With 3 FDA authorized vaccines being administered throughout the US, but new variants growing in number, we are at a crucial moment in the COVID-19 pandemic. 

To get a better understanding of the situation and how the future months could unfold, MPR sat down with Joshua Barocas, MD, an Assistant Professor of Medicine at the Boston University School of Medicine and Infectious Diseases physician at Boston Medical Center. 

Joshua Barocas, MD


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Interview Transcript

MPR: First off, how do you feel the vaccine rollout has gone thus far?

Dr Barocas

The vaccine rollout in the US I think has picked up a lot of steam recently. We started out a little bit rocky, there was a lot of uneven distribution early on. This hasn’t necessarily changed, and its not perfect in the US, but now that we’re heading into the time where we have 3 different vaccines by 3 different companies, and there’s now a lot more accessibility, that access has made it a little bit more even.

There are 2 other problems. First there has been huge variation in the efficiency of vaccine rollouts between countries. So while we may be experiencing a maybe smoother rollout at this point, compared to say Israel, we’ve had a really rocky rollout. Compared however to say Brazil or South Africa, we might have had a much smoother rollout. Same places haven’t even started their rollout.

It’s a hard question to answer because there are a lot of dynamics at play here. But overall we are seeing a lot of the kinks being worked out in the rollout system here in the US.

MPR

It seems like we’re at a critical juncture now with the pandemic and the new emerging variants. At this moment, do you think there is a threat of the variants outpacing the rollout of the vaccine?

Dr Barocas

I think the question comes down to: the threat to what? I think that what we’re all worried about is that variants are going to outpace the vaccine rollout in terms of getting us to herd immunity. In that regard, I am concerned. If we look, for instance at the P.1 variant, which has been making its way through Brazil, we’ve seen some indications that prior infection may not fully prevent future infection. We don’t know what this means in terms of the vaccines. So the faster we can get our population vaccinated, 70 to 80% of our worldwide population vaccinated, the more likely we are going to get to herd immunity and elimination.

But I am concerned because as of today in the US we really have only vaccinated a very small minority of the population and that doesn’t even include vaccinating the population which is under 18, which is not an insignificant number of the population. So we’re at a point where, unless we can really ramp up our vaccination efforts at the local, the state and the federal level then variants probably are going to outpace our vaccination rates.

What that means for achieving herd immunity is still unclear, but I would like to just point out a really important part of this entire discussion is: we’re not just talking about the US. We don’t live in a controlled environment. For instance, if we were trying to achieve herd immunity within our households because we never went outside our household, then sure, you just need both parents vaccinated. If you have a 2 parent household you only need both parents and the children are fine. But of course we don’t live in that sort of community and we don’t live in that sort of world. We have worldwide travel and commerce. This is not a US problem, this is not a Canadian problem, this is a global issue.

MPR

There is growing skepticism whether herd immunity can even be reached, and whether the SARS-CoV-2 pandemic will become endemic and we will face a new normal.

Dr Barocas

I would not be surprised if we just did not reach herd immunity, and as you said, we figure out a way to make this coronavirus endemic. We live with the seasonal flu. We accept influenza. We accept that we have to get vaccinated every year for influenza because there’s changing strains, dominant strains. We accept a certain level of morbidity and mortality from influenza. I think that it is becoming less and less likely that we will actually achieve herd immunity and whether or not we could’ve ever achieved herd immunity is up for debate as well, because of the uneven vaccine rollout, because of the uneven restrictions across the world.

And across the United States there was no unified front early on. It’s very unclear if we would have ever been able to get herd immunity now, when we are largely relying on vaccines as states begin to reopen some sectors of their economy and are relaxing mask mandates etc. I’m becoming increasingly skeptical that herd immunity is something that we are going to achieve and in fact, what we’re going to have to say to ourselves as a society is: how are we going to live with this? What is that new normal? Do we make it so it’s like influenza, that you get a shot every year and you know that you might get sick during the winter time? Do we work on better therapeutics and just live with it? It’s a really big question right now that is without a good answer.

MPR

What does the latest data show on transmissibility for those who have been vaccinated? And if the data are not strong now, when do you feel like we might have strong data on whether these vaccines can halt transmission in a big way?

Dr Barocas

That is the million dollar question. It’s a great question and I think it’s the question that is on everyone’s mind. The data that exist are varying in terms of what they show as far as transmissibility but also they’re varying in how robust those data actually are and what we should actually believe in what’s coming out. I have seen numbers that say it decreases transmission by two-thirds, some studies have said higher.

One of the things I have thought a lot about is: what’s our goal here? And when we talk about what these vaccines do. They do a very good job of preventing infection, but they do an even better job in preventing disease. It’s a very subtle difference. COVID is the disease caused by the virus and there’s a slew of different symptoms that can come from it. Everything from sniffles and sore throat to hospitalization, needing a respirator to help you breathe, and of course, death.

What we need to know is, if your goal as an individual, as a society, is to prevent a high level of disease, hospitalization and death, then the vaccines are incredibly effective. What I think your question is getting at is, how well do they prevent the sniffles and the sore throat too in a vaccinated person? And how well do they keep someone from transmitting to somebody else? I think that’s where that two-thirds reduction comes in.

I don’t want everyone to hang their hat on that two-thirds, but it does help quite a bit I think. You have to remember, we’re only 3 months into vaccination. This is brand new. Just like last year at this exact same time, we were 1 month into our pandemic, we were asking people to be patient with the new knowledge coming out. We were asking people to remember this was an emerging infectious disease. Similarly, this is an emerging vaccinated disease. We have very little data as opposed to influenza, measles, polio, where we have years and years of data. We are building the plane as we are flying it.

MPR

I’d like to ask your thoughts on long-COVID. There seems, in some sections of the media, to be some alarmism around this state that has no definition. How do you perceive these cases and in the future how would you like to see this phenomenon researched?

Dr Barocas

Luckily, this idea of long-COVID emerged really quickly. Numerous researchers across the country and globe have collaborated together to help study long-COVID and actually develop better definitions. I think that, and this is a key, that we don’t necessarily have for other – I’m going to call them ‘contested illnesses’ but I don’t mean that to be offensive to anyone – but we know that there’s quite a bit of debate over things like chronic Lyme disease. I think we’re in a lucky position here, if I can use the word lucky, with long-COVID because we started gathering data immediately. We have data from the earliest survivors of COVID and I think that’s going to help us really tease out a) what physiologically is happening and b) perhaps figure out who is more at risk, if there are treatments that can help prevent or treat it.

And I think early on in this whole COVID story, but especially in this long-COVID story, the best thing to do is to keep an open mind on both ends of the spectrum. Researchers, physicians and public health experts have to admit that we don’t actually know what’s underlying this. At the other end, patients need to also recognize that as new data emerge we’re going to have better definitions, and I hope that we have answers for people, but that’s going to take time and it might be frustrating.

I am heartened to know that, really researchers saw this, and not just researchers. Thanks to patients who were advocating for themselves. They said, ‘you know, you told me I recovered from COVID but I still feel like I have it, what’s going on?’ So it was this dialogue between the research and medical communities as well as the patient community to say: something strange is going on. And because that dialogue was open and we were learning from each other early on, I’m hopeful that we’ll have answers more so than we have for other more chronic syndromes.

MPR

What are your thoughts on vaccine hesitancy and personally if it’s frustrating for you to see certain states drop mask mandates?

Dr Barocas

I think one of the problems we’ve encountered throughout this entire year is there has been a lack of unified effort. I know that there are varying reasons, and this doesn’t necessarily get to the vaccine part of this, but certainly in the mask mandate in some of the shut downs, the shelter in place orders, there was no comprehensive national plan. I think we’re seeing some of the fallout from that now.

With vaccine hesitancy, this is a whole 3 hour discussion in and of itself because there are structural reasons, institutional reasons. There are legitimate reasons for people to be hesitant or mistrustful. I think instead of getting frustrated, I’ve noticed that I get frustrated with people in general – I think we all do – when we tell them something and they don’t believe us. What I think public health experts and medical professionals need to do instead of saying ‘do this, do this, do this,’ is take a step back and say: here’s some evidence that I have. Here’s evidence of how these vaccines were developed; here’s data we have so far. What are your questions? What is it that’s keeping you from doing this?

Keeping in mind that there are a myriad of reasons, and some are very deeply rooted, why people are mistrustful or don’t want it. I think that listening has been the biggest key in our vaccine rollout and some of the best success we’ve had, as opposed to telling. Medical professionals, I say this as one myself, we do a very poor job of listening. We do a better job at telling; I’m a good teller I’m a bad listener. When it comes to these big population level issues, listening is actually the biggest key and I notice when we do these listening sessions and listen to people’s concerns, most people are satisfied and say, ‘Huh, what you did was you heard my concerns, you helped me understand where my concerns were coming from, now I’m going to go get the vaccine.’ It takes a lot more time to listen than it does to tell. Part of where we’ve all struggled is that we feel like we’re racing against the clock. Right now, its either we race against the clock and take an extra couple of minutes to be effective or just keep pounding our heads against a wall, which is not a useful way to use our time. 

MPR

Is there anything else you’d like to add?

Dr Barocas

I appreciate the time and ability to talk with you on this. One of the things that I’ve grappled with, whether it’s herd immunity or vaccinations or whatnot, is that we have focused very much on the dichotomy: we either reach herd immunity or we don’t, we either succeed or we fail, we’re either vaccinated or we’re not vaccinated. And in fact, the conversation really needs to come to more of a continuum. We need to look at this pandemic through the eyes of a continuum. And the way that we structure our discussions. Yeah, herd immunity is an option. So is making it somewhat endemic vs we’re going to be locked down in our houses forever. There’s gradation here and I think we’ve touched on a lot of that. I want people to understand that there’s going to be grey area for a while.

This article originally appeared on Psychiatry Advisor