As the vaccine rollout proceeds in San Francisco and several vaccines have completed Phase 3 trials, the Covid-19 pandemic is throwing what UCSF Grand Rounds moderator Dr. Bob Wachter called the “curve ball of variance” as the first two cases of the B131 “South African” variant were confirmed in the Bay Area. But it did not take long for Dr. Monica Gandhi, his first guest, who looked at data from the vaccine trials, to dispel fears regarding the variants. Other guests addressed strategies to address vaccine hesitancy and insider perspectives from President Joe Biden’s Covid-19 Task Force. Wachter pulled together a team of seasoned experts.
Vaccine trials
There are currently six covid vaccine trials with Phase 3 data. Two, the Moderna and Pfizer vaccines, are approved in the United States, and one more, the Johnson & Johnson vaccine, will be considered for Emergency Use Authorization by the Food and Drug Administration on February 26. These vaccines, along with AstraZeneca, NovaVax, and Sputnik V, all work by introducing a harmless spike protein, unique to covid, to cells. Once introduced, the body recognizes the foreign protein and begins to produce antibodies to fight the infectious agent.
Vaccines are important in eliciting antibody responses, such as B cells and plasma, but they also “elicit a robust T-cell response,” said Gandhi, associate chief of ZSFG’s Division of HIV, Infectious Diseases, and Global Medicine and director of the UCSF-Gladstone Center for AIDS Research.
This T-cell response is important because “there is lots and lots of data that, essentially, T-cell responses modulate severity of disease. In fact, strong T-cell responses were documented in all six of these trials. It likely led to this prevention of severe disease,” Gandhi said. If an individual gets reinfected (after natural infection or the vaccine), the disease should be mild, as long as the body mounts a strong T-cell response, she said.
Gandhi also conducted an overview of each of the vaccine’s non-clinical results, how protective the vaccine was against hospitalization and severe disease, and efficacy in mild disease, which can be viewed in detail below.
Except for the Johnson & Johnson vaccine, which must be administered only once, all vaccines require two doses.
The Moderna mRNA vaccine stimulates neutralizing antibodies and was found to create 97-percent effective protection against covid hospitalization and severe disease. It was 94.1 percent effective against milder disease. The side effects, which she said could be “quite heightened,” include fatigue, muscle pains and headaches. However, the mRNA stability of this vaccine means it can be stored in a regular refrigerator for up to 30 days.
The Pfizer vaccine created the “same wonderful immune responses,” with 100 percent protection against hospitalization and severe disease, as well as being 95 percent effective against milder disease. Outside of mild fatigue and headaches at the time of vaccination, the only difficulty is that the vaccine must be stored in -70 degrees Celsius freezers.
The J&J single-dose vaccine was 100 percent protective against hospitalizations and 89 percent against severe disease. It should be noted that it had 89 percent protection against severe disease in South Africa, where 95 percent of strains found there are the South African variant. Its efficacy against milder disease was “more disparate,” however, with 72 percent efficacy in the United States and 57 percent in South Africa. No injection site reactions were observed.
Gandhi believes vaccines will decrease transmission, citing a study from Catalonia that found that viral load in nasal mucosa is a main driver of transmission and that a lower viral load causes four times lower transmission. She also cited a paper posted from the Pfizer data in Israel that there is four times less viral load in the nose after vaccination.
Variants
Thus far, there are 932 cases of the “United Kingdom” B117 variant, which you can read about alongside the South African variant in our previous Grand Rounds coverage. Nine cases of the B131 “South African” variant have been confirmed in two states, including two in the Bay Area, alongside three cases of the P1 “Brazil” variant.
Gandhi said that data for both the Moderna and Pfizer vaccines has shown that they produce very high neutralizing antibody responses against all of these variants. The J&J vaccine seems to protect against severe disease and death, even from the B131 variant. Gandhi quoted another doctor, Warner Greene, who noted that even one dose of the vaccine prevents severe disease, hospitalization and dying, which is all we want from a vaccine.
Gandhi said we should not be worried about variants, because data for neutralizing antibodies against the variants is “comforting.” Additionally, she said, “mRNA and DNA vaccines can be easily tweaked. You don’t even work with live virus . . . You can even put a couple of variants in there and you can do a booster shot in the future.” Moderna and Pfizer are already working on these.
Vaccinated individuals should “feel free” to mingle with one another without restrictions, but should still follow precautions when interacting with unvaccinated people in public. She also believes that mRNA vaccines are “very safe” for pregnant women.
Addressing vaccine hesitancy
Dr. Marguerita Lightfoot, professor of medicine and chief of UCSF’s division of Prevention Science, made her debut on Grand Rounds to discuss vaccine hesitancy and the importance of communication around covid vaccine concerns, especially for communities of color.
“We know that humans are not always rational, but usually there’s a reason why we engage in the behavior that we’re doing,” she said. Discussing the Associated Press poll that found one-third of U.S. adults were skeptical of the vaccine, she said “We have to realize that hesitancy is really rooted in a social, cultural, political, religious context, or the context that people live in.”
While providing research findings is necessary, it is not enough, she said and encouraged messaging based on listening, community engagement and respect. “They have to recognize people’s lived experiences and the reasons why they’re not taking the vaccine,” Lightfoot said.
She said messaging should include incentives such as being able to spend more time with friends and family. She discouraged restrictions to certain services based on vaccination as doing so may reinforce existing disparities.
Low vaccine uptake in communities of color may also be due to problems of access, such as not having insurance or a primary care provider.
Insight into the Biden task force
Two members of Biden’s Covid-19 Task Force, Dr. Robert Rodriguez and Dr. Eric Goosby, spoke about their roles on the task force and their observations on the transition.
Rodriguez has three goals on the task force: to advocate for frontline providers (especially around mental health), to engage with the Latinx community and make their voices heard on the task force, and to advocate for other under-resourced communities that do not have the hospital staff to deal with covid hotspots. To answer Wachter’s question of how much traction he obtained, Rodriguez said there was “a good response,” but it was very difficult to balance the needs and desires of different constituencies competing for limited resources.
Goosby focused on engaging with city-level and state-level responses to look for disparities in outcomes for hospitalizations, transfers to different units, intubation, and death, especially in minority populations. He and other members of an advisory board would consult with constituencies and would confer back and forth with Biden’s transition team on various policies.
“The discussion around these disparities really presented an opportunity to the Biden administration to embrace a broader engagement around access and retention for minority communities at a more basic level than just a pandemic,” he said, noting that the covid outbreak emphasized existing “minority and socioeconomic lanes.”
Goosby, who has already gone through two presidential transitions, also noted the lack of cooperation with the Trump team. Typically, government agencies have two to three months to prepare a briefing book with salient issues for government transitions, but the Trump team did not make any documents or communicate that they would not make documents.
Once Biden was elected, the team was “stuck in reacting to the Trump behavior in the kind of specifics of the transition,” though Goosby did not blame them for this. Discussion of specifics didn’t occur until after the 20th and decision making has been slowed, but it’s “nothing that we won’t recover from,” he said.
See our previous Grand Rounds coverage here.
I love these grand rounds reports. Thank you