Why This Epidemiologist Says The Vaccine Is Not A Silver Bullet For The U.S

December 14, 2020

By Adam Chapman, EyeForPharma on Mar 21, 2019
The doctor is injecting a male patient with a needle.
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Complexity is the defining business and leadership challenge of our time. But it has never felt more urgent than this moment, with the coronavirus upending life and business as we know it. For the past few months, we’ve been talking to leaders about what it takes to lead through the most complex and confounding problems, including the pandemic. Today, we talk with Pia MacDonald, Infectious Disease Epidemiologist at RTI International, a non-profit research institute. Dr. MacDonald has 25 years of experience in domestic and international epidemiological research and public health. She has an extensive background in infectious disease epidemiology and surveillance, global health security, public health preparedness, and outbreak investigation and control. Currently, Dr. MacDonald is an adjunct associate professor in the Department of Epidemiology at the University of North Carolina at Chapel Hill. She has been certified in public health by the National Board of Public Health Examiners.

David Benjamin and David Komlos: Tell us a bit about yourself and your area of expertise.

Pia MacDonald: My area of expertise is preventing, detecting, and responding to infectious diseases near and far, and building and improving the systems to do this vital work. In my 25-plus year career, I've worked on a lot of different outbreaks - from food-borne disease investigations in North Carolina to international efforts on Zika, Ebola, and now Covid-19.

Benjamin and Komlos: You’ve been following the path of Covid-19 since December of last year. Was there an early ‘Brody Moment’ when you realized that its trajectory was of significant concern?

MacDonald: I can remember the absolute day, the first day of March when I realized there was something very troubling with how the country was responding to this. Our government couldn't get a working test quickly distributed to states and therefore were severely restricting who could get tested.  With the restrictions, our ability to detect community transmission was severed. At that moment, I knew that we were flying blindly into a massive outbreak without any understanding of its movement within the United States. Undoubtedly, this would result in the virus taking root in the U.S. and spreading quickly, evading detection by public health.    

Risk communication best practices that CDC teaches: communicate often, be clear and transparent about what is known and what is not known, were limited. Unambiguous, easy to follow guidance for individuals, communities, schools, businesses, healthcare settings, etc., did not materialize quickly.  

Benjamin and Komlos: If you could travel back in time to December 2019 and tell epidemiologists and governments how this was going to play out, is there anything you would recommend they do differently?

MacDonald: We should have been very clear from the beginning that there was a lot we didn't know about this brand-new disease and this new form of coronavirus, and because of that, there were unbelievable unknowns around transmission and disease expression.

In the U.S., instead of systematically deploying public health strategies that we know work, we left things like wearing a mask up to individual choice. With that came a politicization of mask-wearing, which still baffles and saddens me. We had very little coordination and cohesion in our country when what we needed was an all-of-society united response. As an example, we should swiftly have given clear guidance around wearing masks and physical distancing, guided by evidence about the virus at that time.

The CDC didn’t have the capacity to provide all the testing, and we needed the private sector to step in, but instead, there was a delay of many months before that happened. We should have immediately engaged the private sector, and removed any roadblocks, to have them quickly ramp up our capability to do widespread testing.

Finally, I’d say that we did a disservice to people with the message that this was going to quickly turn around because they thought they could just hunker down and isolate until it passed. If we had been really clear from the beginning that people needed to pace themselves and create a new normal that would work for a year or two, I think we’d be far better off in terms of mental health and more creative approaches to a sustained new normal.

Benjamin and Komlos: How much do we currently know about the virus relative to what we can know or need to know? Are we close to a full understanding yet, or are we still learning new things every day?

MacDonald: I don't think we're nearly close to understanding either the virus (SARS-CoV-2) or the disease (Covid-19).

With this virus, there is an incredibly wide spectrum of things that can happen once you are infected - you can be asymptomatic and never have any symptoms; you can feel like you are experiencing allergies; you can be sick and on a ventilator in the hospital really quickly. The number of different manifestations after being infected is quite novel and that means a ton of unknowns: If I've had it once, what does that mean for future infection? What does it mean 10 years out in terms of impact on my body? If I lose my sense of smell and taste, how long will I continue to experience those sequelae? If I experience brain fog, how long will that last?

Then you get into the topic of vaccines. The measure of effectiveness, currently, for a Covid-19 vaccine is that by taking it, I won’t become sick if exposed. But can I still transmit the virus, even though I'm not sick from it? Am I protected six months from now? One year from now?

Interestingly, I do think there's going to be a lot of advances in medicine beyond what we learn about this virus and this disease. For example, we know that influenza is an on and off switch - you either get influenza, or you don’t. With SARS-CoV-2, we're seeing that the amount of virus you’re exposed to may trigger variations of disease expression. That’s pretty novel, and characteristics like that may have us rethinking some diseases and viruses of the past that we thought we understood.

Benjamin and Komlos: What insights can you offer for leaders as they think about the next 12 months and beyond?

MacDonald: For the next 12 months, we need to accept that the Covid-19 pandemic and how it's expressed in the United States is not going to change quickly, even with a vaccine. That means we must pace ourselves and be very innovative. We can’t afford this idea of hunkering down and waiting for things to go back to the old way. That’s not going to happen, no matter what. There's no going back to yesteryear, only forging a new reality and a new future.

In the past, the business community has not appreciated how much even a small outbreak in one country can impact them. In fact, I recently did a study showing that the majority of Fortune 500 companies had not included the risks related to outbreaks or pandemics in their 2018 10-K filings - risks to their businesses, their workforce, their supply chain, their manufacturing and production, and so on. I hope that’s now changed as they make plans for the future.

Benjamin and Komlos: What are some important milestones we can all be watching for, in terms of early signals that we’re through the worst of it?

MacDonald: We want to see the number of cases decreasing every single day; that signifies that the outbreak is waning, and we are on the road to recovery. Once you see cases going down, all these public health measures like contact tracing and testing in smart, timely, and more comprehensive ways will get easier. I will feel a lot better when I see sustained declines in the number of cases, hospitalization rates, percent test positive, etc.

Vaccinations are not the silver bullet for the United States. They may be for other countries, but not here because a significant portion of our population either don't believe in vaccines or don't trust them and want to wait for more evidence that they work and are safe. There are also potential access, manufacturing, distribution issues, and logistical questions around who's going to get which vaccines and in what priority sequence. It is critical to understand, it's going to be a slow process and we won’t turn the corner overnight.

Benjamin and Komlos:  Based on past human experiences with global health crises, how is this pandemic most likely to end? What is the prevailing thinking about when it is that we’ll likely be able to declare the pandemic over?

MacDonald: I have not actually seen a lot of discussion about how this ends, but there are precedents we can look at. For example, with measles, we have a vaccine, but we still have measles outbreaks. Despite eradicating polio in many places around the world, we have pockets where polio remains a problem. I expect SARS-CoV-2 to be similar. We're going to face some of the same challenges that we faced with measles, polio, and various other diseases that we should be able to eradicate in theory but haven’t been able to do in practice. And it’s important to understand that it doesn't matter if we eradicate it in the United States when we have so many people who travel beyond the US, and from other places who travel here.

For now, when there are so many factors we don’t understand, it makes sense to be blunt with our measures and to apply clear easy-to-understand rules. As we understand things like transmission better over time, we’ll be able to get a lot more nuanced in how we behave.

Blunt approaches are safest right now because of the lack of understanding that prevents people from making good choices themselves. For example, some areas in the country are forced to close all bars and gyms because people are not behaving responsibly in those places to reduce transmission. If every single person was going to those places only with people inside their household and wearing masks, and those places were configured to keep people far apart and outside, then we wouldn’t have to be that blunt. Over time, Covid-19 will become more manageable in our daily lives, especially so with a vaccine and more evidence around transmission.

Benjamin and Komlos: Any other advice you can offer? Any parting thoughts?

MacDonald: We need an all-of-society effort to get past this crisis, with every single person doing their part. We’re all going to have to work together, not just here, but globally. We’re inextricably intertwined with the rest of the world when it comes to our economy, supply chains, travel, and people. Isolationist policies are definitely not the answer.

The private sector is a critical partner in this pandemic response, and for the growing future disease threats as they emerge. They can urge Congress to invest in public health preparedness and health security, domestically, and globally. They can continue driving innovation. Engaging the private sector for the long term will be key to saving lives and minimizing the economic impact of the inevitable next public health emergency. It’s absolutely in everyone’s best interest.

Original article posted on Forbes on Dec 14, 2020

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