UCSF Department of Medicine Chair and Grand Rounds moderator Dr. Bob Wachter began today’s session by commenting on the “jarring juxtaposition of both the horror (record-breaking cases and deaths) and the joy that comes from the vaccination process.” Today’s guests touched on various topics, including the lessons learned (and lost) from the SARS pandemic, how vaccine distribution is proceeding at UCSF, and the question of immunity passports.
Former CDC Director discusses pandemic preparedness
Following the recent resignation of the chief of staff at the Centers for Disease Control and Prevention, Wachter spoke with former director of the CDC (from 2002-2009) Dr. Julie Gerberding to understand how the SARS epidemic shaped the CDC and government’s preparation for future pandemics and where that preparation fell short.
When the SARS pandemic emerged in the early 2000s, the CDC had to mount a large-scale global response without a preparedness doctrine, instigating a major effort to invest in pandemic preparedness in the following years, she said. “And when I say major, I mean involving multiple countries, involving laboratory science,” Gerberding said.
“I think we leaned as far into influenza pandemic preparedness as you would probably expect any government to ever imagine, let alone execute,” she said. Each phase of the pandemic preparedness plan had implications for the public health system, the healthcare system, and the educational system.
You may be wondering where the effects of all of this planning have been the past several months. Gerberding acknowledged that the CDC’s plans did not consider implementing widespread testing. Its model was based around an influenza outbreak and planners didn’t believe diagnostic testing would be important in such a scenario. They also did not engage with Congress to create a plan for offsetting the economic interventions following restrictive health measures. As a result, responses now are being invented on the fly, she said.
When the threat of avian influenza receded and the tension moved away from emerging infectious diseases, “all of that focus and all of that energy got dissipated and displaced into other other priorities,” Gerberding said.
Today, a major problem Gerberding has noticed is communication between scientists, the government, and the public.
“The principles are, you know, tell people what you know honestly, but you also reveal what you don’t know or what your uncertainties are,” Gerberding said, noting that people don’t expect you to know everything, but rather expect you to keep them informed about what you have learned with time. “And if you prepare people for that, you have a much better chance of sustaining confidence and trust and hopefully willingness to follow the recommendations that are emerging as the science evolves.”
These problems of not being transparent have played out recently in San Francisco and elsewhere in California, when health officials failed to explain the data being their lockdown decisions. To some, those decisions seemed arbitrary and a few — closing playgrounds, for example — were reversed.
While Gerberding did not specifically discuss the closures, she said that officials are also missing the demonstration of care and recognition of hardship for what people are going through.
Discussing vaccine availability, Gerberding listed five hurdles: efficacy of the vaccine, safety, length of immunity, whether the virus will mutate, and the triple whammy of vaccine uptake, access and distribution. The final trio is the most difficult, she said, because it involves supply chain logistics as well as sociological factors, affordability, and globalism over nationalism.
UCSF begins vaccine distribution
UCSF’s Chief Pharmacy Executive, Desi Kotis, and Health’s Chief Faculty Practice Officer, Susan Smith, followed Berberding with an in-depth breakdown of distribution at UCSF, what Kotis called a “very coordinated dance.”
As we head into the new year, UCSF personnel will have reason to break out the champagne early, because the university has already received its first 3,900 doses and plans to have Phase 1A of vaccinations (frontline healthcare workers with frequent exposure to covid) finished in the next seven to 10 days. It vaccinated 220 people yesterday, and more than 500 more people are scheduled to be vaccinated today.
The Moderna vaccine is being presented to the Food and Drug Administration today for emergency use authorization, and we will know by the end of the day tomorrow if it has been approved, Kotis said. If approved, UCSF should receive an additional 7,900 doses next week.
California is expecting 330,000 doses of the Pfizer vaccine and 1.5 million doses of Moderna (if approved) before the end of the year, which is enough to vaccinate almost all of the healthcare workers in Phase 1A. At UCSF, they are preparing plans to vaccinate those in Phase 1B (high-risk patients and other essential workers, such as teachers) in the second or third week of January.
The debate around immunity passports
As covid immunity becomes more widespread, the issue of “immunity passports” for those who can certify their immunity to the virus through previous infection or vaccination has risen once again.
“Once some of us are vaccinated and some are not, particularly if the vaccine supply becomes plentiful and some folks simply choose not to vaccinate, you can count on a level of controversy over immunity passports that will make the mask controversy look like a stroll in the park,” Wachter said.
The idea of immunity passports emerged in late spring, said Dr. David Studdert, a professor of medicine and law at Stanford University.
While one of the major issues surrounding these passports at the time was the question of acquired immunity, “there is mounting evidence that it’s substantial and real, at least for some period of months,” Studdert said.
The other argument against passports is one around social fairness, “the argument was that discriminating on the basis of community status was just wrong,” Studdert said. “Critics also pointed out that this is exactly the kind of program that history tells us is likely to be used to benefit the powerful and to disadvantage those without power, particularly minorities and the poor.”
Studdert believes that these are legitimate concerns, but said that passports could actually conceivably create progressive leveling effects. Because of the disproportionate impact of covid on poor communities and communities of color, antibodies will be more prevalent in these groups and thus they would be able to get passports at increased rates.
Studdert worked with Dr. Mark Hall of Wake Forest University to survey 1,300 people on immunity passports, and 55 percent opposed them and 45 percent supported the idea. Women and Latinx people were less likely to support the passports than their counterparts (by 35 and 50 percent respectively).
Unlike most other coronavirus policies, political leanings didn’t appear to influence opinions, which Studdert said may be because the immunity passport concept “sits in a sort of pre-political embryonic state right now.”
However, this concept is developing in the private sector, where groups such as the airline industry are considering certification as a way to staff high-exposure worksites with less-vulnerable people.
Studdert believes they would be legal, sayingm “if the program is implemented for a good, legitimate reason and it’s administered evenhandedly, these kinds of programs in other settings have consistently survived challenges.”
See our previous Grand Rounds coverage here.
Administration of vaccine needs to be prioritized at nursing homes with active outbreaks, like San Francisco Jewish Home, the second largest nursing home in the city right now or there will be vastly more deaths (4 and rising as of now). One cannot stop nursing home staff from bringing it in, but one can prioritize where the vaccine goes. January will be too late.
Hands down the best part of this deadly global pandemic has been watching big science flex and work in real time.