Podcast: Boosters? Vaccines for kids? Where do we stand heading toward winter?

Jim Dryden (host): Hello and welcome to “Show Me the Science,” conversations about science and health with the people of Washington University School of Medicine in St. Louis, Missouri … the Show-Me state. As we continue to detail Washington University’s response to the COVID-19 pandemic, in this episode we speak to two of the university’s infectious diseases experts about the state of the pandemic as we enter another fall, the time when colds and flu normally afflict us anyway. Although last fall and winter saw thousands of hospitalizations and deaths in the U.S. from COVID-19, the flu season was mild. Society also was less open last year than it is now. Dr. Bill Powderly, co-director of the Division of Infectious Diseases, says one way to protect people moving forward is for businesses that draw lots of people — like concert halls, theaters and sporting venues — to require those people to be vaccinated or to provide proof of a negative COVID test.

William G. Powderly, MD: Everybody wants to try and get back to a new normal, or a sense of normal, and it is sensible for businesses whose business depends on getting people together to have their customers feel safe. And the best way for their customers to feel safe is that their customers feel that it is OK to be in a crowd because all the other people are vaccinated.

Dryden: And Dr. Vicky Fraser, an infectious diseases expert who heads the Department of Medicine, says it’s important to get many more people vaccinated all around the world to slow the spread of the virus and to prevent it from mutating into something we cannot treat or prevent.

Victoria J. Fraser, MD: The virus will continue to mutate. As long as it has hosts that allow it to survive. That’s what viruses do: They mutate to survive. And they will become more infectious, more virulent, and they may at some point also mutate in a way that makes them less susceptible to our available treatments and to our available vaccines.

Dryden: Vaccines have been at the forefront of the news recently as Pfizer has sought approval to vaccinate children between 5 and 11. And as the FDA and the CDC have decided that only the elderly, those with compromised immune systems, and some front-line workers should get booster shots. Powderly says boosters may help some people but, he says, most younger people in lower-risk jobs probably don’t really need a booster.

Powderly: I think we should go back to the beginning and realize that the vaccines are very effective. The vast majority of people who receive a full dose of a vaccine have protective antibodies that protect them against hospitalization and disease and death. What has happened, though, is the level of antibodies in the bloodstream has decreased gradually in many but not all people. That makes it more likely that you might have an initial infection. So the vaccines are very effective against disease, but they have been less effective, over time, in protecting against infection. And that data really was well shown in studies from Israel. And in Israel, what they did was they gave boosters, and they showed that you could raise the antibody levels and have better protection against infection. So the question really becomes a balance: Who’s the group that is of greatest risk should the vaccines fail? And it is the elderly and those with compromised immune systems. But equally, people who are younger who’ve been vaccinated, their risk of developing severe COVID is extraordinarily small, and at this point, there’s no reason that they shouldn’t receive a booster.

Dryden: In other recent news, it appears the vaccine may be safe and effective in children from 5 to 12. How soon could we see kids getting a vaccination?

Fraser: I think that’s actually really good news. Pfizer has been doing a lot of work with children from 5 to 11, and their recent data suggests that it’s very safe, very effective in that age group. So I think they’re going to take it to the FDA for approval, and we’re hoping later this fall that it will be available for that age group. And then there are studies ongoing in younger age groups as well. Being able to vaccinate younger people is incredibly important to get the epidemic under control because we still have large groups of people who cannot be vaccinated — children, predominantly infants, toddlers — and those are the groups still that we really, really need to protect in addition to the very immunosuppressed people.

Dryden: And this pandemic has changed in recent months in terms of skewing younger.

Powderly: We did a reasonably good job in the United States of vaccinating older people. But because this surge in hospitalizations and in deaths is in unvaccinated populations, you’re going to see a skewing toward the groups that are less likely to be vaccinated, and they tend to be younger. And so as a consequence, that’s exactly what we’re seeing. The absolute risk of developing severe illness if you’re younger is lower than if you’re older. But if lots of young people are getting infected, you’re going to see some of those in the hospital, and some of those will die.

Dryden: As we talk about young people and school — and we’re entering fall — a year ago, there was this concern about a double whammy of COVID and influenza, and then we had a light flu season. We also were taking a lot of precautions then. What do we expect this year?

Fraser: It was incredibly remarkable that we had virtually no influenza last year. And we had limited respiratory viruses in general, and that was the greatest natural experiment ever. And I think that reduction in respiratory viruses, colds, flu, was related to the masking and the social distancing. So I think if you ask the vast majority of ID docs what they’re going to do during flu season for subsequent years and when they travel and they’re in crowds, they’re going to wear a mask because it was highly effective. With less masking and with people getting back together again, there is every reason to believe that influenza will come back and likely will come back with a vengeance. And so I think it’s really important for people to get their influenza vaccines and also to continue wearing masks indoors and wearing masks when they’re around a lot of people, because masks and good hand hygiene are really effective against respiratory viruses.

Powderly: I would echo that. I would say that at the moment, I’m cautiously optimistic that we can have a milder flu season than we typically used to see because I think a lot of people have and will continue to change their behavior. I think people are still concerned about COVID, so they will continue to wear masks, and that will also protect them from influenza. But we will see a resurgence because not everybody is behaving as cautiously. And as Vicky said, there’s nothing magic about COVID as a respiratory virus. It behaves just like other respiratory viruses, and the things that protect you are masks, hand hygiene and social distancing.

Dryden: I do want to ask you about another respiratory virus, RSV, because, like flu, it was suppressed last year, but there was sort of a rebound in RSV cases over the summer, other respiratory viruses in children. So what do we expect there, especially in kids and especially with more kids in schools this year than last year?

Powderly: It’s very likely we’re going to see a resurgence of childhood respiratory viruses. What will be interesting, however — and we don’t know the answer to this — is whether the combination of changes of behavior, even in a modest way, will lead to less circulation of these viruses and less infections. It’s harder, as you know, to get young children to mask. It’s harder to get them to avoid being around other young children, so it’s very likely we will see transmission. As Vicky said, this is going to be another natural experiment that will tell us a lot about the transmission of these viruses.

Fraser: I think it’s also important to remember that for the vast majority of otherwise healthy people and kids who are toddlers and above, that RSV is a cold-like virus. It’s a relatively benign respiratory virus. But for infants and for immunosuppressed individuals, people who’ve had transplants, people who have profound immunodeficiency from autoimmune diseases, cancer patients, they can have devastating disease from RSV. And particularly for premature infants, it can be a deadly disease. And so really doing everything we can to protect the most vulnerable is really key. And unfortunately, we don’t have a vaccine against RSV. We do have some treatments, but the treatments are complicated, expensive, require inpatient therapy, and they’re really only given to the most immunosuppressed patients who have very severe disease. So, again, masking, good hand hygiene, social distancing as much as possible, and having people stay home when they’re sick, not going to parties, not going to work, not going to school when they’re sick or have symptoms I think is really key.

Dryden: A number of places in our community and around the country are requiring proof of vaccination or a negative COVID test to attend. You want to go to a Blues hockey game this year, you got to prove you don’t have COVID. The Fox Theatre, other places in town, are on that list. Are those good policies, and do you expect they will become more common as we get into the fall?

Powderly: I think they’re good policies. They’re not foolproof. We know that people who are vaccinated can become infected, but that said, I think everybody wants to try and get back to a new normal or a sense of normal. And it is sensible for businesses whose business depends on getting people together to have their customers feel safe. And the best way for their customers to feel safe is that their customers feel that it is OK to be in a crowd because all the other people are vaccinated. I recently flew back from Europe. To get back into the United States, you have to have a negative COVID test to get on the plane. It’s remarkably reassuring to get on a plane with 300 other people and know every single one of them has had a negative COVID test.

Fraser: I think we’re still in a difficult position in this country, particularly because of the complex politics and just incredible emotions over vaccine and mask policies. So it’s a combination of carrot and sticks, right? We do want life to get back to normal. We want people to feel safe. We want to incent people to get vaccinated and to do the right thing. And so I think it’s amazingly helpful to mandate vaccine in every business that we can and show that we’re committed to doing the right thing to protect the public and also to make it so that people are encouraged to get vaccines. So if they want to get life back to normal and they want to go to games and sporting events and what could be otherwise high-risk activities with lots of people indoors, then they’re incented to get vaccinated and to show proof that they’re negative because then it is safer. Not perfect, but safer.

Dryden: Breakthrough infections. Are they the man-bites-dog of COVID-19? In other words, we hear a lot about vaccinated people who get sick. Is that because it’s news? Because it’s unusual?

Powderly: The short answer is yes: It is a man-bites-dog story. It reflects, I think, also a little naivete about vaccines and how they work. Some in the scientific community overplayed the vaccine story. The vaccines still do what it says on the box. They protect you from serious illness and death in the vast, vast majority of people. They’re not completely effective in preventing infection, but given where we were a year ago, given where we are right now, we should not get overly excited about breakthrough infections and really concentrate on what caused us to be really worried in the first place, and that was the excess mortality.

Dryden: I know that the per capita is different, but we’ve recently seen the total number of deaths in the country from COVID-19 exceed the number of deaths during the 1918 flu pandemic. So I know, in some ways, that’s not apples to apples because there are more people in the country, all that sort of thing. Life expectancy has actually fallen. Are we losing?

Fraser: I think this is just an incredibly sad reminder of the devastating impact of this disease across the world. A huge number of people have died because of COVID-19, which, since last winter, is a preventable disease, largely. And people still are dying, and so that is why it’s evermore important that we continue to do research to identify even more effective strategies for treatment, for prevention and really get everybody vaccinated. The virus will continue to mutate as long as it has hosts that allow it to survive. That’s what viruses do: They mutate to survive. And they will become more infectious, more virulent, and they may at some point also mutate in a way that makes them less susceptible to our available treatments and to our available vaccines. So we still are in a really difficult position where we have to work really hard to get not just our local communities vaccinated but the world vaccinated because this is a global problem. And no one will be safe, and no one will be able to get back to normal until we take care of the whole world.

Powderly: To answer the question you posed: No, we’re not losing. We’re in the third quarter, and we’re in the lead. That doesn’t mean we’re going to win, but we’re in good shape if we continue to use the tactics that we currently use. If you think about where we were a year ago, we were losing. People were dying, and we had no effective treatment, and we had no effective prevention. We now have a vaccine that is incredibly effective, so we can prevent much of this. We have to deploy the vaccine as much as possible but not only in the developed countries but right across the world because if we don’t, this evolution that Vicky talks about will inevitably occur somewhere else, and our vulnerability will remain. We’re ahead because of science, but it’s not over.

Dryden: You devoted your lives and careers to helping people with various viruses and problems. Is there even a part of you that finds this kind of exciting?

Powderly: That’s a fascinating question. I’m going to take you back to the summer of 2019. I gave a lecture here on the interaction between infection and history. My last remarks were, “What keeps infectious disease doctors awake at night?” And what I said was, “It’s a new virus, probably coming out of Asia, to which we have no immunity.” Now, I was actually thinking about a new strain of influenza. So to a certain extent, this wasn’t new. What was new was that it was a different virus. It was a coronavirus. Every challenge like this in medicine is also an opportunity to learn, to improve and to hopefully advance biomedical science, and we will learn enormously from this. So, for example, the technology, the mRNA technology, led to the Pfizer and Moderna vaccines. It’s probably going to be widely applicable in many other areas and will advance immunology and vaccine science tremendously. But is it worth it? The short answer to that is no.

Fraser: It is exciting but in a bad way, right? This was devastating. And I think we do want to make something good come out of it, so translating the science to other improvements in human health, getting public-private partnerships, learning from this terrible pandemic so that it never happens again, so that we rebuild our public health infrastructure, we invest in infectious disease, microbial pathogenesis research, and really shore up the kinds of resources and infrastructure we need to reduce the health disparities. I mean, the other terrible thing that this pandemic has shown us is that there are incredible health disparities and inequity in the way that we deliver care, people’s access to care. And this pandemic has disproportionately impacted people of color, people of lower socioeconomic status, the elderly, the most vulnerable.

Dryden: These aren’t going anywhere for a while, I’m guessing: masks, case rates, high, low, whatever. A lot of us, especially in fall and winter, are going to continue to wear these. You touched on it a few minutes ago. Is that going to be forever?

Powderly: We’ve all learned how to avoid some of these infections. It’s very interesting. If you look at South Asia, after the first SARS outbreak, people changed their behavior. People wore masks all the time, and we in the West sort of looked at that with curiosity. Not anymore. And I hope that people will learn this lesson. I certainly intend to continue to wear masks in situations where I perceive a vulnerability, crowded indoor situations, large crowds, situations that I think put myself at risk but also where, if I have any symptoms and I have to be outside, where I can protect other people.

Fraser: Masks are cheap. They’re safe. They’re effective. It’s a minimal disruption to your life to wear a mask, and it can have a huge benefit, not only for yourself and your family but for those vulnerable people around you. So I think we all need to think from a population perspective as well. This is not just about me and protecting me or protecting my family. We all have to be in this together to protect everybody if we want life to get back to normal.

Dryden: And that, after all, is what we’ve all wanted since March of 2020, though Fraser and Powderly say it’s clear that we’re not quite there yet. So masks, hand hygiene and social distancing remain important. And for those who haven’t yet gotten one, vaccines remain vital. “Show Me the Science” is a production of the Office of Medical Public Affairs at Washington University School of Medicine in St. Louis. The goal of this project is to keep you informed and maybe teach you some things that will give you hope. If you’ve enjoyed what you’ve heard, please remember to subscribe and tell your friends. Thank you for tuning in. I’m Jim Dryden. Stay safe.