Resources

Resources

nextgen-advisors

Hear from NextGen's expert advisors with insights and advice on the evolving COVID-19 pandemic and beyond.

Read Blog
covid-resources

The financial and clinical challenges you face now are evolving rapidly. Here are resources, solutions, and ideas we think will help.

Read Now
Podcast Library > NextGen Advisors Podcasts > Reflections on a Pandemic Milestone

September 28, 2021

Reflections on a Pandemic Milestone

Recently, the U.S. passed a grim milestone with deaths of Americans from COVID-19 surpassing American deaths from the Spanish flu, the deadly influenza pandemic that spanned about 2 years from 1918.  In today’s podcast, the NextGen Advisors reflect on this milestone and the impact that vaccines have had on the course of the pandemic.  The conversation sheds light on the underlying reasons for vaccine hesitancy and the special consideration for pediatric vaccines.

Play

Transcript

Betty Rabinowitz:

Hello, this is Dr. Betty Rabinowitz, NextGen Healthcare's chief medical officer and principal with NextGen Advisors. I'd like to welcome you to our podcast and as usual to them joined by colleagues, Graham Brown and Dr. Marty Lustick. Welcome, Graham, and welcome Marty.

Graham Brown:

Thanks, Betty. Nice to be with you.

Marty Lustick:

Thank you. It's great to be here.

Betty Rabinowitz:

So just this week, the United States passed a grim milestone with deaths of Americans from COVID surpassing American deaths from the Spanish flu, the deadly influenza pandemic that spanned about two years from 1918. It really brought back kind of our reflections and thoughts about that historical pandemic. I wonder in your minds... Graham, maybe you go first, what are some of the similarities and notable differences between these two pandemics?

Graham Brown:

On the similarity side, Betty you just noted the absolute number of deaths from the 1918 pandemic is about the same as those who have passed away due to COVID. But what's changed of course, is the size of the population of the United States in that time where we have triple the number of people living in the United States then we're a 100 years ago. So the absolute number of people that have become ill and died from this is dramatic and a large number, but as a percentage of the population, it's actually considerably smaller.

Graham Brown:

Part of probably what's helped influence and mitigated the volume of deaths are a number of different advancements that come to mind for me in terms of medical technology and how we responded to this pandemic. So the ability to rapidly create tests that identify the presence of the virus, to roll those out while it was problematic a year ago, it still happened pretty fast. There's been the development of rapid antigen tests, as well as the evolution of PCR tests and rapid antigen tests. We've also put in place contact tracing systems. Those haven't been broadly implemented, but nonetheless, where they have put in place, it's really easy to identify clusters and to warn and advise people who may have come into contact with someone who was infected and help prevent further infection.

Graham Brown:

Then there's a whole variety of treatments with regard to managing and lessening the impact of the illness. Our hospital infrastructure, our ICU's, our ability to intubate patients, to maintain them on artificial life support, to provide them with monoclonal antibody treatment, all of those things weren't available 100 years ago. So our ability to save people from a very dramatic illness has certainly evolved.

Graham Brown:

Then of course, the vaccines. The rapid development of vaccines that came to market within a matter of months and were available for testing and evaluation as to their efficacy, certainly brought a huge amount of relief to those that were suffering and preventing further spread. I guess the final thing to note here is our technology in terms of our communication with each other, has also just taken on a totally different world that would not have been anticipated or even foreseen 100 years ago. So that's allowed us to share information and knowledge at a global level, but it's also perpetuated a system of misinformation and sharing of misinformation at a global level that certainly prevented us from responding, enacting always in our best interests.

Marty Lustick:

Yeah, I think an interesting example of misinformation then, and now, I mean, you speak to how social media has made it difficult to separate the wheat from the chef, but the Spanish flu is called the Spanish flu because Spain was the only country that was transparent about what was going on there. So everybody decided because that's what they were hearing that, that's where it came from, even though it didn't. So there was a lot of misinformation in the Spanish flu pandemic, just like there's a lot of information today, even though there was no global infrastructure back then.

Betty Rabinowitz:

Yeah, it's interesting from a historical perspective as well. International travel is much more frequent, and immediate, and instant these days. So the spread of the pandemic was fast, rapid could be tracked quickly and was all over the world in no time. The combination of the movement of troops from the United States to Europe likely acted in that regard similar to the kind of travel that's now everywhere. Had it started, and there probably were flu outbreaks of more aggressive virus, more virulent strains... in the absence of large movements of humans, those probably never developed a pandemic. So it was kind of the combination of something that now is just prevalent, which is people get on planes and within no time at all over the world. I remember us reviewing at the time, the graph of the flights out of Wuhan China, to all over the world and the timetable around that. Each of those places where a plane went, had an index case very quickly.

Marty Lustick:

Along those lines Betty, also, the flu pandemic came in waves also, but they were slower. They were more space between the waves probably related somewhat to what you're describing in terms of the travel back then compared to now. Although [crosstalk 00:05:51] there's also flu is more seasonal apparent than COVID appears to be, but we're seeing the same kind of waves. I think it's important to remind ourselves here that the flu pandemic lasted several years and we don't know how long this one's going to last.

Betty Rabinowitz:

That's correct. The encouraging thing about the flu pandemic is that it eventually receded on its own, either the virus mutated to a more friendly spot, or there was herd immunity in enough spots where it was kind of stopped in its tracks. Reflect for a moment, Graham, you mentioned the vaccine as such a differentiator from the previous historical pandemic, the number of five billion doses of vaccine that's been given across the world reflect on that achievement or milestone.

Graham Brown:

I think it's a massive achievement for the human race and for the development of science and technology, to know that milestone has been achieved within a year, right? I mean, it was just over a year ago that these were first coming out of clinical trials and that we saw that there was efficacy being demonstrated, and they were moving more broadly into a testing on different populations to scale up and grow. So the five billion doses administered is an enormous number. It doesn't obviously reflect the need in disseminating vaccines around the parts of the world that haven't as yet had access to them through lack of availability, lack of purchasing power, lack of authority to kind of get in queue and get access to these vaccines. The disparity that exists from my perspective in terms of where vaccines are manufactured, and by whom, and how rapidly they can get to the target populations because of how things have been aligned in the purchasing of those.

Betty Rabinowitz:

Absolutely. Marty in view of kind of five billion doses provided, talk a little bit about your sense of the risk and safety record of these vaccines?

Marty Lustick:

Yeah. I've been reviewing some of the numbers recently, as you know I love numbers. It's actually quite remarkable, though minor side effects from the vaccine are fairly common in terms of injection site pain, or headaches or fever for 24 hours. But the serious side effects, the most recent data I've looked at is about one per 100,000 doses. If in serious side effects means the majority of those are severe allergic reactions, which of course are treatable and not life-threatening as long as there's the right services and technology available. Deaths from the vaccine are really from what we know today, a small handful out of those five billion doses. Really the only ones where there's good evidence of a true causal relationship is in the young women, a few young women who have died from blood clots. We've actually learned from that, that there's a specific antibody abnormality that those women have that you can actually test for before you give her the vaccine. So now that we understand it better those are preventable side effects, so it's extraordinarily safe.

Betty Rabinowitz:

Mm-hmm (affirmative). Those specifically were with the non-messenger RNA vaccine, or were those in the messenger RNA as well?

Marty Lustick:

I think there were some cases in both, but the non-messenger RNA is where there's considered a higher risk.

Betty Rabinowitz:

So considering that this is an enormously safe and effective vaccine, why do you think we have been seeing so much vaccine hesitancy across the world? It's not unique to us. It's a phenomenon that we're seeing everywhere the vaccine is being offered.

Marty Lustick:

Right. So I didn't mention you're the comparison of one and 100,000 serious side effects versus almost 900 hospitalizations, per 100,000 among people who get COVID and 200 deaths. So there's orders of magnitude difference in the risk of the vaccine versus the illness. Yet, as you say, we still are seeing hesitancy. I'm sure both of you have opinions on this as well, but I think the politicization of the pandemic has been a problem. Part of what's gone along with that is a communication challenge.

Marty Lustick:

Graham mentioned earlier about the internet and social media and the difficulty of getting truth through all of the noise that's in there. I think the politicization of this is actually just exacerbated that problem, so that it's hard for people to know what to believe. If you take underneath that, a sort of underlying distrust of authority and of science and past experience of some populations... You look at the African-American population in the United States that have already an underlying historical, legitimate fear of these kinds of new technologies that the government is sponsoring, so to speak. So I think all those issues play into how rational people can be hesitant about this.

Graham Brown:

Yeah, I totally agree. I think the only thing I would add to what Marty just said is things there's been a real struggle from U.S. and global health agencies to maintain consistency of messaging. So much has evolved in our knowledge of COVID since it first came about a year and a half ago till now, that we've learned more about the disease, how it spreads. We're understanding different variants, but only learning in time, whether those variants are more virulent or just more transmissible, so the anxiety.

Graham Brown:

There are rapid ability to share information globally, there's a new report out. Everyone learns about it, hears about it, but they interpreted in different ways. They interpret it from their own biases and their own perspectives. That flood of new information, that's not kind of curated message and carefully controlled is leading to a place where people can draw from that what they want to, reinforce the conclusions and the biases they already have around vaccines. So I think that our ability to rapidly communicate and disseminate information in some ways, becoming a barrier to our ability to clearly communicate and manage messaging in a way that would be more beneficial.

Marty Lustick:

I also think there's a confusion that people get in understanding the individual risk benefit for them, alongside of the risk benefit from a public health point of view. That there's value in both of those realms. The value equations may be slightly different on someone's individual circumstances, but people I think have a really hard time wrapping their mind around both of those things at once and trying to figure out where they belong in that.

Betty Rabinowitz:

Absolutely. I think additionally, something about the speed at which the vaccine was developed and became available. I think people didn't know that messenger RNA technology was being worked on for 10, 15 years or more before. That it was a historical coincidence that as messenger RNA came of age came this enormous need for it. So it felt to people experimental. It felt as if it didn't get tested enough. I think there was not enough emphasis on the value of five billion, from a biological perspective, five billion shots in populations of a variety of kinds of highly heterogeneous, all ages both genders, et cetera, provides mitigates for the shortness of the experience with it because of the volume of have experience with it.

Betty Rabinowitz:

I think that that concept wasn't emphasized. Clearly people have said, "If this was around longer... I have always taken vaccines. If this was around longer, I would have gotten this." We didn't have time for longer. This was a place where people needed to clearly make a little bit of a leap of faith. The numbers you provided Marty are staggering, the difference between the risk of COVID and the risk of the vaccine, but people don't really think of it in those terms.

Marty Lustick:

An interesting example to me, the communication challenges, all the stuff we're seeing in the news now with healthcare workers, protesting the mandatory vaccination, and people looking at that and saying, "Well, healthcare workers don't want to get vaccinated. They must know something I don't know." Yet even as early as the beginning of June an MNA survey of physicians showed that 96% of physicians in the United States have been fully vaccinated by June. So there are a lot of healthcare workers who aren't necessarily health literate. So just because they're health worker workers doesn't mean that they understand the science. Yet, if you look at the physicians who I would expect to understand it, they're overwhelmingly getting vaccinated. [crosstalk 00:16:24] Yet nobody talks about that. They talk about the protests they see on TV.

Betty Rabinowitz:

Also, the aggregate number, because there're groups of healthcare workers who haven't gotten vaccinated, people are misinformed with an average number of healthcare workers, which is not the way to look at it. Marty, can you talk a little bit about the special challenges in consideration for COVID vaccine in children?

Marty Lustick:

Sure. I would just sort of highlight two things. One is people have questioned why it's taking so long. Although we did just obviously hear about are the approval for five to 11 year olds. There are challenges both logistically and scientifically with moving the vaccine into the younger child populations. Knowing how to dose, whether it's done by weight or by age, and looking at both safety and efficacy in both of those parameters just takes a whole lot more time than you can do in an adult population. There are also in the United States, there are regulatory differences. They require four to six months of follow-up for side effects in childhood vaccines, compared to only two months with adults. So there're just differences in the development that require more time.

Marty Lustick:

The other issue is that we know that children are at lower risk of severe illness from the disease. So there's this question about, should they still be getting it? So as an example, if you look at the numbers in the United States, the hospitalization rate and death rates for children are much lower than for adults. So the death rate is about 12 deaths per 100,000. That's still 10 times the complication rate of the vaccine, but it's not as dramatic as what we see in adults where there's 200 deaths per 100,000. So it's a slightly different equation at the individual level. Although still I would argue, given that we're seeing 250,000 children hospitalized per week over the last month with the Delta variant, that we should still be aggressively moving towards vaccinating kids, even with those less dramatic numbers. So, there are some differences there, but the risk to children is not de minimis. By the way, they also are vectors for spreading it to at-risk adults. So there's clear public health reasons as well to vaccinate kids.

Betty Rabinowitz:

Absolutely. I wish we had more time to explore some more of these topics further, but our time is up today. Thank you, our listeners for joining us today. I'd also like to thank my colleagues, Dr. Marty Lustick and Graham Brown for sharing their insights and perspective. If you've enjoyed today's topic, consider subscribing to our podcast. This is Dr. Betty Rabinowitz, with NextGen Healthcare, have a great day.