HJAR Nov/Dec 2020

DIALOGUE 10 NOV / DEC 2020 I  HEALTHCARE JOURNAL OF ARKANSAS   we’ll have it. The thing I think that everyone needs to understand is that to have enough doses to give everybody in the United States at least one dose (and possibly two doses, because the front runner vaccines currently required two doses for you to have a full immunity) is going to take a while. And that may not happen until the second or third quarter of next year. There will be vaccine, but there won’t be enough to really bring this under control until the second quar- ter. We’re still going to be living under this umbrella of COVID with social distancing, masking and washing our hands for quite some time in the future. Editor What do you think will happen if the vaccine proves ineffective or doesn’t emerge? What is plan B? Romero Well, plan B is what is actually being done. The government has invested heav- ily in a number of vaccines, the vaccine manufactures and a number of methods to develop immunity. The idea is that if you bet on different companies, different meth- ods for developing a vaccine, you will hit on the correct way or on an effective vaccine. I think there are more coming down the line. We have two, three, four vaccines at this point that are in phase-three trials, which is the trial just before you go up for licen- sure. They’re moving forward, and there will be more coming. There are over 200 vaccine candidates in the world, so we’re not the only ones working on it. I think the United States will be successful and so will Great Britain with their vaccine, but there may be other vaccines around the world that are successful. We know that the Rus- sians and the Chinese have vaccines of their own, and they’re using them. We’re waiting to see what data they have from their use. Editor When those vaccines are created, as you mentioned, they’ll be limited to begin with. Who will decide when and how they’re distributed? Romero I think there are two issues here. mental status—there is this fogginess that exists after people recover from this. And, we’re learning that it causes a very unique disease in children. It causes this intense inflammatory response leading to a syn- drome called multi-system inflammatory syndrome of children (MIS-C), and that does in a way resemble some of the diseases that I’m used to treating in children (like Kawa- saki’s disease or Takeuchi syndrome). This intense inflammatory response has never been seen in a virus like this, so vir- tually everything about this virus is brand- new. The fact that such a large proportion of individuals infected have no symptoms at all—they’re asymptomatic, and the trans- mission of the virus is heavily dependent on that—certainly opens a way to control it but also makes it a challenge. I think there’s a lot going forward that’s novel: the diag- nostics that are involved, the evolution—to think that we didn’t know anything about this virus [prior to November]. We knew very little about this virus in November, and today we’re on the cusp of having a vaccine that could potentially prevent it. This is a very rapid evolution that I don’t think any of us have ever seen, and I have certainly not seen this in my lifetime—starting back in the ‘80s when I entered medicine, as an intern, to today. Editor Speaking of vaccine, are you still serving as chair of the CDC’s Advisory Committee on Immunization Practices (ACIP)? Romero I am. I will be the chair until July of the coming year. Editor You have mentioned you anticipate a vaccine is imminent. Do you feel like that is really going to happen soon? Romero Well, soon is a relative term. I expect a vaccine to be available in at least limited quantities before the end of the year, and I think it’s safe to say that we’ll have some- thing by the end of the year, unless there is some major safety finding before that. So, There’s distribution, and then there’s the allocation of the vaccine, that is a prioriti- zation of the vaccine. “Who will be first?” is the question. There appears to be a grow- ing body of consensus that healthcare pro- viders will be among the first to receive the vaccine—in part because they’re important for providing care to those infected and in part because they are on the front line and at risk for acquiring infection. Moving out- side of that, you’re going to have your first responders. There are high risk groups, so the elderly, for example, and those with a medical condition, which we know predis- poses people to adverse outcomes. So, there will be some combination of those individu- als [allocated the vaccine] as we move for- ward. There are several organizations that have proposed a prioritization or allocation schemes for this. TheACIP, which I sit on, has come up with a tentative first group or first tier of individ- uals, which includes the healthcare provid- ers, essential personnel and then if there’s enough vaccine, individuals over 65 and possibly individuals with comorbidity con- ditions. I think we’re going to see a mixing of the different organizations’recommenda- tions to come up with an overall category. Groups like children will be among the latter groups to receive the vaccine, and a lot of that has to do with the fact that we protect our children, and we want to make sure that a vaccine is safe before we begin to use it in children. Discussions are underway now that possible vaccine trials will take place in children in the second quarter of next year. That may be accelerated, but at this point that’s what we’re thinking. Editor How far away would you say the U.S. is in the number of months or years to herd immunity? Romero I don’t think you can answer that now, because with the vaccine, you need to have a certain number of individuals immu- nized in order to achieve that number that confers herd immunity. The numbers that have been tossed around are somewhere