that they suspected via the data ecosystem that operation warp speed generated. And so many states, Tennessee, Massachusetts, have really been forced to create their own spreadsheets of scenario planning, assuming they would not receive the weekly replenishments as requested. We can talk through why that was, but I have to say the predictions have gotten better and better since January 20th, and the Biden administration made a very strong commitment to give states three weeks’ notice of the vaccine supply they would be receiving for the approved vaccines. So this week, they know three weeks ahead of time, I’ll receive X number of doses on each Tuesday of the week, including this week, Johnson and Johnson. So many folks would say, let’s match the supply and then open up an accord, a similar number of appointment sites related to the state deployment. So that’s one matching that needs to happen. This is actually a little bit more complicated than I’m describing, because, as you remember, there’s a federal deployment directive, federal entities within the state, there’s a federal climate directive, federally qualified health centers, and there’s a federal deployment of vaccine directly to the retail pharmacy program, for example, CVS, Walgreens and Wal-Mart. So the state may not have a full picture on any one day, but over a course of a week, they have a good, solid estimate right now, the number of vaccine vials they’ll receive and then the secondary issue here. If everyone had the syringe, they need to extract that last dose out of the vial as well, and there’s likely going to be scarcity of these deadly syringes in the future.
Q: Just a quick follow up about that. Do you know the status of those low or dead space syringes? How many vials are using them now? We’re probably not up to 100 percent. Do we have any data on how much is being wasted because we’re not using the best syringe?
REBECCA WEINTRAUB: I don’t have access to that data, but eager if anyone else finds it, to analyze it together.
MODERATOR: Next question.
Q: Yes, thank you, Doctor. I’m writing a story about front line essential workers and their vaccination challenges, and the main one is that most states are not following the ACIP guidance to put them in the one B group, but are following what came later, the HHS recommendation that people aged 65 and older be vaccinated as soon as possible. So the grocery store workers, for example, are receiving a lot of delays and are kind of wondering why. So I thought I would put the question to you, and from a science perspective, if you can comment? Do you think the science supports one over, you know, the other, for example, essential sort of the ACIP position versus what the HHS was saying?
REBECCA WEINTRAUB: That’s a great question, actually. Can I share my screen?
MODERATOR: Yes, you should be able to do that now.
REBECCA WEINTRAUB: Terrific, just might be easier to answer with the visual here and thank you. You can see the slide that I’m showing. But just to answer your question, so we’ve done the data wrangling to share with you the differences between the National Academies guidelines and ACIP. And as you can see here, we’ve changed the order by occupation, health status and residence and acknowledging those three dimensions, because at this point, you’re absolutely right to the front line. Essential workers were re prioritized by ACIP and the discussion I think many of you are following this week, if you look up to the National Academies guidelines, is that teachers were called out in their framework and they were not determined as a priority group within the ACIP guidelines. And now that’s become a priority of the many states are, in a sense, reordering within the pink bars of each state. So fundamentally, what we’re seeing is a pattern where states are trying to simplify this. They view this as deploying the ACIP guidelines as both too complicated. And the messaging has become one coming from a governor’s office, for example, or the health commissioner’s office. So we’ve seen several states deploy an age band, for example, the state of Connecticut. And there’s concern that in that simplification, some would say the simplification leads to equity because you, in a sense, confirm your age status, you receive the vaccine. Other entities have said this actually makes it quite difficult for front line essential workers to be prioritized because they’re at risk and exposure are quite clear, but they don’t fit in those age bars. So this is very much an ongoing dynamic here. And the other dimension of this complexity is obviously people are viewing what each state are doing and there is some sense of vaccine terrorism where people are migrating to a state, for example, or a county where they can receive vaccination.
Q: Thank you. So just to clarify then, the National Academy of Science recommendation here sort of seems to near a little bit of the ACIP one, and that the age sixty-five plus group is after the front-line critical risk workers, correct?
REBECCA WEINTRAUB: So that’s correct. Age sixty-five is after. That’s not necessarily what we’re seeing deployed today. So these are guidelines given states and then the interpretation of the states is quite different. The other dimension that ACIP did not recognize that twenty-eight states are deploying. Is this idea of using a disadvantage index redeploying vaccine to counties that have been hard hit by COVID-19, Social Vulnerability Index? And we’ve now seen eight additional states in January and February begin deploying that in the midst of the replenishment week by week.
Q: Because the front-line critical risk workers like grocery store workers, they have had outbreaks. There’s been several in California and then the Whole Foods in Detroit. So they feel they’re exposed and definitely at risk. So I was just wondering if you have a personal opinion on this?
REBECCA WEINTRAUB: Yes, I mean, the reason why I’m sharing these differences here is because I think we lost some of the design elements for equity when we moved from the National Academy guidelines to ACIP. And there was the rationale of cutting the front-line critical work first earlier because of both the difficulty they may have of accessing the vaccine, and you’re absolutely right, their daily exposure to the virus due to the nature of their work.
Q: OK, thank you, that was helpful.
MODERATOR: Next question.
Q: Hey, thanks for taking my question. Thank you, Dr. Weintraub. So here in Florida, we’ve seen a lot of controversies around both a lack of equity and some perceived favoritism in how the vaccine has been distributed here. And the Department of Health has really taken a back seat and it’s being all run through the state’s emergency management division and by the governor. We recently reported on how much latitude the state is giving to private partners like Publix, basically letting them send vaccines wherever they want without even a plan. And we’ve also known that the wealthy zip codes here, at least in south Florida, are outpacing fewer wealthy ones on vaccination rates. And white people are outpacing minority groups on vaccination rates. So that’s the context. But my question has to do with a recent executive order from Governor Ron DeSantis, where we’ve officially lowered the age from sixty-five for people who are deemed to be medically vulnerable. But the state policy is that you need a signed physician’s note saying that you are at a severe risk for severe COVID and that they’re recommending you get this vaccine. So I’ve spoken to public health experts who say that this is a major barrier for access and will disproportionately impact low income people. And I was hoping to get your thoughts on this specifically and also if you have them, your thoughts on the roll out here in general in Florida.
REBECCA WEINTRAUB: Thank you. Very important point. I absolutely agree. We actually wrote an op-ed for The Boston Globe in January regarding this issue. So it is a barrier. Remember, most Americans do not have a primary care provider. Many Americans have actually delayed their own health care preventative screenings during this time, and their health has deteriorated in the midst of the pandemic. Some of our most vulnerable populations have added their culture really has gotten more complex because of the nature of the pandemic and their limited access to food, exercise, and the just the stress of the pandemic itself. So in January, Atul Gawande and I wrote a piece about out self-attestation that we believe we should trust most Americans. Most folks know their comorbidity status. They could identify their age status. And in order to move with the speed, scale and equity, we should utilize self-attestation as a means for folks to find their place online. And this has been reinforced when we’ve asked folks for example, I am a resident of X. That requirement has deterred people from coming to access a vaccine concern. What happens if they share their ID, considering other aspects of their status? So I think that’s an unfortunate event that’s gotten built and that will not actually lead to us having an equitable or effective deployment of this vaccine.
Q: And do you know if any states are taking that approach of self-attestation or is this doctor’s note approach common in your view? I haven’t actually done the work of asking other health departments, but I don’t know if you have any thoughts on that.
REBECCA WEINTRAUB: Yes, I’m pleased to send you the list, it’s probably buried. And if you remember, we have over 3000 counties and the counties are organized in sixty-four jurisdictions regarding the immunization registry. So you’re absolutely right. We’re seeing significant heterogeneity of practice. And when there’s a private sector, for example, deployer, Walgreens, Walmart, Publix, Kruger’s, whoever it may be, that’s getting interpreted differently, for example, by the entity that’s running a mass vaccination site.
Q: Here, the situation is that hospitals were given latitude to vaccinate kind of anyone they deemed to be medically vulnerable. But it’s at these state sites and these retail pharmacies that folks have to provide a doctor’s note. So that seems also to cut across the same barrier. Right. If you’re not a current hospital patient, if you don’t have access to health care, you’re kind of out of luck.
REBECCA WEINTRAUB: That’s exactly right. Even creating a new patient file, so when I’m vaccinating you, I have to create a new record if you’re not a patient within my hospital system. There’s actually an administrative cost to creating that. And so you can imagine why people are first, for example, for efficiency sake, that seeing the patients within their populations. But we have thousands of people who need to be reaching. I think the second piece that’s important regarding all this documentation is it actually is confusing for the general public. This is a free vaccine. We’ve already paid 18 million dollars to produce at the discovery side of mRNA vaccines, for example, and when people have to bring documentation in, they’re getting concerned that they may be charged, for example, which is also leading to a population set that is just so concerned to incur a cost in the midst of their economic uncertainty.
Q: Well, thank you so much for your insights, I really appreciate it. And I’ll take a look at the op ed. Thank you.
REBECCA WEINTRAUB: Terrific.
MODERATOR: Next question.
Q: Yes, hi, thanks for taking our questions today. I just wanted to make sure I understood what you were saying before about age-based systems versus the ACIP systems, so are you saying that the age-based systems are inferior and shouldn’t be used? And if that’s the case, could you explain why that is?
REBECCA WEINTRAUB: That’s a great question. You caught me there clearly was vague, so thank you for listening. And so first, I just want to acknowledge that this is changing at a pace that the public cannot understand. So this decision by the state of Connecticut to go by an age status and is different than the ACIP recommendations and that was communicated by the governor’s office and the governor communicated it, this simplicity would actually lead to a more efficient rollout, would lead to decreased requirements. You had to prove your age, not your comorbidities, for example, and that that in and of itself would lead to equity. And I question that I understand why a governor wants the message, because this is a complex, unprecedented process, but age is not the only risk factor to think about, how vulnerable are you to not only be infected by COVID-19 but unfortunately be hospitalized or even die from COVID-19? And so knowing those vulnerabilities in those ongoing risks. My recommendation is actually the National Academies, I think, did an excellent job reviewing the evidence base, and that’s how we ended up with these 13 priority populations and the ordering of those populations. So I guess my quick answer here is age is insufficient and it’s not it’s insufficient to say age alone is the means by which we should allocate the scarce resource.
Q: OK, thanks. My second question is, I’m wondering what you think about, you know, considering the ramp up in vaccine supplies, I think Biden just said the end of May, all adults who want a vaccine should be able to access it. What do you think the shape of the pandemic is going to look like by summertime, do you think will be mostly return to normal? Kind of not really return to normal or somewhere in between? Or how do you see that shaping up?
REBECCA WEINTRAUB: That’s a great question. I have to just take the global perspective for a moment right now, so the difficulty here is that we advanced economies have reserved nine point six billion doses. So there’s been one hundred and thirty seven agreements signed between countries and drug makers and those who have the most sufficient reserve doses, Canada, the UK, Australia, the U.S., have left most countries with a continued they’ll tell you to face scarcity for the rest of 2021. So I say this is insufficient to manage transmission, to manage a novel virus that we deployed the scarce resource and allowed certain countries to procure, for example, five times more doses than they need to cover the population. So what I predict is going to happen is we’re going to see outbreaks, the new variants in other parts of the world, and then those variants will come within the US borders and we’ll have to think through how do we both contain the outbreaks and use vaccines as a tool to contain an outbreak? And then think about boosters for the variants.
MODERATOR: Do you have a follow up?
Q: Thanks for the global perspective, I think that’s important and gets lost sometimes. But I guess just in general, for the US, in light of the fact that we are one of the fortunate countries that is going to have a lot of vaccines coming our way and most people getting them are eligible to get them. Does that mean like our summer summertime is going to be closer to normal in terms of the activities that we will be able to do? Or do you see it as being less of a happy version of the future than that?
REBECCA WEINTRAUB: Yeah. Thank you. I, as an individual don’t have a crystal ball and I’m sitting here as a provider, what I suspect is that we will be wearing masks for the rest of this calendar year, that the ability of the masks to decrease transmission and its ability to protect you and others is significant. I think the question of different entities reopening and the data is quite clear. We can reopen schools in a safe way to decrease transmission. We can operationalize our outpatient care facilities. We have been able to decrease transmission, for example, with our skilled nursing facilities and acute care and rehab facilities. So I think there’s tremendous lessons to learn from there of how do we manage in the midst of a circulating novel virus. And on a personal front, I did learn how to build these protocols. I was a camp physician for two overnight camps in August of this past year. It seems like a long time ago, August 2020, and we had two to three hundred children in these camps. It did not have one case of COVID-19. So I think this will take a good amount of diligence and asking to ensure within the children and the adolescent population. I think regarding the vaccine and its uptake, I believe with increased supply locally and it’s being offered by your primary care provider, for example, your local pharmacist being able to access it in close proximity to your residence. We’re going to see ongoing and tremendous demand across the nation.
MODERATOR: Are you all set?
Q: Yes, thanks. Appreciate that. Also, if you were part of that Maine summer camp, MMW, our thanks for that. That was a fascinating study. That’s it. Thanks. Have a great day.
MODERATOR: Great. Next question.
Q: Just wondering if you could sort of help paint a picture of what you think is going to happen once, we are sort of flooded with vaccine by the end of May. What is that going to look like? Can we start shipping vaccine abroad? Should we or how can we convince other Americans to take the vaccine?
REBECCA WEINTRAUB: That’s a great question. So I think right now is the window to prepare last mile delivery channels. So this is where primary care providers typically vaccinate forty six percent of Americans. And we have not made the vaccine supply available. We now know not only the Johnson & Johnson vaccine, but the mRNA vaccines are more stable. It will be easier to administer these vaccines. So first, we need to ensure our primary care providers can be part of the delivery of the COVID-19 vaccine. In addition, I think to other settings, I think we’re going to see the vaccine availability. For example, at E banks where people are facing food scarcity, they’ll be offered a vaccine in other places where community vulnerable communities are congregating. The question will be, how do we redistribute our vaccinator workforce to these settings? So it’s a bit of an operational excellence question of ensuring we have both the workforce and supply. And I absolutely agree. And I think we had the type of leadership in the Biden administration, Samantha Power at USAID. And it’s been quite clear with the very quick resumption of our roles and responsibilities with the World Health Organization and COVAX, that we will be participating as a nation. At the same time, we have to acknowledge we are delaying the deployment globally by our procurement processes and obviously it’s not only Canada and the UK, but Australia also ordered 2.5 more doses than they have populations. So we hope this will be modeled by the US early and those donations will be redistributed. It does make us question how we need to think about these types of agreements where a country did procure more doses than their population, that might be for another day.
Q: I guess I was just wondering also about the balance between how much do we push our own citizens to get vaccinated who are hesitant versus sending these shots?
REBECCA WEINTRAUB: Yes. Well, I mean, one thing that is quite clear is vaccine confidence has risen when the vaccine is locally available and we’ve been looking at the effects of the vaccine coming to your locality or, you know, an individual knowing that their neighbor who’s a nurse or their cousin who’s an essential worker, has received the vaccine that propagates concentric circles and increased vaccine confidence and demand. So I would suspect because the horizontal cooperation between pharma companies so significant as we’re watching Merck participate, Novartis participate, that the supply will be constrained, it will be able to do that type of replenishment. And then the Biden administration will kind of hit a moment where the can be confident enough to start sending supplies elsewhere. I hope that will just lead to continued interest in the vaccine. And I suspect we’ll be vaccinating in the US throughout this calendar year.
MODERATOR: I am going to do something I usually don’t do and call on somebody.
Q: Yeah, that would actually be awesome. Thank you. And I’m sorry if I missed this earlier, but just got on. But in Ohio, we’ve seen about five percent of all vaccine doses that have gone out to black Ohioans who are about 13 percent of the population. How did something so predictable actually end up happening, and are there any specific strategies or things governments need to start doing to right the ship a little bit?
REBECCA WEINTRAUB: Thank you. Well, that is a great question. And this is in a sense. Why we tried to work upstream, which sounds old now, but this is in July and August of 2020. How do we help prepare states to design this deployment with equity, not only by your exposure, but by race, occupation and other factors? One thing I will say that, and I don’t know the exact data set in Ohio, but I will say I suspect that at almost all the vaccine registries, the data is incomplete. There’s supposed to be twenty-two to twenty-four data elements per individual vaccinated. And what we’re seeing and trying to audit some of the data is that in many instances, unfortunately, race, for example, was not delineated in the data that’s been uploaded to the CDC data link. The question will kind of become over time, not only how do we help ensure the data is better, but I think we’re going to continue to see this pattern that you’re speaking to. And I think it does speak to something bigger than the vaccine and the deployment of one element. But the unfortunate nature of our health care system where there’s been a way in which certain individuals are able to find their place next in line, they may not be about eligibility and how this vaccine was deployed. And we’ve acknowledged first in December to long term care facilities, health care workforce, but second, by these age brackets. So if we look and I don’t know the data in Ohio as well, but in Massachusetts, if you look at age brackets, we know that African-American men, their longevity is not the same as white men. So when we say seventy five plus, that in of itself is redistributing the vaccine to a white population, so in many ways, these allocation principles that need to be multi-dimensional that has led, I would say, and propagated this inequity in access. Sorry for that long winded answer.
MODERATOR: Are you all set?
Q: I am all set, yes.
MODERATOR: Great. I have an email question. She said that and I know you touched on this a little bit, but how important does testing remain and why?
REBECCA WEINTRAUB: First, we have to remember that most Americans are not vaccinated, and even after we received the first vaccine of either the Pfizer or Moderna, you are not fully protected. The early data on your ability to transmit to others is incomplete, though positive. So at this point, we have to assume even if you receive that first vaccines in between that time, between your first and second doses, you can be an asymptomatic carrier you could transmit to others. So what we do know is the virus is circulating in our communities. And so one of the most effective ways to understand, as I did infected or could I be infected, someone is to get tested. And the idea of deploying the rapid test is one that Dr. Mina has spoken about quite urgently. And we all agree this needs to be deployed alongside the vaccine and actually would be. It would be quite afforded to have both available to the general public over time.
MODERATOR: OK, great. I think that’s our last question we have up so far, if anybody has any last questions, please let me know. If not, it looks like that might be it. Dr. Weintraub, do you have any other final comments before we go today?
REBECCA WEINTRAUB: Thank you, I mean, I just want to thank all of you as reporters, because this is quite a complex dynamic to be involved in. And I think I’ll just acknowledge that many of the state officials that I speak to are so beleaguered by the pace of the pandemic. What’s happened to their own workforce and the lags in notification in December and January put them in a situation where they did not have sufficient information to plan this rollout. So we’re seeing a significant catch up from where they were thwarted because the first quarter of activity and in many ways we’re trying to march this out so other countries can learn from the experience and do this differently so that equity, speed and scale are all strategies that are integrated within their plans for the vaccine rollout.
This concludes the March 4th press conference.
