COVID vaccines, overcoming skepticism, and pandemic theater [PODCAST]

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“Environmental cleaning rightfully plays a more prominent role within health care facilities to control the spread of other diseases, but even hospitals have overreacted when it comes to contact precautions for SARS-CoV-2.  I recently went to get a flu shot from one of the hospitals I cover, and I couldn’t help but think that several steps in this process seemed wasteful.  Even though everyone was already masking and maintaining appropriate distance, recipients were each assigned one large desk and one pen to fill out the obligatory paperwork.  Once complete, the pens went into a “dirty” cup, and a gloved staff member had to wipe down the pen, clean the entire desk surface and dispose of the cup before anyone else was allowed to use that station.  Before I could sit down and receive the vaccine, I had to stand back and allow the administering nurse to wipe down the whole chair with isopropyl alcohol.  We didn’t go to these lengths before the pandemic, so why go over the top now for a virus that, for all intents and purposes, is not spread by contact?”

Clayton Foster is an infectious disease physician and founder, AirborneID. He can be reached on Facebook and Twitter @AirborneID_CO.

He shares his story and discusses his KevinMD article, “COVID transmission should not be a touchy subject.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Here on the show, we have Clay Foster. He’s an infectious disease physician, and he wrote the KevinMD article “COVID transmission should not be a touchy subject.” Clay, welcome to the show.

Clayton Foster: Thank you, Kevin.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?

Clayton Foster: Of course. You know, I was one of those who knew from about age seven that I wanted to be a physician, and I never looked back. I still think it was the right choice for me. I spent the first 26 years of my life in Birmingham, Alabama, and then towards the end of medical school, I decided that I wanted to see a different part of the country. So I ended up matching at the University of Colorado, where I finished internal medicine and infectious disease. I really liked living in Denver, so I’ve continued on here. I started out in a traditional infectious disease practice after my fellowship, but I have now moved into kind of doing my own novel thing with telemedicine, using technology and the internet to help increase ID influence and education.

Kevin Pho: Tell me a little bit more about your infectious disease telemedicine practice.

Clayton Foster: So I started it really with the critical access hospitals and SNFs in mind, mostly the facilities who traditionally don’t really have access to infectious disease coverage on a regular basis, or if they did, they’d have to sort of pay over market value to entice someone to move there full time. I’ve always seen this telemedicine platform as a great opportunity to really be able to reach out to those facilities, seeing as how most of our ID docs are concentrated in urban areas. So I think this is a way where we can all kind of stay put and still be able to reach a broader audience and keep more patients near home. And that’s sort of expanding into ways that I might be able to actually educate some of the docs that work at these more remote facilities, rather than just doing the traditional consultation services.

Kevin Pho: And what were some of the factors in the decision-making process when making that transition from a traditional practice to a telemedicine practice?

Clayton Foster: I’ve always had an interest in technology, and I think even from a young age, I was sort of an early adopter, getting on with the internet. I’ve always used the computer for my work, school, and leisure time, so it’s been a big part of my life. Coming out of fellowship, I knew telemedicine was already on the rise and had some interest in it, but just with the way my initial job at that practice was structured, it wasn’t really feasible to have a major telemedicine component there. So ultimately, I decided after a few years that I would strike out on my own and see if I can make it work.

Kevin Pho: And of course, we’re speaking at the end of December, and some would say it was a pretty prescient move, moving to a telemedicine practice in the midst of a pandemic. Now, what are some common questions that you’re answering right now in the latest wave of the pandemic?

Clayton Foster: Most of the questions right now, as you might imagine, are about the vaccine. As with many things, we’ve seen different stages of the pandemic. There’s some misinformation out there and some misunderstandings. I think the fact that we have this brand-new type of vaccine, the mRNA vaccine, has a lot of people nervous, thinking that this is this untested, novel technology. And while it is the first of its kind, it’s not a new thing. It’s been researched for a number of years. I think it looks very promising and very safe, so that’s what I’ve been trying to reinforce when I get those questions.

Kevin Pho: And are a lot of those questions coming from patients or from clinicians themselves?

Clayton Foster: Both, really. I think there’s just so much information out there that’s COVID-related, and clinicians are largely swamped with their work right now, so they might not have had time to catch up on all the latest reading with COVID vaccines. So I’m educating both parties: the general public, patients, and then my colleagues as well.

Kevin Pho: All right, let’s transition into that KevinMD article that you wrote earlier this year, “COVID transmission should not be a touchy subject.” Now, for those who haven’t read the article, can you just walk my audience through it and share the story of why you decided to write it?

Clayton Foster: Sure. So this really started back during the summer, when everyone first started venturing back out, going to restaurants again. I recall the first couple of times that I tried it out, I would see things like they took away the regular silverware and gave everybody plasticware instead, or they took away the menus and you had to scan the barcode on the table with your phone to get the menu. And even at the time, I was thinking, “You know, this seems a little overkill, maybe.” I understand it’s sort of an overreaction to a scary situation for a lot of people, so maybe it’ll settle down. I feel like that persisted over a number of months, though. I saw things about the enhanced cleaning protocols.

And really what inspired the article was I went to get my flu shot at one of the hospitals I cover, and their process involved placing people at these large individual desks. They’d give you a pen to sign the paperwork, but then they had to wipe down the entire desk, throw away the pen, and just replace this whole area, and wipe down the chair that people were getting their injections in. And I kind of thought, “You know, this is really over the top.” I don’t think this degree of surface cleaning is going to be sustainable, and it’s really not necessary for a virus that, for all intents and purposes, is not spread by contact.

I mean, this is a droplet virus, probably with a small component of airborne transmission. While surface, you know, contact transmission is possible, it’s not likely. And that’s really what I wanted to drive home, and kind of get the message out there that I think I’m seeing a lot of waste. I’m seeing a lot of undue anxiety over environmental cleaning. And I just want people to be aware of how this virus is primarily spread and take appropriate precautions.

Kevin Pho: And just to be clear, like you said, is there any evidence supporting these enhanced cleaning procedures, especially when it comes to surfaces?

Clayton Foster: Not that I’m aware of, no. It’s not for the contact portion specifically. And, you know, the best we have is sort of indirect evidence, looking at things like how long does the virus survive on various surfaces. I’m sure people have heard the news snippets about those, and it’s true that there are certain situations where the SARS-CoV-2 virus might last up to seven days. But we have to look at the context. Most of those studies were done in very tightly regulated environments. They were done with a much larger inoculum of virus than most people are likely to deposit when they’re sick with this virus and happen to maybe cough or sneeze into a hand and then touch a handrail. There are also environmental factors, like UV light and desiccation, that will cause that virus to inactivate much faster than what we see under experimental conditions.

Kevin Pho: So someone called this pandemic theater, right? All these enhanced cleaning procedures that are likely not effective. Now, all that effort that goes into enhanced cleaning procedures, how could that be better spent?

Clayton Foster: Honestly, just reinforcing hand washing is what I’ve tried to reiterate to people. I mean, in general, we should all be washing our hands. We should have been doing that before the pandemic, so I think this would be a good time to reinforce that particular point, because to me, that’s the point of the chain that makes the most sense. If you’re going to infect yourself with a virus by touching a surface, you’re going to do it by touching that surface and then touching your face.

So we hear these impractical bits of advice, like, “Don’t touch your face.” Well, we all do that reflexively. There’s really not a way to completely avoid touching your face. It’s also really impractical to disinfect every surface around you in your environment. So the part that makes the most sense is to focus on hand washing. That is something that we can do fairly easily and regularly.

Kevin Pho: We’re talking to Clay Foster. He’s an infectious disease physician, and he wrote the KevinMD article “COVID transmission should not be a touchy subject.” Clay, let’s pivot towards the next few months. So we have two vaccines that have been approved, and the AstraZeneca one is likely going to be approved very soon. I think today it was approved in the U.K. So can you play out the next few months for me? How do you envision that playing out?

Clayton Foster: So the last estimates I saw for the two vaccines that have been approved, which are Pfizer and Moderna, those companies combined are estimating they can put out between 50 and 60 million doses by the end of the year. Obviously, we’re very close to that time point now, so I don’t think we’re quite going to hit that goal. But through the next year, they’re hoping to get up over a billion doses, perhaps into the 2 billion dose range. The difficulty is just sort of working out the kinks initially, as we’ve seen some of the difficulties with, perhaps, I think there was a dose metering issue with some of the manufacturing equipment for Pfizer, as I recall.

But the good news is there are even more vaccines on the way. So Johnson & Johnson and AstraZeneca are kind of next in line to get approvals for the U.S. market. They’re looking at an early February approval time frame. So as we get further into winter, the good news is we will have more types of vaccine and more manufacturers putting vaccine out there. I think the big-picture expectation right now is that we’ll start getting some of our high-risk populations maybe around the March, April time frame, and then probably work our way back to the relatively healthy general public in May or June at the earliest. That’s just the unfortunate reality of trying to get enough vaccine out to everyone, particularly when most of these vaccines are a two-dose series.

Kevin Pho: And I guess the question everyone’s asking me is, when do you think we could start having gatherings again? How long do you think that we need to continue wearing masks for?

Clayton Foster: It’s a good question, and the key point here is even after you get the vaccine, we are all going to need to continue wearing masks. It’s difficult to say exactly for how long. The best I could say is hopefully by the end of 2021, we can start to back off on some of our precautions with the distancing and masking. But some of the difficulties that I’m foreseeing is that even as more people get vaccinated, it’s going to be difficult to tell very quickly, just out in a public setting, who’s been vaccinated. You can glance at someone and tell if they’re wearing a mask. You can’t glance at them and tell if they’ve been vaccinated. And if they have, they could very well be in that 5 percent or so of people who don’t necessarily get protection from the vaccine. So until we reach that herd immunity point, which I think, best guess, is quarter four of 2021, we’re still going to be dealing with our social distancing and masking precautions.

Kevin Pho: And I know that some companies, like airlines, are suggesting things like immune passports, where you have to show some type of proof that you’ve been vaccinated. What are your thoughts on those going forward?

Clayton Foster: You know, we have some precedent for that. I was thinking about things like yellow fever. You know, if you get a yellow fever vaccine, you get a little yellow card to carry around with you, and if you’re going to a country that requires that vaccine, then you have to show it as part of your arrival procedure. So I could certainly foresee that. I know a lot of countries outside the U.S. right now have entry requirements that include COVID testing within a certain time frame before your arrival. And I think the next logical progression of that is, once the vaccine is more widely available to people, to tell the travelers that “we need to see proof of vaccination before you’re allowed to come into the country.” I’m not sure whether or not we’ll implement that in the U.S. I think it’s a complicated issue, but I think we will see some evidence or some examples of the vaccine passports being implemented. It’s just difficult to do that on a very broad scale.

Kevin Pho: I’m in primary care. I do internal medicine, and like you, I see a lot of patients who are a little bit skeptical about the short time frame that the vaccines were developed under. Now, I’d like to hear, what’s your approach to alleviating that skepticism when they address you in your telemedicine practice?

Clayton Foster: I just kind of walk them through what steps were skipped in the process and why we were able to reach the finish line on these vaccines so much quicker than in the past. Historically, vaccine development took anywhere from 15 to 20 years, but a lot of that issue was funding. These vaccine manufacturers didn’t want to dump too much money into a product until they had a good sense that it was going to work. So they’d start out small, maybe with just a few animal trials. They’d work up to a few small human trials, and it was just this very gradual building over a period of years, where they would take these measured steps to make sure that this vaccine would remain profitable.

What helped in this case was that governments started funneling a lot of money into the vaccine development, and we sort of skipped the animal trials, which I think is totally reasonable, because really, we’ve done enough vaccine research at this point. We have 120-some-odd years’ worth of experience with vaccines. We generally know what works and what’s generally safe for people. So I think it makes sense to start skipping some of those steps, and going forward, we can start to get vaccines out faster. I think under the circumstance, given the pressing need to get these out, these vaccines have been as well vetted as they could be. I think we have pretty solid data, really, all things considered, to show that it’s safe and effective.

Kevin Pho: So some of the pushback I get from saying that is that the mRNA platform is relatively new and hasn’t been done before previously in vaccines. What do you say to that?

Clayton Foster: I think the key point there is that effectively we’re doing the same thing that a lot of our older vaccines would use: an antigen, a particular protein from a virus or bacteria, plus an adjuvant to try to create that immune response. And the mRNA vaccines accomplish the same thing. They just use our cellular machinery to create the protein rather than directly injecting the protein. And the big advantage there is that it increases our immune exposure to that particular protein. When we just inject the protein with an adjuvant, that gets recognized as foreign material and degraded relatively quickly. But if we sort of sneak those instructions into our cells, and our cells see that mRNA and say, “OK, here’s something I need to translate into a protein,” and that protein is what creates the immune response, that increases the length of time that you can develop a greater immune response and should improve the vaccine efficacy over the long term.

Kevin Pho: Any concern about potential long-term effects from the mRNA platform?

Clayton Foster: I mean, just knowing how they work, I would say no. One thing I like to reinforce, you know, one of the conspiracy theories out there is that these mRNA vaccines are going to rewrite our base code somehow. But that’s a one-way process. You know, normally, with transcription inside of our cells, our DNA is transcribed into messenger RNA that goes to proteins in the cytoplasm. And all we’re doing here is we’re skipping that step of base DNA transcription. We’re just directly introducing a piece of mRNA with protein instructions for the protein we want it to express, and then our cells just go to work using those instructions. But there’s really no mechanism for working that process backwards, using the mRNA the vaccine provides to alter our base DNA in any way.

Kevin Pho: And my final question, Clay: What’s your take-home message that you want to leave with the KevinMD audience?

Clayton Foster: Let’s all be rational about our COVID precautions. So I think medical masks give you your best bang for the buck. Wash your hands. But we don’t need to go crazy and do gowns and gloves and disinfect our entire environments, because we’re still going to be dealing with this for some time to come, and I think we’d all like for this to be a little more palatable and sustainable.

Kevin Pho: Clay, thank you so much for your time and insight, and thanks again for being on the show.

Clayton Foster: Thanks for having me.

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