Vaccine Results
This month’s episode of “News you can Use” in the traditions of “Ask Me Anything” on HealthcareNOWRadio features news from the month of December 2020.
You can read more about the series here and the concept of keeping up with innovation in healthcare. Please send me your suggestions on topics you’d like to see covered. You can reach out direct via the contact form on my website, send me a message on LinkedIn or on my Facebook page (DrNickvT), or on Twitter tagging me (@DrNic1) and #TheIncrementalist or you can click this link to generate a ready-made tweet to fill in:
As I did last month I am talking to Craig Joseph, MD (@CraigJoseph) Chief Medical Officer at Nordic Consulting Partners. This month’s news is filled with the results of the US elections that we both correctly predicted the outcome (the winner and how long it would take for the results).
All About Vaccines
We discuss in detail the three vaccines that have now made it through Phase 3 trials (Pfizer, Moderna, and AstraZeneca) and showing positive results. we dive into the details of distribution, what the cold storage requirement means on the ground, and the challenge of tracking multiple doses that are timed differently dependent on what vaccine you end up receiving since you can’t mix and match.
Craig shares the background to the counter-intuitive details around the efficacy of the AstraZeneca vaccine that is more effective when the first dose is given at a lower dose and how they discovered this detail. Listen in to hear what this will mean in practical terms for our world and how people should process the continued emerging news.
Listen live at 4:00 AM, 12:00 Noon or 8:00 PM ET, Monday through Friday for the next week at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.
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Transcript
Nick van Terheyden
And today I’m delighted to be joined as I am each month by Dr. Craig Joseph. He is the Chief Medical Officer of Nordic consultancy. And he is with me each month to talk about the latest and greatest in news. Last month, we covered the election. And both of us made a prediction if I recall, I said the election was going to go the way that it did. I I think it has based on where we are at this point that
Craig Joseph
Biden is now the president elect. And you made your own prediction. Craig, right. Yeah, mine was a much braver prediction, I think. And I said that we were not going to know the results of the election for several days, at the very least. Yeah. And I think it’s been a lot longer than that. I’m not even sure I think it was maybe a week or I’m not, I can’t even tell it was, it was a whole painful process. But it was I know, exactly was two and a half years. From the time of the election, to the time that many people thought they knew who won it was two and a half years. Yeah, no. That’s in COVID years, obviously.
Nick van Terheyden
So clearly. So this week, I think, some substantial news, certainly from the last time that we talked and, you know, relevant to COVID-19, I think the first thing we should talk about is vaccine. So, as of today, three counted 123 solid vaccine candidates. And they’re quite different in the way that they work. And also in some of the storage and transportation requirements. I know you’ve had lots of experience. As a pediatrician, you were giving lots of vaccinations? Did any of those require some of the requirements that we see with some of these covid vaccines? And what are your thoughts around all of that?
Craig Joseph
Well, first of all, let’s point out that I also predicted that multiple vaccines would have a 95% efficacy rate. And so I don’t recommend you go
Nick van Terheyden
back on that. I’m just not we have a whole fact checking
Craig Joseph
team here. I don’t think you should go and check that but just go with the fact that I say that I predicted that. No. So obviously that was false. It was not true in any way. Did so yes. As a pediatrician, I think most primary care physicians give vaccines, which means we have to receive the vaccines and store the vaccines. And there were certainly that that required refrigeration and or freezing. However, nothing like the Pfizer vaccine, that was the first announced and will be most likely the first to be licensed. That requires freezing at around negative 90 degrees Fahrenheit. And until I think you have like an hour before administration. So you’ve got you know, some time but not significant. And so I think the majority of physicians in offices do not have a freezer that is capable of getting to be that cold and consistently that cold. So that’s going to be a problem for distribution, for sure. And so I you know, I suspect I don’t think there are very many people that think that you’re going to get a COVID vaccine from Pfizer, or at least that one from your local doctor’s office like that.
Nick van Terheyden
Totally dive into that it’s probably worth just talking about the three vaccines and you know what they are so Pfizer and modern are in the same grouping that is in messenger RNA virus, right? Yep, that is a stimulant to create the immune response to specific elements of the COVID-19 virus particle that has been essentially engineered based on the genetic code that was translated from the original virus. Those two are the same, but they actually have different characteristics in terms of storage. And then AstraZeneca, or stroke, Oxford, different virus that uses a an ad, no virus cold virus that has been engineered to produce those viral proteins and creates an immune response. That one doesn’t require I don’t want to say any, it doesn’t require the same kind of levels of cold storage. That’s a killed virus or one that’s been inactivated. As we think about those, you know, you’re talking about the Pfizer one, which has this very cold storage, you know, dry ice level, the other two do not. So do you think that we’re going to see more of those as a result of that?
Craig Joseph
Well, I, you know, I think that it’s really difficult to predict. And so, you know, two or three months from now, I will say that I predicted exactly correctly, because I clearly have a history of falsely saying that I’m smarter, judging the future than I am. However, you know, you have to look at data that don’t, that don’t exist yet. Right. So we don’t know how they differ in terms of their efficacy is one, it sounds like the Pfizer and the maternal ones, are very similar, at least in the initial data that they have publicly released the efficacy rate, meaning the percentage of patients who they help seems very similar so and well, well beyond everyone’s wildest dreams. So including the manufacturers, no one could have thought that it would be that high, which is just amazingly helpful. So but it sounds like the AstraZeneca, one has a lower efficacy, which is fine, if it’s also cheaper to produce and more easily to mass produce, and more easily transported and stored. And so yeah, it might be that the the mRNA vaccines that are going to come out first are going to be a big for the first groups of waves of patients that are getting them. And then it might be that the actual work, the actual hard work of immunizing the vast populations of the world will be from the from manufacturers, such as you know, the AstraZeneca, Oxford, one where you can get that to areas where they absolutely don’t have the technology to support these, you know, frozen frozen vaccines. And so we clearly we meaning humanity, we need more than one vaccine there. So the more manufacturers that come out and can get approval from the various governments in the world, there as far as I’m concerned. And and so it’s I don’t think anyone could could predict I, you know, one of the things that’s going to be interesting to discuss and to see is who gets it first. And what percentage of those groups, those waves actually elect to get a vaccine.
Nick van Terheyden
Right. And there’s some complexity in there with the requirement for two doses. I think we should come back to the two doses on the AstraZeneca. Because you had some really interesting insights as to that efficacy, right, that rose. But I want to push back a little bit and say, you know, if there’s one thing, while there’s not one thing, the military system is very good at lots of things, but logistics is one of them. And I’ve seen that firsthand. In a number of instances, we also have distribution of the Ebola virus that was not the virus, but the vaccine that was also at this cold storage level. And they managed to do that to remote parts of Africa successfully. And I have to say, I have higher confidence in the capacity of the system to be able to get this out. And they’ve already sort of pre staged using some intelligent resources of you know, cold storage that is available in hospitals, research places, a lot of universities, certainly some that I’m working with actually have this in place and is now being used as part of that staging. And the other thing I would say is that I don’t think it’s quite that short a period of time, it is short from the time that it thaws, and there is some requirement. I do want to get back to that. Because I know you know, one of the things that introduces additional complexity for the medical profession here is that and they’re going to be ones that are right in the middle of this is when they have spoiled vaccines. And you had you talked about some of the the temperature thing, you’ve got to deal with all of that as well, that’s going to add this additional layer of complexity on top of all of this.
Craig Joseph
Indeed, yeah, and and I, your I think you’re absolutely right in that various organizations militaries included, have have done this kind of work before. There’s also I’ve read about containers specialized containers that can get you like the last mile So that can potentially get you to, from a, from a central area maybe out to the private doctor’s offices so that it is something that you could get at your actual local doctor’s office every morning, they get a box as a specially produced kind of super cool box. And so think it’s certainly all possible. And it’s just difficult to remember the last time pretty much every human was supposed to get a vaccine, we, you know, within, within a matter of months, never been done before, or whatever the number is, at this point, I’m not even sure there’s a lot of us. Yes, Dr. Nick, that’s all I’m saying
Nick van Terheyden
worldwide too, as well. So. And, you know, let’s, whilst we’re on this sort of distribution, you sort of mentioned that AstraZeneca, you know, doesn’t have as much of the same cold storage, it also has a very compelling piece, which is it’s very inexpensive, designed to be very inexpensive, so more accessible, but it had this, what I would say is counterintuitive, certainly to, you know, on first blush, the data that emerged that said that it was 70%, effective, you know, after giving two doses, but you could raise that to 90, at least, and maybe it was a little bit higher than that. If you gave less of a dose in the first instance, and then up to the dose to the second. Now, that’s a little bit counterintuitive. And I’m thinking, Well, that was clever them. But actually tell us the background to that, because I think it’s really interesting. It’s one of those enormously important points. Well, it
Craig Joseph
was a mistake. And this is not based on any first hand knowledge, but just reading. Yeah, it was, as I heard about this, I was like, why would it be more effective to give half the dose as the first dose and then double it to the what your initial full strength dose was supposed to be for the second dose? And, yeah, there was a mistake in mixing the dose for a good chunk of the patients who got who were involved in the initial research. And they decided once they once they discovered that a significant proportion of patients had gotten half the dose that it was intended. They just went about and and noted it and continued the study. And at the right time, whatever those times were, gave them the second dose at the intended at the intended, you know, the intended dose, and then found that those patients did significantly better than patients who got the same dose both times. I don’t understand how that it. Certainly I’m not an immunologist, or biologist or expert in any vaccines, it just is counterintuitive that that would that would, that’s a thing. But certainly that’s what they found. And, again, this is all preliminary data. So things do change. But they they seem to have been if we continue with the trends that they seem to be holding, and let’s hope that they do. All of this, though, is very complicated for practitioners, right? Because the two mRNA vaccines Pfizer and Madrid, I think one is supposed to be given three weeks apart. Another one, the magenta one, I believe it could be off on this is supposed to be given four weeks apart. And so and now you’re talking about what the AstraZeneca won, I don’t know how far apart those are. But you have to make sure to give, again, assume we’re assuming a ton of things which could turn out to not be true. A different dose based on the you know, the first one and the second one, and these are not interchangeable. So you if you get the Pfizer vaccine, you need to get both doses from Pfizer, you can’t change from one to the other. So it’s fine if one country or part of a country or state just gets one vaccine, and then it’s highly likely everyone will know the rules in Illinois versus in Virginia. If it goes like that, I doubt it. It’s going to go like that. It seems like the plan right now is to equally to give out vaccine the first that’s available to give it all out based on our needs. So every state says what they think they need, and they just divvy them up and send them out.
Nick van Terheyden
So for those of you just joining, I’m Dr. Nick the incrementalist and today I’m talking to Dr. Craig Joseph, Chief Medical Officer for Nordic consulting partners and also my regular companion for news you can use on each and every month. We were talking about the vaccine, the vaccine distribution, the complexities of multiple instances, the timing of that making sure that you get the same ones. You can’t get AstraZeneca and then Get madona although I’m willing to bet that we’re going to have some small subset data points to be able to study in the future to see what that does, of people that do that. And specifically around the AstraZeneca, this counterintuitive notion of, you know, lower dose in the first instance. And the fact that that was serendipity. And that’s what we got, which, you know, it’s terribly exciting to me, it’s one of those eureka moments that I don’t know if they occur a lot of the times, but, you know, we learn from it importantly, from the data. And it also explains why I think, online, even with people that have way more insights and intellectual capacity to be able to apply to this, that there is no really solid answer to this that I’ve seen. I’ve seen lots of different ones, Vectra immune response, there’s certainly
one
Nick van Terheyden
explanation that I heard that made sense is if you give a large dose of this, the body’s reaction is so overwhelming to smash it to pieces that you don’t generate enough of a lasting immunity and giving a smaller response allows the body to sort of generate and then you give a second challenge response. And that gets you to the neutralizing antibodies. You know, some of those makes sense. I don’t know that we fully understand. I’ve certainly seen some experts with, you know, the right background say, Oh, yes, this makes sense. But I’m thinking Hmm, okay, I’d like to understand it more. But that’s as far as I’ve gotten to. I think, for me, the complexity of this, and this is where, you know, certainly our perspective. You know, this is a technology problem. In many respects, tracking and tracing all of this, this is not about contact tracing. This is about making sure that the right person shows up two weeks, three weeks, whatever, following through giving them the right nudges, that to me is all about tracking and tracing of individuals and having a really solid system that does an appropriate follow through. And I’m not sure that we have that certainly not anything that I’m aware of, are you aware of anything that would fill that bill?
Craig Joseph
No, it doesn’t exist. And, and and at least in the United States, and that’s a problem. And it’s not a new problem, it’s a you know, we don’t have a medical a unique medical identifier here in the US. So there’s not a number that every American gets. And this is your your number that you use to track these kinds of things. And so, and that’s by law, that’s actually written in the federal law that the the US government cannot create such a such a number. In the past, folks have attempted to use such make up a number such as your social security number. Not allowed to do that. And and so that’s one problem. And so we we kind of make up for that by using a bunch of algorithms to try and say, Well, if this is your birthdate, and your last name is kind of like the same as this other person. And your address is, you know, pretty close. And if your phone number, the digits are. So that’s a it’s a problem here in the US that other other countries don’t have. But it certainly that that’s one, we don’t have a national system for tracking that vaccine registry. We those are generally on the on the state level. And don’t you worry, some states, there’s a state, I think one or two that doesn’t have a vaccine registry. And there are other states that have multiple vaccine registries. And so you’re looking at a lot of different groups trying to kind of keep keep on top of that. So So to answer your question, it is very complicated. And we don’t really have a great infrastructure here in the US for for keeping that straight. And so there are going to be people who fall through the cracks. I think this is a great opportunity for small kind of, potentially for app developers to Hey, you know, if you want to make sure that you get your right vaccine, give us the information that what you got. And then we’ll tell you when we’ll send you a text and reminders and emails to tell you when to get the next one now. So I that’s just one way, but I think it is going to be a problem. Although the good news is it’s not like you have to wait two months. And so the we’re really talking weeks so far for the vaccines that we’re aware of. And so it is much easier to remember I’ve got to go back in three weeks than it is I have to go back in three months by then it’s forgotten about it. And
Nick van Terheyden
I’m glad you you have better memory over three weeks versus three months. I’m not sure that that’s true for all of us. But
Craig Joseph
while I definitely I didn’t say a good memory but a better memory for three weeks, then than three months. And I you know, obviously the some of the keys are just going to be Hey, don’t leave until you have your next appointment and give us a way of contacting you to remind you that you need to come back, because one dose clearly is not going to cut it, it’s not going to give you the level of immunity, again, based on the initial data that we’ve seen, not going to get you the level of immunity that you that we would call protective.
Nick van Terheyden
Yeah. And it’s probably just worth calling out at this point, as I have in other instances, but you know, there seems to be I know, there’s a wish, and it’s a good wish. It’s one that I have, but it’s not based in any kind of scientific reality, once the vaccine has been released, and there is a block of people getting it. And you know, that list of folks and now you allocate, I think is a huge challenge and the whole show in its own right. But once that’s happened, nobody flicks a switch and says, All right, that’s it, all bets are off, you can go back to usual behavior, we’ve still got an extended period of time where we’re going to have to manage and deal with spread, we’ve got to get some level of herd immunity, hopefully through vaccination, not through the disease progression through the population. So we’re going to be living with this, and we’ve got to manage that. And then you’ve also got to determine who’s had it, who hasn’t. And then treat those people appropriately. I know that sounds a little bit big brother ish, but you want to protect those that haven’t had the vaccine, if at all possible. And make sure that we you know, purge this virus as much as possible. The good news that I’ve seen, and I haven’t seen the data here is, everything seems to point that this is a one time deal, or two time you have to have the two vaccines. But once you’ve had it, you don’t have to keep going back to the well like the flu shot. This is more like the measles where you know, you have it and you’re good, good to go.
Craig Joseph
Well, I you know, I’m not convinced of that. And and and certainly that’s not, I think you’re I think what you said is true, that that’s what it seems to be. However, I wouldn’t, and no one should put all of their hope and expectations in that it certainly could be that you need to get booster shots. It could be that this is like a flu shot. And that, you know, we’re not going to be talking about just, you know, flu season when we’re talking about flu and covid season. I hope that’s not the case. But it you know, so it’s too early. And it’s one of the things that you mentioned, I wanted to just pick up on a little bit the the concept that probably we made it, someone made a mistake. And it turned out to that that actually helped, you know, create a great vaccine, we are learning things that could be wrong. When we first hear them, you and I are using the more clinical term counterintuitive, right? But if you could just translate that as well. That’s wrong. That’s done that doesn’t make any sense. And and I think a lot of the problem in the again, speaking just about the US where people are, are saying fake news, and I don’t trust this group. And I don’t trust that group. Well, it’s, you know, how can you trust him? Because he said that masks weren’t helpful at the beginning of the pandemic in February. And now the same guy is saying, you have to have a mask? And and, you know, obviously he’s not telling the truth one of those times? And and the answer is no, that was actually the that actually made the most sense back at the beginning. And now we know more. And we actually and as you kind of pointed out, first we figure out what the answer is, and then we try to figure out why. Right? So we can understand that. But the Y comes after the what. And so, you know, I’ve explained to lots of people that hey, I was the first one to kind of laugh at people who are wearing these, these cloth masks thinking like that is absolutely not going to protect you from this virus, right? That is not a good enough barrier, it’s not fitted across your face, you definitely can still get virus in there. That’s That’s insane. We now know that, hey, those cloth masks, your right don’t stop all that all the virus but they apparently significantly decrease your ability to get a big viral load. And we now know which we didn’t know before that the the morbidity and mortality the the bad effects from this bought this virus are clearly based in some part on how much of it you got and where you got it. Right. And so if someone coughs in your face, as you’re taking a deep breath, you’re getting a bunch of virus particles and they’re all going deep in your lungs, and your chances of having a bad outcome are great. So, so that, you know, we learn things and and things evolve and the fact that we said something, one month into the into the pandemic, and we’re saying the exact opposite six months of the pandemic, that is to be expected and it’s going to continue to happen. And that’s how science works. And that’s not fake news or someone lying to you. That’s true. Fast science,
Nick van Terheyden
such great points and such important points to really emphasize I think, you know, the way I like to think about this is that the best available option is always available. Perfect almost never is. And we always try and present the best available option based on the data, the current circumstances, resources available in the case of masks, in some respects that has to do with resources and trying to protect our staff who desperately needed them, by the way still need them because they still don’t have peepee. And that, to me is a terrible, shocking statement. But no, I think extremely important. And that will be the continuing message ongoing and certainly part of our discussions. We ran out of time, I’m afraid but that’s a good thing. It’s always a great discussion, I think incredibly important, focused on the vaccines and what that’s going to mean in terms of practicality. So it just remains for me to thank you for joining me once again. So Craig, thanks. Thanks for joining me on the show. Always, always a pleasure.
