‘Vaccine is not 100% protective, but it’s highly effective’: Former CDC director
Tom Frieden, a former director of US Centers for Disease Control and Prevention (CDC), runs Resolve to Save Lives, a global public health organisation. He lived in India from 1996 to 2002 when he worked with the World Health Organization and the World Bank. Frieden spoke to Sunetra Choudhury about the second wave of Covid-19 in India. Edited excerpts:
What do you make of the situation?
The whole world is watching India and sympathising with the great difficulty it is going through now. What we have learned is that this virus is a very challenging enemy... Right now, it is just humanity against the virus and what we must do is to save lives.
Authorities in India have said that they were taken by surprise, that no one could have actually predicted this. What is your take on that?
...there is a lot we do not know. So, I think the best thing we can all do is focus on the future as to what we can do to have better control of the situation to save lives and to keep our economy and our educational system going. The first thing to understand--and this is true everywhere in the world right now where you have uncontrolled spread--that you have to reduce the spread. You have to do that by universal indoor masking and by imposing closure on the hotspots that can lead to the exclusive spread and that means indoor closures, locking travel. These are some of the things that are driving the huge spread in countries around the world. But we’ve learned a lot; there are ways to close and be safer, but also keep the economy moving. We understand that the outdoors is generally safe. Though, with people out there being very close for a long time, that’s more of a problem. ...even if there were enough vaccines, it takes a long time to get them out and it takes weeks or months to develop immunity.
The second thing very important to me is organisation. I’m not making any comment about India, but it is out of the experience of my organisation, which works with more than 40 countries...what’s very important is an organised response which somewhere means an incident management system. This is needed at national, sub-national, and local levels as a crucial component of epidemic response so that there is a clear organisation that is kind of a model centre.
The third is to reduce deaths. ...it’s very important to provide clinical care and strategic vaccination. So, clinical care means organising rapid progression of oxygen and all the methods on clinical care. Also, for strategic vaccination, you look at who is dying or the age or the order of about two-thirds of the deaths or people over the age of 60. So, you really want to make sure you’ve got over 60 vaccinated as quickly as possible, understanding that this will still take many weeks or months to get it done. Vaccinating the elderly on priority is very important because the sad fact is that there are not enough vaccines in the world. And my organisation thinks that there should be more sharing of vaccines. We think that there should not be just an opening up of the intellectual property but also hands-on technology transfer to get all the effective vaccines including the mRNA vaccines to everyone.
But because there aren’t enough vaccines in the short term, we really must focus on vaccinating two groups, health care workers and older people. Health care workers because...people don’t trust the health care system. You’re going to see many deaths not just because of Covid, but from many other conditions as well, from measles, rotavirus, and other vaccine-preventable diseases.
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...We’ve seen a real setback in tuberculosis control. Fewer patients are coming forward to be diagnosed. ...in addition to my first point of closures, the second being organisation, third the clinical care, fourth the strategic vaccination, the fifth would be communication which means providing fair information on what’s known and when it’s known, establishing fair dashboards, establishing a risk alert system so people know what their risk is and that can be resolved by organisation.
We’ve done this in the US by working with the newspaper The New York Times. So, you can see whatever community you’re in and what your risk probably is. It shows the equivalent of how far Covid is in my community.
So, would you disagree with the way we opened up vaccines for all age groups above 18?
I’m not in India, so I’m not seeing the realities there. And so, I would not like to comment on what’s happening there. What I can say is that in India, health workers are better there. But the Centre has a critically important role to play. I know that really, the efforts are being made to scale up vaccine production. I think in that area, there are a series of things that need to be done to save lives and also reduce the burden of Covid on health and society more generally.
The models suggest, the better-targeted vaccines are, the more lives they will save. There is some controversy about that because, for example, in India, a lot of the spread is happening among younger people. And so, in theory, if you were to vaccinate the younger people, you could reduce stress and therefore have more of an impact that’s what I think ultimately of what we’ve learned about it.
...The virus... is going to be around for a while. I come back to a fundamental point that our most important priority is to reduce the risk of death.
There is a lot of panic because of the high number of deaths. ICMR, our medical research body, has recorded that 4.5% of people were infected after being vaccinated. In India, there is anecdotal evidence of doctors who are fully vaccinated and yet dying after being infected. What would you say to people who are afraid because of this?
US CDC has reported more than 100 deaths among people who have been vaccinated and appear to have gotten Covid...not all of them may have died of Covid but some of them certainly did. ...there is an old saying in the US, the only things certain in life are death and taxes... a vaccine is not 100% protection. There are breakthrough infections. Most of them are mild, but not all of them are mild. And so, we can’t assume complete protection from vaccinations, even if it’s a complete series, even if it’s the mRNA vaccines, which appear to be even more effective than the others. And that’s why it’s very important that we think of this as a multi-layered approach to increase protection.
...vaccination will be more effective only if other people around you are also vaccinated because you will be safer, and the risk rate is lower. This is why we have emphasised the issue of risk alert levels, usually a four-level system or maybe a five-level system from extremely high, very high, moderate, and too low. To understand that if you’re vaccinated, you have an underlying condition or you’re 80 or 90 years old and you’re in a community that has a very high level of spread, you’re still going to have to be careful as compared to if you’re in a community with a low level of spread. We really have to understand the context and avoid concerns here. But fundamentally, the vaccine is not 100% protective, but it’s highly effective. What we need to understand is that vaccination works best in the context of a comprehensive program. I’ll give you an example. Israel has one of the highest vaccinations in the world. And because children are not vaccinated, there’s a mandate for children in schools to wear masks and they have not had outbreaks in schools since. So, there are many different components of making sure that we save lives. And vaccines are the most powerful, but they’re not yet as widely available as we wish they were.
What about the variants emerging all the time? There’s an Indian variant, before this, the concern was the UK variant. Are the vaccines protecting us there?
There’s still more information to come on this. Some of the variants appear to be able to evade immunity from some of the vaccines, but we don’t yet know to what extent and which variant and which vaccine. So, we’re going to have to learn more about that. But it does tell us that this is a really difficult virus to fight. And it’s important that we not only vaccinate but also reduce the uncontrolled spread anywhere in the world.
We have the AstraZeneca Covid-19 vaccine and Covaxin. The UK is offering an alternative to the under 40 population. Does that apply to the rest of the world as well?
Well, I would leave that for national governments to recommend and for patients and their doctors to discuss. ...it does appear that with a J&J vaccine and likely the AstraZeneca, there is a very rare but potentially serious adverse effect on the number of who will be benefited...for the past at least three months, my organisation has been advocating opening up intellectual property and providing hands-on technology transfer to scale up mRNA vaccine production around the world. This is for the global public good. The mRNA vaccines are quicker to produce, they are more certain to produce and easier. It is not that easy, but it is less difficult to produce rapidly. They appear to provide a very robust level of immunity and they have not been associated, as we know so far, with the kind of rare adverse event. ...we have to deal with the world as it is today, not the world as we wish it would be. And certainly, someone living in an area that has the spread of Covid will want to strongly consider getting vaccinated. The mRNA vaccines are our insurance policy against variants, against the production delays with the other vaccines, and against the possible need for booster doses. It will take far longer than we wish to scale up our manufacturing and that’s why we need to start it today.
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One of the ways that you advocate tackling Covid is with the help of statistics. When do you foresee places like India having a majority of its population vaccinated?
Well, I can’t predict the future. I don’t know what’s going to happen with the vaccine production, but I know that there are not going to be enough vaccines as soon as we would wish. And that’s why closures and masking are very important in the short and medium term. I do think the world will get through this pandemic. I think we will ultimately get into a situation where we have limited Covid and we will still have outbreaks of clusters, but we will be at a new normal. I think masks will be part of the new normal in certain circumstances. For example, during influenza season, it’s very clear that masks have saved tens of thousands of lives from influenza by crushing the curve of influenza. I think people who are not feeling well as they do in East Asia should wear masks because this is affecting people around them. People with underlying health conditions, who are going into crowded areas, should wear mask because that will protect them from a wide range of infections. So, I think there is a real value to masks and if you look at countries like Singapore, regions like Hong Kong...the widespread use of masks...has been quite important in limiting Covid and other infections.
In many countries, the real number of deaths is underreported. How important is it to have the actual numbers?
Transparency is extremely important. We’ve seen lots of controversy about reporting deaths. We have worked with the World Health Organization. This is just one way of doing this... Covid disrupts the health care system and therefore people there die from a wide range of causes. That’s why it’s so important to protect the continued health care services such as immunisation. ...in nearly all countries, there are more deaths from Covid than the deaths reported. That is true for the United States and it’s true for most countries in the world. How much more? That’s a question that needs to be looked at in each country individually...fundamentally, an effective disease response system relies on real-time data to address the real-time response.
Umar Sofi contributed to the story
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