Orignially recorded April 27, 2021. Transcript has been updated to reflect current information about the COVID vaccine. 

KW: Welcome to M.ED: Medical Education for the Practicing Clinician. Today, we're very lucky to have with us, Dr. Andy Pavia, who is a Paediatric Infectious Disease doctor at the University of Utah. He got his Bachelor's and medical degree at Brown, and then did a combined internal medicine and paediatric residency at Dartmouth and the University of Utah, and a fellowship in paediatric and adult infectious disease at the University of Utah, and then he trained as an epidemic intelligence officer at the CDC.

He's been on faculty at the University of Utah since 1991 and since 2003, he's been the Chief of the Division of Paediatric Infectious Disease. He's very involved on the national scene of infectious disease and epidemiology. He has served two terms on the CDC Board of Scientific Counselors, a member of the board of directors of the Infectious Disease Society of America, chaired the vaccine safety working group at the CDC, and been the PI or co-PI on grants from the NIH, the Bill and Melinda Gates Foundation, and the Centers for Disease Control and Prevention. He's a frequent consultant to the CDC. You may have heard him on NPR discussing COVID, or I just found a video of you testifying to Congress on Public Health Threat Preparedness from a while ago. So I guess maybe we should have listened a while ago when you were talking. Is there any other big notes that I missed that you want us to tell, tell us about yourself?

[chuckle]

Andy Pavia: No, that makes me sound very old and feel very old. But you did bring up that testimony before Congress, and really, I've been involved with a lot of other experts in this area on pandemic preparedness now for some 20-odd years, trying to raise the level of awareness and the level of preparation on pandemics. Of course, we put flu at the top of our list, and pandemics and coronavirus at number two, so we were wrong about that and so many other things. At least we knew that we needed to be better prepared for pandemics.

Was the coronavirus thought about prior to the pandemic?

AP: No, the SARS pandemic, which wasn't really a pandemic although it did spread around the world. The SARS crisis was really a wake-up call. People will probably have forgotten most of the details. I believe it was in 2003, involving four continents, and killed about 8,000 people. It was really quite lethal and spread easily in hospitals, but it was easily contained because it didn't spread outside of hospitals. People only were contagious after they got very sick.

It was a wake-up call that these coronaviruses, which are everywhere in the animal kingdom, had the ability to spill over, or jump into our species. And then MERS, which people may remember, is the other coronavirus that took on an epidemic form, spread from camels, who presumably were infected by another reservoir like bats but caused some pretty severe disease in the Middle East with one outbreak occurring in Korea. We knew coronavirus had a lot of tricks up their sleeve, but we were still... we underestimated our opponent.

Have we learned some lessons that will better prepare us for the next pandemic or epidemic that will eventually come our way?

AP: Well, I have two answers for that. Scientifically, I think we've learned a lot. We've learned a lot about the flexibility of coronaviruses. We've watched this coronavirus really evolve in front of us, from its first jump into humans to becoming this very efficient and deadly pathogen that spread so easily. We've learned a lot about how to track potential emerging infections, how to dig down and look at their genetic code to understand what they can do, to try and figure out when it's a completely new disease and what it might mean. So, I'm optimistic about that part.

The other part is, are we going to invest in the infrastructure it will take to detect something early? Do we have the will to stop it if we have the tools at hand? Even though I'm normally an optimist, I'm kind of pessimistic about that. I think as soon as the pandemic goes away, our attention will turn somewhere else. Nobody ever wants to invest in the fire department until the house is burning. I think we're going see the same thing when the time comes to build up our preparedness.

KW: That's unfortunate. For now, let's focus on the present. Let's talk about the vaccine, which I'm sure a year ago, no one thought we'd have in millions of people's arms by now. It's pretty incredible. The downside is that not everyone is taking it. Let's start with efficacy.

What is the efficacy rate of COVID-19 vaccines?

AP: These vaccines exceeded our wildest expectations. We didn't expect a vaccine that would exceed 90% effectiveness. The 70's would have been a great target for efficacy. These vaccines have proven to be really very, very safe. The mRNA vaccines, aside from anaphylaxis, have really not had any serious or life-threatening side effects, at least as we understand it so far. The clotting side effect that appears to be associated with the J&J vaccine appears to be extraordinarily rare and the incidence of really severe side effects is probably on a par with other vaccines that we use. 

We were able to produce really effective vaccines in record time and do it well, such that we have really good safety data and have confidence using them.

KW: Can you explain to people what the vaccine efficacy of other commonly used vaccines? It's much lower than 90-95%, right?

AP: Well, it ranges all over the place. One good example is the influenza vaccine. A vaccine I'm very fond of, I think it's very important, but its efficacy ranges, in an average year, about 50% to 60%, but we frequently have years in which it's not very effective at all and may have an efficacy of 20% or less. Pertussis is another one that everyone thinks about and everyone worries about whooping cough, and yet the efficacy of the vaccine is probably in the range about 80-ish percent in the first year or two afterwards, and it fades to close to nothing by 10 years.

Only a handful of our vaccines get close to 90% efficacy. Measles is our previous champion and the new shingles vaccine exceeds 90%, which you can count on the fingers of one hand, vaccines that are as good as these COVID mRNA vaccines.

Here are a few approaches we're taking to engage underserved populations.

KW: Thank you. Let's shift to address some of the most common questions that people on the frontline get when talking to people about vaccines. I'd like to start by sharing what I do in my own clinic.

My clinic is a little unique because we see a lot of refugees and immigrants, and people where English is not their first language, which presents its own challenges. We are fortunate to be a vaccination site for the Health Department, which allocates a number of doses per day for our own patients. This means that because most of my patients are under 16, but obviously their parents usually aren't, I can say, "Hey, you're here for your two-month well child check, we can do your COVID vaccine today too. Isn't that great? You don't have to go on the website, you don't have to coordinate the scheduling."

For my patients who English is not their first language, I've been able to get a fair number of them to get vaccinated that way. Not every clinic is able to do that, and it's really great that the Health Department recognized this underserved community and its needs. And then having the opportunity to tell people that it's free and that anyone can get it regardless of insurance, or for those who might be undocumented or not have immigration status they want to disclose, that they can get it for free as well is great.

I also typed up a little piece of paper that says, "Dear caregivers and parents, I got the vaccine. I think it's safe. My family got the vaccine, it's the best way you can protect your children since most children can't get vaccinated. Please get it, and let me know if you have questions and here's the website." It's on the back of all my clinic doors so they can look at it while they're waiting.

What do you think of these approaches? Are they a good start? Are there any major flags that you think I could be doing from the very beginning?

What works when communicating with patients about the vaccine? 

AP: Giving people straightforward messages. "This vaccine has a lot of benefits for you, it's available, I'd like you to get it today," is a much stronger message and more likely to lead to someone getting the vaccine. Focus on the positive aspects rather than trying to talk them out of bad information.

Another thing we know really helps people make the decision to get vaccinated is hearing that it's something we do all the time for our patients and we expect that it's good for them. Really clear messaging about the benefits of the vaccine, people want to know what's in it for them? And, importantly, protecting our children is one of the very top values that we all have.

KW: "Protecting your kids the best way. If you don't get sick, they're much less likely to get sick." I've found that really resonates.

AP: In a more upper socioeconomic group, they might want to be able to get on airplanes, they might want to be able to go to work in person, so that's a clear benefit for patients facing the kinds of challenges that your patients do. There are jobs that will only be open to them eventually if they're vaccinated, they can protect their kids, they can probably feel safe working in jobs where they don't have the kinds of protections of working that many people do.

One thing you do that I think is really terrific is, people trust us. When they see that we're walking the walk and talking the talk it matters. I always start out my conversations about vaccines by saying, "My kids are vaccinated with every vaccine on time and my daughter got the first dose of Haemophilus influenzae B vaccine given in the state of Utah, outside of a clinical trial. And I've gotten every vaccine I'm eligible for." It means we're not saying, "Do as I say, not do as I do," this is how we treat our own families as well as our patients.

KW: Right. If you, as a provider, as a caregiver, tell them, "I did this myself, I want you to do it." That's better than anything they're going to read really. If they trust you, and you as their physician tell them, "Do this, it's a good thing. I did it." It seems to be the best way to convince people.

How to address vaccine hesitancy with patients.

AP: When I was on a vaccine safety subcommittee for the National Vaccine Advisory Committee, we did a lot of digging into the literature on the psychology of vaccine hesitancy and there are all these things that were counterintuitive.

If you start to talk about autism with somebody who has heard that vaccines cause autism, rather than hearing you say that there are over 20 high quality studies that disprove this and Andrew Wakefield is a fraud, they just hear autism. "She's talking about autism. There must be something to this" and it just triggers that memory that there was something to worry about.

KW: That's an interesting way of thinking about it. And I was thinking of that paper that you sent me about COVID vaccine hesitancy and one point being the political factors. That's not something I address at all in the clinic, and I don't know if you recommend... I don't know how to even open that or if it's worth it? I just don't do it because I don't know what to say.

AP: Yeah. I don't know either and I'm still kind of flabbergasted about the entry of politics into this pandemic, whether it's about masks and now about vaccines. We've heard over and over again that Republican men who voted for Trump are the least likely group in the country to get vaccinated. Alternativley we hear, "We don't trust the medical establishment because of Tuskegee and because of our unequal access to quality of care," and you have to say, "Well, okay, that's a reason to be somewhat distrustful." But to distrust because people who share your political views have downplayed the pandemic or have tried to convince you that it's not real, that's really hard to get your hands around.

So how would I approach it? I guess I'm often in the position of trying to help people understand the gravity of the situation. That the pandemic is really real. I share stories of my friends who spent the last year working in an ICU who pronounced three people dead in one shift. I say, "Talk to the people who've lost a parent or a grandparent. This is as real as can be." That may help in terms of believing that the disease is bad, but I don't know whether it really helps people want to get vaccinated, if they've got political reasons not to.

KW: Let's talk about that group. The "No, I'm not gonna get vaccinated at all," group. I'm torn. It feels like if I mention it, it might open the door for next time I see them to be a little bit more open to it. But I don't know, maybe it's just a waste of time. But it's what I've been doing thus far.

AP: I think it's very similar, you probably do this, but maybe not so much in your population, about people who are hesitant about childhood vaccines is, you open the door and if you get a firm no, you just come back to it on the next visit and the next visit rather than trying to hammer. In my experience, which isn't as deep as yours, people come from countries where childhood diseases are rampant and where they've seen children die. They really understand the value of vaccines. When they're seeing children die of measles, can't wait for their child to get their MMR vaccine.

KW: The amount of vaccine hesitancy I have in my refugee population is pretty much zero, but it's interesting. I have a lot of hesitancy from their parents, which has been a bit frustrating. One of the big things is that they're worried about the long-term effects, and I feel like I don't have a great answer for them. What is your suggestion for addressing that question? 

How do you address questions about long-term effects of the vaccine?

AP: The long-term side effects of vaccines that are bad almost always present right away. So something like Guillain-Barré syndrome occurs within a few weeks, those rare cases of encephalitis that we used to see with the old APT vaccine, those came on within a few hours to days. There really are no side effects that we know about that show up months later for any other vaccine, so we don't expect that it is likely for these vaccines. And we're now five months in. 130 million Americans have been vaccinated, save nothing for the rest of the world. So if there were really bad things cropping up with any frequency, I think we would be begin to see them. While we always have to acknowledge that no medicine is completely safe, vaccines are probably the safest of of all our medicines, but they're still medicines.

KW: Right. Another question I get is concern over how rushed the process to develop the vaccine was compared to other vaccines. People have this idea that vaccines take years to develop, so how could it have been developed in a few months? What's your answer to that?

How do you address questions about the rushed production of the vaccine?

AP: I tell people that the process itself was not rushed. What they did was cut out the dead time, they cut out the time between phase one, where they sit around looking at the data, they cut out the time that it takes to start producing the vaccine while waiting to see how the phase two and phase three studies turned out. That left them ready to put the vaccine in arms as soon as the phase three studies were finished, as opposed to another year or two to build the factories and get them certified that we would normally see.

There was legitimate reason to worry about politics intruding, and we all worried about it in September and October. Some of the things that were said by the past administration made you nervous. But when all was said and done, I also tell people, the FDA made all of the data they reviewed public. I sat up the night before the FDA hearing, just like the people on the committee and pored over the data for myself. And our patients can do that too. So I think transparency is what really gave us confidence.

KW: Yeah. I think it's a very good thing to remember when we're talking to the patients. Another problem I have is that, since I have a pediatric population, most of their parents are on the younger side. They tell me, "Well, the chances of me getting sick aren't high", or, "I already had COVID and it was just like a bad cold, so why should I get vaccinated when I'm not gonna be that sick?" And I tell them, "Well just because you had COVID once doesn't mean it will be the same way the second time you get it." And then a lot of my families live in multi-generational households, so I try and say, "Hey, you can protect your mum, your great aunt, whoever lives with you." But I think it is hard to say. I don't know, that can be a challenging one. It's more of an altruistic thing, it's not just you.

AP: I think the other thing that young people worry about are the long COVID type symptoms, because even if the disease itself isn't that bad, if you can't work, if you can't play soccer, if you can't concentrate for a few months, that can be pretty devastating to your livelihood and your ability to do things that you care about. That probably matters more to young people than that very small chance of dying or even of being hospitalized and ending up on a ventilator. And I think for lots of people, as you said, the ability to protect those around you is ultimately gonna be an important reason to do it. If you infect your mother or your grandmother, how are you going to live with yourself? Or for that matter, just a neighbor.

KW: Right. Are younger people more likely to have long COVID symptoms versus older people who survive COVID?

AP: I don't think we know that. But I think long COVID is much more disruptive. It's much more of a real threat to young people in terms of how they think about it. They get over it in a week and maybe they felt terrible, but they recover, but if they have heart scarring, if they've got persistent memory deficits or sleep disturbance, that really is really problematic. As somebody who mostly does paediatric infectious disease, I don't see a lot of the young adults with long COVID, but my colleagues who do tell me that people are missing work for weeks and months.

Tell us about the Long-Hauler COVID-19 Clinic.

KW: Tell us about the Long-Hauler COVID clinic at the University of Utah. 

AP: So there's one that just started at Intermountain and now there's one at the university. And it has two purposes. One is to figure out how best to care for people in the short term, but the other is to really do the research it takes to figure out what the right treatments are. Because right now, we don't really know.

KW: Right.

AP: We know that we have to look for organ dysfunction, a small proportion of people with long COVID symptoms will actually really have heart damage or pulmonary fibrosis. But we also know that some of the people complaining about brain fog when they have neuropsych testing really are showing major cognitive deficits. And we're trying to figure out what to do about that. For many of the others, it looks like the post-viral fatigue syndrome that we've all dealt with in primary care, we don't understand very well, but the symptoms are very, very real.

KW: It's interesting how some people with long COVID get better after they get vaccinated. Does anyone know why that's the case?

Why do some people with long COVID get better after they get vaccinated?

AP: We don't know. When the first reports came out, people were very skeptical, but there's now some beginnings of data that suggest that it's real and that vaccination may reset the symptoms for people. You can imagine a couple of ways it might work, but we have no data. One is, and probably the one I think is most likely, is that if a dysfunctional persistent immune response is what's causing the symptoms, that vaccination resets the immune response, perhaps to more of a Th1-type response, perhaps some other more subtle change in cytokines, and maybe that's what helps you feel better.

Others have speculated that maybe there's some viral antigen that persists and by making more antibody, you bind that, and you're protected. I think that's a little bit more in the realm of hypothetical. We just don't know. And we're not a 100% sure that vaccination is the answer, but I certainly would recommend that anyone who has long COVID symptoms, who hasn't been vaccinated, give it a try because the anecdotal data does not suggest it makes people worse.

KW: Right. And it used to be that if you had COVID, say, wait 90 days to get vaccinated, wait 30 days, but now is there any wait time that you should wait before you get vaccinated now that it's available everywhere?

Is there a wait time after having COVID before you should get vaccinated?

AP: Early on, telling people to wait was a way of stretching the vaccine supply because people who hadn't had COVID in the last 90 days were less likely to get reinfected in that short time period. But now that the vaccine supply has increased, we're really recommending that people get vaccinated anyway. The other thing that's really interesting is that people who've had COVID before mount a very good response after their first dose of vaccine. And it's quite possible that with a little bit more data, we're gonna recommend that if you had COVID before, you only need one dose of the mRNA vaccines. We're not there yet, we don't have the answers. Check with the CDC for the most updated recommendation.

Let's talk Fauci. You've known him for 30 years?

KW: So this has been great info. My last question is, I know, you're on a first name basis with Dr. Fauci. What is he like in real life? He's like this mythical hero to all of us doctors out here.

[laughter]

AP: So I've known him for about 30 odd years. We're not good friends or anything, but we've worked around some of the same diseases and have been in a lot of meetings together. He is incredibly smart. He is quite decisive, but in a very nice and humble sort of way. I will say that when I was a young HIV doc, I was in meetings with Dr. Fauci, I was pretty intimidated. But I was also full enough of myself to challenge him on a few things. I usually turned out to be wrong and he was right. He's mellowed with age. He's incredibly caring and thoughtful. For somebody who is one of the premier scientists of our age, he's also somebody who still goes on rounds or did until the COVID outbreak, and saw patients in infectious disease consultation. He really is certainly one of my heroes.

KW: Yeah. And I don't think many people knew his name before a year ago, and now he's definitely well-respected throughout the country, so that's pretty great. My last question is, how did we keep you in Utah, if you do all these national things? Is it the mountains?

AP: I'm not telling, but if you look in my garage, you might find a few clues hanging on the walls.

KW: You were one of my teachers in residency. I think I remember you riding your bike to work or biking a lot. Do you still do that?

AP: Yes. I try and get out on the road bike, the mountain bike, backcountry skiing, downhill skiing, all the great things that Utah has to offer.

KW: Right. Just don't tell the people from California. [chuckle]

AP: Yeah. No. It's terrible here. Tell the people from California that it's hot and dry, and crowded, and you can't get a drink.

KW: Right. [laughter] There you go. Well, thank you so much, Dr. Pavia. I think this was really good information for folks to hear. I really appreciate it.

AP: Well, thanks so much. It was great doing this with you.