Information equity is a critical part of the whole picture

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Podcast Transcript – Dr. Robert Breiman

“Information equity is a critical part of the whole picture”: Dr. Robert Breiman on COVID-19 vaccine development and distribution

Dr. Robert Breiman talks about where different SARS-CoV-2 vaccines are in development and clinical trials, and considerations for production and distribution related to logistics and equity. How might vaccines be allocated fairly, both in consideration of essential workers and those at higher risk of developing severe COVID-19 outcomes?

00:00

Leanna Ehrlich

Welcome to the COVID-19 Equity and Outcomes podcast series. Today we’re talking to Dr. Robert Breiman, a Professor of Global Health, Environmental Health, and Infectious Diseases, at Emory’s Rollins School of Public Health and at the School of Medicine. Today we’re going to be talking about progress in development of a SARS-CoV-2 vaccine, or multiple vaccines. So could you first give everyone an overview of how to your knowledge, vaccine development is progressing? How many different vaccines are in development? And where are they in the clinical trials phases?

00:33

Dr. Robert Breiman

Yeah, thanks, Leanna. Great to be here and talk about vaccines, my favorite topic. We are in an unparalleled time right now. If you think back on it, we all first started hearing about this virus in January, and the pandemic ended up being called in March. And, here we are, in the first week of November. And, we have a panoply of vaccines that are in development. I’ve been doing epidemiology, public health, and prevention for my whole career – more than 30 years. And most of the time, when we talk about vaccines coming along, we have a 10 to 15-year window.

I remember when I was just starting out at CDC, and working on pneumococcal conjugate vaccines, back in 1987. And the word was, at that time, that the conjugate vaccines were two years away. And we thought, two years, that’s a long time. But it wasn’t till another 11 years – actually sorry, it wasn’t until 13 years – until that vaccine actually became available in the United States and more like 20 years, in places where it’s needed the most. So to have more than 100 vaccines in development [for SARS-CoV-2], this early, this quickly, is truly a testimony to technology advancements, and also to partnerships. And actually for, you know, to government, for stimulating, pushing, if you will, the vaccine development; and in helping to shoulder some of the risk – the financial risk – that allowed companies to move forward so aggressively.

And so there are there are five vaccines that are in in late staged evaluation clinical trials, in other words, either in phase three trials, or in the case of one vaccine, just about to move into a phase three trial. And, the other thing that is quite remarkable at this moment in time, is that the US government, and also other governments, have paid the vaccine companies to produce vaccine, so that it’s waiting in the wings, in case the vaccines are safe and effective. If they’re not, they’ll just discard the vaccines. But if they are safe and effective, there won’t be the usual many months or years to await production and having vaccines to actually give to people. So that’s another amazing thing is that once these trials are done, and they go through rigorous regulatory review – which I always have to say, is crucial; you can’t assume these vaccines are safe and effective. They have to be shown to be in the trials and then reviewed by regulatory experts and approved; and once you get to that point, there won’t be much in the way to at least having vaccines that can start going into distribution.

03:48

Leanna Ehrlich

That is really good to hear. I think a lot of people are anxious for the vaccines; and of course, a wait of many months after a discovery of the correct vaccine wouldn’t be ideal, even if that’s completely normal for basically any other vaccine. So to follow up on that, what do you see as an optimistic and then perhaps a more realistic timeline for vaccine distribution of the actual correct vaccine or vaccines that work, worldwide and within the US?

04:14

Dr. Robert Breiman

So, the four vaccines that are in phase three trial trials now include two vaccines that are

messenger RNA vaccines, that have to be kept in very cold storage – like at minus 80 degrees; and then can only be out of that frozen state for a short relatively short period of time. And then the other two vaccines, which are – the first two are produced by Pfizer, and a company, a new company, called Moderna; and then the other two that are in phase three trials, Johnson and Johnson and AstraZeneca vaccines, in trials in the United States, I mean – are produced on an adenovirus back bone, which doesn’t require freezing, but does require very careful storage. And so the big issues are actually going to be how these vaccines, in large amounts, are brought to points of use, in ways that they can be easily used without a great deal of wastage. And it’s going to really be a challenge, a major challenge, for immunization managers, to ensure that the vaccine that they receive, it’s stored properly, and is handled properly, so that it can be given relatively easily to the people who need it the most. And the other big challenge is that these products, at least at the moment, based on what is understood, cannot be mixed and matched –they can’t be interchanged. And so the systems will also have to, once there’s more than one vaccine on the table, be able to differentiate between people that have received vaccine A, or vaccine B, or C, and so on, and make sure that their second dose, which needs to be a month later, is with the same vaccine.

06:25

Leanna Ehrlich

Oh, that is complicated, because you’re relying both on the people who you’re giving the vaccine to, as well as health care systems, to keep track of that.

06:31

Dr. Robert Breiman

Yeah, I don’t think there’s from an immunization standpoint, I don’t think we’ve ever had a challenge quite liked this one.

06:37

Leanna Ehrlich

Yeah, that’s really, really complex. So I’ve read some interesting pieces recently, about how vaccine distribution can, or will be, prioritized. And I think lots of people agree that prioritizing essential workers, especially those working in healthcare settings, seems like a very natural first step; they’ve already made many sacrifices and are definitely in a high-risk environment; and then maybe considering other essential workers like those in food services, or other emergency services. But then, I’ve also read some ideas about prioritizing different groups of people, people with underlying health conditions like diabetes, or asthma, or those in minority groups, ethnic or racial groups, because they may have a higher risk of severe outcomes of COVID-19. So I’m curious to hear your thoughts on equity surrounding vaccine distribution. Do you think that there is a certain prioritize scheme that should be used for deciding how and when vaccines are allocated, that would best promote equity, and also meet with public approval?

07:33

Dr. Robert Breiman

So the vaccines, even with this advanced market commitment, and vaccines being produced in parallel to the trials, so that, you know, we can get to them quickly – there will just be a relative trickle of vaccines early on, once they do become safe and effective (I always feel like I have to emphasize that), vaccines are available. And therefore, immunization managers, people in charge of the programs, health care providers and so on, may have a certain amount of vaccine in their stock, will have to have some sort of prioritization for who gets the limited numbers of vaccines first. And there are two philosophies around that, around how to do this, and, the concepts, I should say, work side by side. One is to use a safe and effective vaccine to keep society, all the key societal functions, operating; and that includes making sure our health care workers, both physicians, nurses, others involved in providing hands on health care, are able to keep doing that. Because you can imagine how devastating that would be if we had a shortage produced by the pandemic of healthcare workers. And as you say, there also is focus on protecting those who are involved with essential functions, critical functions in our society, especially among workers, who are substantially higher risk of exposure while carrying out those functions. So you have that side of things where you’re thinking about using vaccine to protect our critical resources, if you will, or critical human resources.

And then you have the consideration of, there are certain people who are at disproportionate risk for illness, hospitalization, and death due to COVID. And so there would be interest in using limited quantities of vaccine to prevent illness and those that are at higher risk. And there has been a general move away of focusing use of vaccine based on racial characteristics, but more on social determinants of health. So that, the reason there is disproportionate risk among people of color in the United States for COVID is not necessarily related – or, there is no reason to think it’s related, to any inherent qualities about them, about their physiology, and so on. But it’s more related to structural imbalances in terms of the type of living and working conditions that exist that put certain populations at risk. So the focus is likely to be on those social determinants, if you will, rather than specifically on race.

10:58

Leanna Ehrlich

Okay, and then do you foresee any barriers in vaccine distribution and uptake, specifically related to health disparities and health equity? Just some ideas that came to mind might be getting vaccines to rural populations, especially if you’re talking about a cold chain supply management, or other medically underserved populations; or maybe overcoming social issues related to vaccine hesitancy or distrust in public health figures?

11:23

Dr. Robert Breiman

Yeah, I mean, there’s been a lot of focus on how to distribute the vaccines so that they can be placed at locations that would enable vaccine to reach those that are normally hard to reach. So that might include communities that are far away from hospitals or research settings where the cold chain can be maintained. So, figuring out ways the vaccine can be moved to places where people would have greater access.

There’s also discussion of using sort of non-traditional places to get vaccinated. I mean, one thing that we always used to call non-traditional, one place, are pharmacies themselves. And those are no longer non-traditional, because as you know, pharmacies are often places where many people get their vaccines now. And so they will almost certainly be right in the midst of things when it comes to COVID vaccine distribution.

But, other considerations that people are exploring is, can, for instance, houses of worship, serve as places that are both resources for trusted information about the vaccines, as well as places where people could actually go and get vaccine? And that might be a way to reach people, especially in communities that tend to be more marginalized. And then, there’s also discussion of certain kinds of workplaces and actually offering vaccine directly there to people that are at increased risk. So there’s a lot of strategies that are coming out that will require new ways of, you know, distributing vaccine.

And so, you touched on something that I think is really important, which is many of the people that are at disproportionate risk for COVID because of exposures – because their working conditions don’t allow them work from home, they’re often in situations where they’re more likely to be exposed to the virus; maybe their living conditions at home also put them at increased risk for transmission – many of those communities and those populations, may be not only an increased risk for COVID, but they may be at increased likelihood to not accept a new vaccine that’s been pushed along at warp speed, promoted by the government, and so on. And, maybe less likely to trust such an offer, such a system. And so, there does need to be a thoughtful, context specific, culturally appropriate and relevant translation of the science, as it comes out, in a transparent and clear way. So that there is what we call “information equity”: so that regardless of the community, that people will understand, in ways that are appropriate for their context, what are the benefits and what are the risks associated with being immunized with a COVID vaccine; and to be able to ultimately make an informed decision about getting vaccinated. And I think that information equity is really a critical part of the whole

picture to address that issue because, as Walter Orenstein says, you know, “vaccines don’t save lives, vaccinations do.” So we can produce all these wonderful vaccines and have them distributed right where people are, but if they don’t get into the arms of people who need them the most, they won’t really, they won’t clearly, have done their job. So it’s really important to have this information effort, as well.

15:40

Leanna Ehrlich

Absolutely, I have never heard it particularly phrased that way. But I think that’s such an important perspective, like information equity is absolutely critical. And it’ll be interesting to see what happens. I’m a public health student right now. So I know everything happening over the past year, and over the next year or two is going to become a case study that we’ll all learn about for future public health practitioners. But of course, we also want everything to run smoothly, without too many hard-won lessons. So I guess we’ll just have to wait and see how everything unfolds.

16:07

Dr. Robert Breiman

Yeah, it’s kind of a scary thought that, you know, oftentimes, we look back on the 1918 flu pandemic with sort of a morbid curiosity, you know, “how could things have been so severe?” And how could people have, you know, dealt with these things in the ways that they did, or early on, and so on. But it’s somewhat concerning to imagine that decades, maybe even a century from now, people will look back on this period with amazement and wonder, both in terms of, maybe what we didn’t do, despite the fact that we could have; and also those great achievements that we’ve just touched upon, especially around hopefully, the availability of safe and effective vaccines and a strategy equitably administer them.

16:58

Leanna Ehrlich

Yes, absolutely. I think that the vaccine development and the scientific progress during COVID is, within the US, probably the best part of our country’s response.

17:08

Dr. Robert Breiman

Yes, I agree with that. It seems non-partisan, almost. Which these days is refreshing?

17:19

Leanna Ehrlich

Yes, absolutely. Almost everyone wants a vaccine, and hopefully it will be trusted and accepted. So I was wondering if you have any other outstanding issues that you can think of related to vaccines and health equity that come to your mind that we haven’t talked about today already?

17:34

Dr. Robert Breiman

Yeah, there’s one issue I just would like to touch upon. And that many of us in public health are automatically focused on a prevention strategy, like immunization, as a way to save lives and prevent hospitalizations and, you know, prevent suffering. And, those are the right things to focus on. And in addition, because of the way our society is structured, and because of

the social, the systemic social inequities that exist, that much of what makes our economy run is built on people that, you know, keep the trains moving, if you will, and, you know, keep the food moving and keep businesses and office places open. And those are the people that are at disproportionate risk for COVID.

So, it’s our premise, and we’re working with a group in Boston, that is going to be modeling the actual magnitude of this; but it’s our premise that an equitable use of a safe and effective prevention strategy, not only makes sense from a standard health standpoint, but it also will save huge amounts of money. It’ll be economically rewarding in ways that haven’t been considered as well. And it’s this nexus, I think, of public health and economics, that I think is particularly important to consider, and helps to make people think, regardless of their perspective, of where they are in society, in a parallel way regarding – in a similar way regarding – the benefits of not just giving vaccine out, but giving it out in the most equitable way possible.

19:42

Leanna Ehrlich

Yeah, absolutely. Thank you so much for joining the podcast today, Dr. Breiman, this was a really important conversation. We’re getting pretty close to vaccine distribution. I mean, not next week, but it’s definitely on the horizon of our future. I think a lot of people will find this information really useful as this sort of starts to become more and more the topic in the news related to the pandemic. So thank you for sharing your thoughts related to vaccine development and issues of equity.

20:09

Dr. Robert Breiman

Thank you. Pleasure to be here.

Addendum:

Since this podcast was recorded, Pfizer and BioNTech announced successful Phase 3 clinical trials of a COVID-19 vaccine that appears to be more than 90% effective. We reached out to Dr. Breiman to get his comment on the new development, and he said “I look forward with great enthusiasm to seeing the data from the trial of the BioNTech/Pfizer mRNA SARS-CoV2 on efficacy against a variety of outcomes and on safety. Findings from the vaccine trial on safety and efficacy for people in a variety of risk categories (like underlying diseases, advanced age, and race/ethnicities) will be very helpful. While the recent press briefing certainly suggests that this vaccine (and potentially other formulations) offer substantial promise, the jury will remain out until the complete data are presented and there is rigorous regulatory review.

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