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Long before he was named the White House’s new COVID-19 czar, Ashish Jha, MD, acknowledged that US strategy to overcome the pandemic needed a new direction. Thanks to safe, effective vaccines, Jha reasoned, it was time to move on from the early goal of trying to prevent every SARS-CoV-2 infection to a primary goal of averting severe disease.
“It’s very difficult—I would argue nearly impossible—to suppress all infection,” Jha said during a recent interview with JAMA. “If there are things that we can do to keep infection numbers low, we should do those things. But what we really need to be focused on is preventing those infections from turning into hospitalization, into death, into severe, long-term disability.”
Jha, whose official title is White House Coronavirus Response Coordinator, discussed the pandemic, now well into its third year; his new job helping to oversee how the US government responds to it; and what comes next in a May 9 conversation with Preeti N. Malani, MD, MSJ, a JAMA associate editor and the chief health officer and a professor of medicine at the University of Michigan. The following is an edited version of the conversation. Since then, the Food and Drug Administration on May 17 amended the Emergency Use Authorization for the Pfizer-BioNTech COVID-19 vaccine to authorize use of a single booster dose for children aged 5 through 11 years at least 5 months after completion of a primary series with the Pfizer-BioNTech vaccine.
Dr Malani:We’ve now shifted from preventing every case to preventing hospitalizations and deaths in high-risk individuals and preventing disruption. My question for you is, what comes next? Where are we headed?
Dr Jha:If you go back to May of 2020, so 2 years ago, a case that somebody got infected with almost invariably had a pretty high risk of leading to hospitalization, leading to death. That is much less true now than it was 2 years ago, right? Because even though we have waning immunity against symptomatic infection, what we know is that people who are vaccinated and boosted have a very high degree of protection against severe illness and we’ve developed new therapies that are also making an enormous difference.
Dr Malani:Let’s talk about vaccines. I have a couple related questions. First is, who should be getting an additional booster now? Who should maybe wait a little bit, perhaps in the fall? And speaking of fall, should people expect to be getting boosted again in the fall, and will that vaccine be a different formulation?
Dr Jha:In my mind, if the question is, “Who should get a third shot?” it’s every adult. People over 60, if you’re 4, 5 months out from your first booster, you would benefit from getting that second booster.…50 to 59 is an age group where we just have less data. There are a lot of high-risk people in that 50 to 59 group. I think this is why FDA and CDC said you should consider it in that age group and talk to your provider.
Let’s talk about the fall and what we might expect. This is a guess because, again, we haven’t seen the data and the FDA’s going to make the call, but my expectation is we’re going to see a new generation of vaccines this fall that will probably be a bivalent vaccine. And obviously, we want to make sure we have the resources to buy enough for every American.
Dr Malani:Any word on vaccine availability for the under age 5 group?
Dr Jha:Where we are right now is Moderna has submitted their application, and that is being reviewed by the FDA. I’ve spoken to leadership of FDA. They’ve been very clear to me and I think it’s been very clear to the public that they’re going to go through the data expeditiously, and as soon as it meets their standards for a decision, they will make that decision. And the good news is we have plenty of vaccines ready to go.
Dr Malani:It would be nice as a back-to-school gift for families.
Dr Jha:What I say to folks is we obviously want to move really quickly on this, but we really, really want to get it right. And so what’s important here is, again, this is the last group of Americans who are not yet eligible. I know parents have been waiting a long time. My hope is it happens reasonably soon.
Dr Malani:We still have large numbers of people who are eligible but unvaccinated. Can you comment on any new efforts that are being done to help nudge some of these unvaccinated individuals to being vaccinated?
Dr Jha:Obviously, it’s complex why some chunk of Americans still have not gotten vaccinated. We’ve been doing a pretty deep dive trying to understand why. We’re trying to create a lot more targeted programs, trying to reach out to trusted voices.
One group that I think could be doing even more, and I know that they’ve been on the front lines on this, is primary care physicians and other physicians who are trusted by patients for their health. Helping doctors advise their patients about what’s right for them, I think, is going to be another important strategy for getting more people vaccinated.
Dr Malani:Let’s shift to testing. Testing is widely available. At the same time, there’s been less routine asymptomatic testing. It feels like we’re moving away from that, especially in schools and college campuses. But one group that is still required to test is people returning to the US after international travel. Now that mask requirements on planes have been changed, will routine testing to return home also be eliminated?
Dr Jha:I still think there’s a really important role for routine testing in many parts of our lives. This is a way to keep infection numbers low. We talked earlier about the goal of preventing severe illness, hospitalizations, and death, but there is still a goal of keeping infection numbers low, and I actually think routine testing could make a big difference there.
On the issue of predeparture testing for people coming back to the United States, I know this is an area of a lot of debate and discussion. This is really a decision that the CDC makes around travel safety, and so CDC is looking at this, as it is at all times.
Dr Malani:As case numbers are rising, I’m getting lots of calls and emails about oral antivirals. And one of the things I like to emphasize to people is that treatment works best if given early. Yet so many people with COVID, including some of our most vulnerable, are simply not connected to medical care. The Test and Treat Program was designed with these access issues in mind. Can you explain a little background around Test and Treat for people who are not familiar with the program and also tell us how it’s working and where and how it might be improved?
Dr Jha:The idea is very simple. What we know is that the new treatments that are coming out, these new oral antivirals, they work best when you give it early in the disease course. And so you want to tie testing to the treatment. And you want to create a seamless experience where people who test positive, if they develop symptoms or if they’re testing asymptomatically, that they immediately get evaluated for treatment, and that these 2 acts of testing and treatment really get brought together, because we know that the benefits of treatment are optimal when it happens early.
Let me start off by talking about where most Americans are getting [the oral antivirals] Paxlovid [1 dose = 2 nirmatrelvir tablets plus 1 ritonavir tablet] and molnupiravir [Lagevrio]. Most of that is still being prescribed by physicians to patients they know and getting filled at a pharmacy that patients may use on a regular basis. But you’re absolutely right—there are plenty of vulnerable people who don’t have a regular source of care, who don’t have a primary care physician that they can turn to.
So what do they do? Test and Treat was designed in large part for them, but it was also designed for other people who may have a primary care physician. So right now, there are about 2200 Test and Treat sites across the country. That’s good. We want to keep working on expanding more of them. And so there are a lot of federal sites that do testing already and we’re looking at setting up a treatment site right next door to it. We’re working on that. We’re talking to other pharmacy chains. Right now, the FDA has authorized only physicians and nurse practitioners and PAs [physician assistants] to prescribe this.
Dr Malani:I wanted to talk about post-COVID conditions, often referred to as long COVID. Long COVID remains very poorly understood, and the approach to management varies a lot. I know this has emerged as a high priority issue for the Biden administration, so what’s being done to improve our understanding and really to inform management of long COVID?
Dr Jha:The problem with this clinically is that it’s such a range of conditions. We know from lots of viral syndromes that people can feel not quite back to 100% 4, 6, 8 weeks later. But then there are people who are truly debilitated by this, who months later—some people up to 2 years later—continue to suffer substantial debilitating symptoms.
We need to clinically understand what’s going on. For some people, this is clearly immunologically driven and for other people it may happen with viral reservoirs that have not gotten fully cleared. There may be a combination. So there’s a lot of work to be done just clinically in sorting out different types of patients, what’s driving it, et cetera. Because obviously, if we don’t do that, it’s going to be very hard to study them and come up with effective interventions.
The next thing is, the president put out a presidential memorandum on this. There’s a lot of funding now going into building cohort studies because you want to track people over time.
And then I do think that there’s a lot of work being done to look at potential therapeutics. If you’re talking about people with a potential viral reservoir, then potential antivirals, oral antivirals, may be a really important tool. Again, these are things all being studied right now.
Dr Malani:I wanted to end our conversation by asking you what we’ve learned during the pandemic and how can that be applied, going forward, to improving health in general?
Dr Jha:I think this pandemic has really made that very, very clear that you can’t separate out public health and medicine, that they really are intrinsically linked to each other. And one of the lessons I’m hoping we learn from this is obviously we’ve got to invest in a much stronger public health infrastructure. If not, it’s the health care system that really suffers.
Créditos: Comité científico Covid