Andrea Garcia, JD, MPH, on third dose vaccines for the immunocompromised [Podcast]

In today’s COVID-19 Update, a discussion with AMA's Director of Science, Medicine & Public Health, Andrea Garcia, JD, MPH, on COVID-19 vaccine numbers and trending topics related to the pandemic over the past week. Also covering third dose vaccines for the immunocompromised, vaccine recommendations for pregnant people and state-level approaches for students headed back to school this fall.

Learn more at the AMA COVID-19 resource center.

Speaker

• Andrea Garcia, JD, MPH, director of science, medicine & public health, American Medical Association

Unger: Hello, this is the American Medical Association's COVID-19 Update. Today we're taking our weekly look at the numbers, trends and latest news on COVID-19 with AMA's Director of Science Medicine and Public Health Andrea Garcia. I'm Todd Unger, AMA's chief experience officer in Chicago. Andrea, a lot's happened since we last talked a few days ago. The big news is about the FDA's authorization of a third dose of the vaccine for people with weakened immune systems. Can you give more details on who qualifies for that and how this would work?

Garcia: Yeah, thanks for having me, Todd. The FDA amended the EUAs for both the Pfizer and the Moderna vaccines to allow for the use of additional doses in certain immunocompromised individuals. They specifically called out solid organ transplant recipients or those considered to have an equivalent level of immunocompromise. That action allows physicians to boost immunity in those individuals who need extra protection from COVID.

Other individuals who are fully vaccinated are adequately protected and do not need an additional dose of COVID-19 vaccine at this time. We know the ACIP is meeting today. They are expected to vote on recommending additional doses of mRNA COVID-19 vaccines as a part of a primary series. So they're not putting in that language around boosters. It's really a part of the primary series for this population.

Unger: We'll have more information from Dr. Sandra Fryhofer, who we've heard from several times before about the ACIP's meeting. Andrea, when you talk about immunocompromised as a population, what kind of size are we talking? What portion of the population do those folks represent?

Garcia: So, I think this will depend in part on that specific language we see from ACIP but generally we're talking about 7 million adults or 2.7%, who are immunocompromised. And that usually includes people who've received a solid organ transplant, cancer patients, those living with HIV or those taking immunosuppressive therapies.

We know that these populations are likely to experience prolonged infection and shedding. They are more likely to transmit the virus to their household contacts. And they're more likely to have breakthrough infections. So, really the emerging data is suggesting that an additional COVID vaccine dose will enhance the antibody response in these populations. And I think Dr. Fauci really explained this well, when he said, "This is not considered a booster. It's part of what the original regimen should have been in these populations, since they need more vaccine to be protected than the rest of the population."

Unger: Again, we'll have more details from Dr. Sandra Fryhofer about the conclusions from the committee. Andrea, the CDC also upgraded its recommendation for pregnant people to get vaccinated this past week. What drove this change?

Garcia: Yeah. So, on Wednesday we saw the CDC strengthen their recommendation that pregnant people be vaccinated against COVID-19. They pointed to new safety data that found no increased risk of miscarriage among those immunized during the first 20 weeks of gestation. We previously had data showing that vaccine later in pregnancy was really reassuring in terms of safety and efficacy. But really now we were missing that gap in the early stage. Now that that has closed, we've seen CDC move from a permissive pregnant people can be vaccinated to pregnant people should be vaccinated. So, really the benefits here outweigh the risks. And I would just note that this recommendation by CDC aligns with what we've seen from both ACOG and the Society for Maternal-Fetal Medicine.

Unger: Does that have anything to do with the Delta variant?

Garcia: I mean, I think throughout the pandemic, we've been weighing risks and benefits and certainly with the Delta variant surging across the country, we know that there's low vaccine uptake among pregnant people. They're at increased risk for severe illness and complications due to COVID infection. So, really this recommendation to make vaccine for this population, it's more urgent than ever. So, just to reiterate, their COVID-19 vaccine is now recommended for all people 12 and older, including people who are pregnant, breastfeeding, trying to get pregnant now or might become pregnant in the future.

Unger: So, that is very simple statement and very clear, which is all people 12 and older, very important. So, speaking of vaccinations, are we seeing any movement in the numbers or improvement in the numbers this week?

Garcia: No, it's really slow going at this point that the numbers are inching upward. It's not significant. Daily doses administered continue to climb. We were administering about 608,000 doses on July 28 compared to around 729,000 doses on August 11. As of last Friday, the CDC reported about 196 million people who've received one dose of a COVID vaccine. That's 59.1% of the population. And that includes 167.1 million or 50.3%, who've been fully vaccinated.

Unger: Obviously, that's the number one tool for combating this pandemic. Unfortunately, with that moving so slowly, we are seeing the ticking of the cases and deaths, where do we stand with that right now?

Garcia: So, today we're at 36,305,005 reported cases and 619,098 reported deaths. Over the past week, there's an average of 124,200 COVID cases reported each day. That's an increase of 86% from two weeks ago. The number of deaths is up by about 75% to an average 552 deaths per day for the past week. Four states, Louisiana, Florida, Mississippi and Hawaii, have reported more cases in the past week than in any other seven-day period. And roughly 68,800 patients per day have been hospitalized. That's an increase of about 82% from two weeks ago.

Unger: Astounding numbers and quite a turnaround from where we were early in the summer. Timing could not be worse because here we are about to start school, many kids are already going back. Are we seeing an uptick in pediatric cases? I know I'm seeing a lot of the physicians from the AMA on social media saying that's the case and what are the numbers saying?

Garcia: Yeah. So, we are definitely seeing cases among children surging in the U.S. Doctors are reporting more critically ill pediatric patients than in any other point during the pandemic. We know, as more adults get vaccinated, the kids are making up the increasing share of COVID cases. So, the AAP reported that between July 22 and July 29, kids accounting for 19% of new reported cases of COVID. And the children entering the hospital with COVID, those numbers have been climbing and we're nearly matching those levels from earlier in the pandemic at the peak in January.

Unger: The Delta variant is of course predominant at this point, almost all the cases at this point, over 90%. Are we seeing more severe illness in children than we were before?

Garcia: I don't think we have the evidence to conclude that at this point, that it's resulted in more severe disease in this population than other variants. I think what we're seeing is that Delta is more contagious, that people under age 12 are not yet able to be vaccinated. So, we are seeing more kids hospitalized. I think that makes sense. If you have more cases, that's going to trickle down to kids who aren't yet protected. And the best thing we can do at this point is to make sure that those who are eligible for vaccine, who are around kids, are protected and are vaccinated.

Unger: I'm sure this is obviously going to impact back-to-school plans. You've got governors basically refusing to have a mandate for masking in schools, things like that. It's pretty confusing. What are you seeing out there in terms of back-to-school plans?

Garcia: Yeah. So I think what we're seeing is really a patchwork of public health intervention emerging across the country. This, it's highly contentious, there are a lot of debates going on and a lot of anxiety among families, teachers and education officials. Most of these are centering around vaccination and masks. We know President Biden and federal health officials are emphasizing that remote learning isn't the answer here, that we really need to open schools full-time this fall. And I think in order to do that, and in order to not have most of the class in quarantine, that we have to take some public health interventions and make that in-person learning.

Unger: There is really a spectrum here in terms of how states are reacting on one end, as I talked about before, you've got Texas and Florida that are saying no to mandates. On the other end, you've got some states that are far more proactive. What are you seeing there?

Garcia: Yeah. So, we're starting to see some requirements come into play in a few states. So, California is requiring all teachers and staff members to either provide proof of vaccination or to be tested weekly, that applies to both public and private schools. Hawaii is requiring all state and county employees to be vaccinated or tested. So that includes public school teachers. Denver has said that city employees, including public school teachers, must be fully vaccinated by September 30. We're also seeing a few states implement mask mandates for schools. So, New Jersey, California and also right here in Illinois with mask mandates for schools are in place.

Unger: So, for those states that are seeing roadblocks to mandates, what kind of actions are occurring there?

Garcia: Yeah. So, Florida, Arizona, Texas, some of the places where we're clearly seeing a surge, they are forbidding districts from implementing some of these public health measures such as mask rules. They're really casting these requirements as an infringement on personal freedom and parental rights. I think this is a concerning trend that we're seeing play out across a number of jurisdictions. We've talked about how public health officials are being threatened and harassed but we're also seeing them being stripped of their authority to take action to protect the public.

In some places in Texas, we're seeing counties like Dallas that are putting forth legal challenges to the governor's mask prohibition. So, I think the question there is going to be whether the local health authority or local officials have that ability to adopt evidence-based rules to protect the health and safety of their local communities. We know Dallas public schools and others are really opposing the mask ban and they're planning to require everyone on school property to wear a mask. This'll certainly be playing out in the courts moving forward.

Unger: Yeah. And we're seeing, I mean, there's a lot of activity in the court and I think yesterday's Supreme Court ruling that basically the Indiana University vaccine mandate is still in effect and won't be challenged.

Garcia: Yeah. That's right. I mean, that was the first case of a COVID-19 mandate to make it to the court. They're really upholding that Seventh Circuit opinion there and saying that mandate can stand, which we know is consistent with Jacobson v. Massachusetts.

Unger: So for that level of education, at the college level, that's a pretty important ruling, but as you're pointing out, at the younger school level, we still have a lot of action there. One of those is that the nation's largest teachers union just came out to support the policies that would require teachers to get vaccinated or submit to regular testing. What's the news there?

Garcia: Yeah. So, the National Education Association endorsed COVID-19 vaccine requirements for school workers. This is a shift, which could make widespread vaccine requirements for teachers more likely. I think this is notable because they represent about 3 million members across the country, including many in rural and suburban districts, where vaccine mandates may be lower. Obviously this is still a decision that will be made by local and state officials, whether or not to mandate vaccines. But I think this is an important position for them to take and will be influential.

Unger: So I think one of the thing we're learning is the situation is fluid. The solution continues to be to increase vaccination rates at this point and we'll be paying attention to the latest rulings as the courts see more action here. Andrea, thanks for being with us today. That wraps up our COVID-19 Update. We'll be back with another one next week. In the meantime, for resources on COVID-19, don't forget to visit ama-assn.org/COVID-19. Thanks for joining us. Please take care.

Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.