UCSF Chair of Medicine Dr. Bob Wachter talked at Thursday’s Grand Rounds about boosters, mandates, the Biden administration and more with Dr. Ashish Jha, dean of Brown University’s School of Public Health.
Jha became the nation’s Walter Cronkite during the pandemic, Wachter said, referring to the long-time anchor of CBS evening news, who ushered the country through the trauma of President John F. Kennedy’s assassination and the Vietnam War.
Wachter said Covid-19 created a need for individuals “to understand this rapidly swirling ecosystem of information, tinged with politics, often changing all the time,” and that Jha was someone who could “deal with this firehose of information, make sense of it and provide it to us in a way that was thoughtful and trustworthy.”
The two conversed about the hot issues of the day, what we have learned over the last 10 months, and how to better prepare for the future.
Wachter kicked things off with boosters, a relevant topic given that a U.S. Food and Drug Administration advisory panel voted on Thursday to recommend Moderna booster shots for emergency use authorization.
“My sense is, people are going to need boosters,” Jha said. “Is it absolutely essential that people get boosters? No. We still see very high levels of protection against severe illness [without boosters], but severe illness is not the only thing we care about.”
We should start with giving boosters to high-risk people and then move on to everyone else, Jha said, adding that he would be surprised if not everyone is advised to get a booster by December or January. He does not see boosters as a trade-off with vaccinating those in other parts of the world (or in the United States) who are unvaccinated.
“We can do both,” he said. Though some people worry that talking about boosters will increase vaccine hesitancy among the unvaccinated, Jha said he is “not at all convinced that if we stop talking about boosters and let elderly people have breakthrough infections that somehow that’s going to get a lot of unvaccinated people to line up.”
On a global scale, Jha said, redistribution of the limited supply of vaccines is more complicated than simply cutting off boosters. Because more than 80 million vaccines have already been distributed to several states, they cannot simply be sent to a country like India, due to chain of custody issues. Not using them would add to the more than 15 million doses we have already wasted. Jha also argued that the booster supply is a “drop in the bucket on the globe.”
Shifting to vaccine mandates, Jha said they are working, despite a noisy minority in most industries of one to two percent who refuse to get vaccinated. Though he always wants to start with persuasion as a person in public health, he said he doesn’t believe there are any other tools that will motivate large numbers of people to get vaccinated over the next few months.
Regarding rapid tests, Jha acknowledged they would have made an enormous difference last year and are important among unvaccinated populations, but said that “the question of how to use them in a vaccinated population is far less well understood.” Rapid tests are helpful before big gatherings, and for people who are more risk averse, he said.
Children in school can also benefit from rapid tests. Jha, who advises his son’s elementary school, recommended that everyone at the school wear a mask and get tested once a week. Weekly testing should be spread out over several days, with 20 percent of the population getting testing each day, he said. In addition to weekly testing, he also advocated for a test-to-stay strategy, wherein children who are exposed to covid take a rapid test to stay in school, as opposed to quarantining entire classes.
Jha advised a vaccine mandate for all adults in Newton, Massachusetts, where his son attends school, which the mayor implemented. He said he did not think a vaccine mandate was necessary for 12- to 18-year-olds at the moment, though he supported Governor Gavin Newsom’s policy requiring one for school next year.
Moving onto Merck’s new antiviral pill, Jha said it is helpful to have an oral therapy that reduces the severity of covid, but he sees it as part of a tool set as opposed to a game changer.
Evaluating the Biden administration
The Biden administration has done “reasonably well,” Jha said. “Are there things they could have done better? Absolutely.”
Biden’s first job was to get vaccines into arms, which he did, Jha said. However, Jha wished Biden had listened to Wachter and other scientists who advised delaying the second vaccine shot in favor of vaccinating more people for the first time. He also wished the administration had ramped up testing last March, instead of relying so heavily on a vaccination-only strategy.
Jha also said that the White House, the Centers for Disease Control and Prevention, the FDA, and Anthony Fauci “should have done a better job of coordinating the communication strategy.”
Jha suggested several reasons for communication issues, including structural problems. Because Biden was reacting to the Trump administration’s harmful micromanagement of messaging, he may have wanted to not appear to be shaping messaging, Jha said.
While Jha understands the intent of listening to the scientists, he said the different messaging created dissonance. For example, Anthony Fauci became aware of the U.S. Centers for Disease Control’s changing mask guidance for vaccinated individuals this summer only one hour before the public knew.
Both the CDC and the FDA need a “fundamental reboot,” Jha said, expressing doubt that the agencies are ready for a future pandemic. He said he worries people will attribute the struggles of the pandemic solely to the Trump administration instead of systemic problems.
Jha expects we will need a yearly booster “for a while.” By his estimates, there is a five percent or less likelihood that a variant worse than delta will come along, because delta is so contagious.
Wachter raised comments from Trevor Bedford, a virologist, who predicted there will be 40,000 to 100,000 covid deaths annually, and that 20 percent of the world will get infected each year. Did Jha agree?
Jha said he doesn’t see Bedford’s prediction becoming a reality, because we will be forced to make structural changes to mitigate this possibility. There will be more investments in indoor air quality, some cities may implement mask mandates when illness is spreading, and workplace cultures around showing up to work when you’re sick are changing.
When asked how we can get the next pandemic bug “right,” Jha responded that he doesn’t know if we can. The system tracking infectious disease outbreaks will likely have more reports in the coming years (most of which will turn out to be nothing), Jha said. New surveillance systems will need to be built to help us find the signal in the noise, but sometimes predictions will be wrong, he said.
See our previous Grand Rounds coverage here.