Stephen Parodi, MD, on shifting from pandemic to endemic [Podcast]

In today’s COVID-19 Update, AMA Chief Experience Officer Todd Unger talks with Stephen Parodi, MD, the executive vice president of external affairs, communications and brand at The Permanente Federation, and associate executive director for The Permanente Medical Group in Oakland, California, about pandemic vs. endemic and what that shift will mean for our COVID-19 response.

Learn more at the AMA COVID-19 resource center.

Speaker

• Stephen Parodi, MD, associate executive director, The Permanente Medical Group

Unger: Hello, this is the American Medical Association's COVID-19 Update. Today we're talking with friend of the show, Dr. Stephen Parodi, executive vice president of external affairs, communications and brand at the Permanente Federation, and associate executive director of the Permanente Medical Group in Oakland, California. We're going to be talking about the move from pandemic to endemic over the coming months. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Parodi, I remember very distinctly, about two years ago, the last conference call that we had in our office at AMA headquarters was with you, where we kind of huddled around and listened to your early reports from the front lines out on the west coast about the pandemic and how you were approaching it. I'm glad to say that two years later, we're talking about coming out the other end here and I'm eager to hear your thoughts about this shift from pandemic to endemic. Why don't we just start by talking, what's that mean?

Dr. Parodi: Yeah. Good to be with you Todd and talking in the context of a lot more people being actually vaccinated today than what of course, was possible back in 2020. What I think of when, as an infectious disease specialist, an endemic, it means that the disease is still around but that it's at a level that is not causing significant disruption in our daily lives. That being said, endemic disease can be at different levels, and of course, we've lived with endemic diseases in the past, right? We've had measles, mumps, rubella. Before we had vaccines available, those were endemic as well. What's different about COVID-19 is that we do have a choice now about the level of endemicity.

So, endemic diseases can be at high levels. They can be at lower levels. So, where I think we're at a crossroads is that we have an opportunity to actually get that to a lower level, manageable level, where we're not getting impacted in our hospitals, not having to close down schools, close down businesses. That really is through a combination of a concerted effort around testing, vaccination, isolation, quarantining, that looks a lot more normalized than what we've had to do over the last two years.

Unger: Now, you talked about some of those formerly endemic disease or endemic diseases that are very serious. Do you think we're going to end up more in like influenza territory here?

Dr. Parodi: I think what we saw with the latest surge, with Omicron, in particular, the vaccinated population and the ones that have received boosters, that for the most part, people had mild disease or asymptomatic disease. So, I think that it's within our grasp, particularly with the populations that are currently eligible for boosters, that if we get that word out, get people's arms with that booster in tow, that we can move this in a way that the disease is milder. Of course, that's all caveated with the fact that we could always have another variant around the corner. But the hope here though, is that at least so far, vaccine-based immunity appears to provide very broad-based immunity against multiples of variants.

Unger: How do we know when we've officially hit the endemic stage with this virus? There's not going to be some alarm. I think everybody thought there would be kind of a, more of a distinct line drawn here. What are the signals?

Dr. Parodi: So, I think actually, the CDC's recent guidance gives us a bit of a pathway for where that's heading. So, for example, initially, with the pandemic we were, and really up until now, have been measuring infections in the community as a marker for whether or not there's significant impact from COVID-19. This shift to looking at it from a severity of disease standpoint, I think is actually important. I actually endorse that, where we're measuring based on hospitalizations and the number of people perhaps populating intensive care unit related to COVID-19. I think that's actually relevant. It is following the science, because of the effectiveness that we're seeing with vaccines. So, I think, a measure of endemicity really is going to look at how many people are developing severe disease at a given time. If we're seeing increases in that, we've got to take action. If we're not, that's a different set of actions, and that's similar to what we do for influenza year over year.

Unger: How does immunity, which I just saw a statistic kind of trying to estimate, pretty significant population of folks that have had COVID, and now we have vaccines and Omicron. How do those all come together to drive this shift?

Dr. Parodi: That's a great question. So, what you're getting at is that there's a mix of vaccine-based immunity and a natural-based immunity. Both have actually, their parts to play here, in my opinion. So, the vaccine provides that broad-based immunity. It also appears to be protective against really severe disease. We also have data that if people had "breakthrough" infections, they got Omicron on top of having been boosted, that they actually have an even more robust immune response at post-infection. For those that haven't been vaccinated and have had natural infection, they have at least some narrow-based immunity to that particular variant that they got infected with. We now have enough data to say that those folks are still susceptible to other variants, perhaps down the road.

But what we're really getting at is that we're getting, over time, a more immune population. So, we've got populations actually in the U.S. here, that now have up to 90% of the population is actually vaccine-based immune. Then you add the natural immunity on top of that and you're heading towards a place where you are going to, I think, start to see a leveling off, again with the caveat that hopefully we don't have another variant out of the blue, like Omicron.

Unger: Yeah, I keep thinking myself, fingers crossed, every time we say that and let's hope that we have indeed a window here. One group that isn't eligible yet for vaccines, still waiting for authorization, for younger children under five. How important is it that this population be vaccinated, to the move toward endemic?

Dr. Parodi: I think actually, vaccine-based immunity for children is critically important, from a couple of perspectives. So, it's obvious for those children themselves, that they need the protection, even though they're less likely to develop severe disease. They can. So, being able to protect those individuals themselves is important. But on top of that, it impacts people, parents. Can I go on a trip? Can I go out to dinner? Can I send my kids to school? That's all important. Of course, it's not just the parents. It's also the other children in the household who, even though they have vaccine-based immunity are still being potentially exposed or could expose those children at home. So, knock on wood, I'm hopeful that we do have some recommendations in the near future for the six months to four-year-olds to get vaccinated. I do think that is a part of coming out of pandemic stage and more of an endemic stage. Really, the hope would be over the next couple of months that we do have good news on that front.

Unger: Well, speaking of, kind of coming out of the pandemic stage, we've been through mask mandates and we've had pretty large-scale shutdowns that are not often part of an endemic conversation but vaccines are and will remain. Do you see vaccine mandates playing a role as we progress into this stage?

Dr. Parodi: So, vaccine mandates actually played a role, particularly in the health care sector, and actually remain enforced, based on some decisions that were made at the national level over the last couple of months. I think that has actually been important. I can speak to our experience that we've had less people get breakthrough infections and infections altogether because of the fact that the health care workforce is now largely vaccinated. There have been employers who have also pushed the vaccine mandate, even though, and this was before the Supreme Court rendered its decision, I think that's also played a role in blunting the effects of Omicron, particularly with our hospitalization rates. Do I see that as a future forever? Hard to say. I think we need to follow the science. We need to understand, with future boosters, what's the level of effect with immunity? What's the level of effect with preventing additional surges and then being able to make decisions at that given point in time.

Unger: Well, your home state, California, recently became the first state to formally shift to this kind of endemic approach. Are you in agreement with this approach and how important is it to have kind of buy-in at the state level, as we move in this new direction?

Dr. Parodi: So, I think actually this is the time to be having that conversation about moving to an endemic state and having those collective conversations. So, certainly all public health really boils down to local decision-making. So, for the state to actually take a step and initiate that conversation, so that systems, physicians can converse with their public health colleagues and actually come up with a unified response that is then explainable to the general public, I think, is critically important. Some of the steps that were outlined in the California recommendations, I think, are highly relevant. When I think about testing, we've taken a very broad-based approach to testing that really has melded both public health and community health, as well as basic medical care, all in one. It's time to probably move beyond that.

So, for example, I'll just give you one, with California. They're going to do surveillance testing on wastewater to understand whether there's an increase in number of variants that are recoverable or PCR-positive samples, as a way of telling us whether we're actually starting to see increased activity in the community, as opposed to requiring and putting on the backs of our patients, or even us, as physicians, to do broad-based surveillance testing, particularly with the shortages of tests that we've had available. So, it's working towards getting to a more sustainable approach, making sure that therapeutics and masks are available when we need them and setting those thresholds, whether it's hospitalization rates or ICU rates and then saying, this is the time to put on the masks and then when you're below that threshold, take off the masks.

Unger: Speaking of therapeutics, how does the presence and hopefully the appropriate supply of treatments, help power this shift? Do we need to get better in those areas? What's holding us back?

Dr. Parodi: No question that we got to get more therapeutics available and it's not just the monoclonal antibodies. I think that when you're talking about an endemic state, you've got to have the backstop that helps patients beyond just the vaccine or here's the vaccine and prevention is, of course, the best medicine but people are going to get ill in endemic setting. Ideally, these therapeutics, many of them are given before somebody requires a hospitalization. That means you've got to have them at your fingertips. So, I think there's work to be done nationally, with the manufacturers, to make sure that we have enough supply available if we need to stockpile for particular exacerbations and anticipate that we might have states where we have higher-prevalence situations that the state governments and federal governments are preparing for that as well.

Unger: What role do you see large health systems like Permanente playing, as this shift begins?

Dr. Parodi: So, I think a couple of things. One, is the importance of messaging about what number one, endemic means but number two, what we're doing with isolation, quarantine, testing, and therapeutics and vaccination and countering the misinformation and disinformation that's out there. I think we have a responsibility as a system, as individual physicians, to continue to combat that. The more that we can have a unified voice with public health will help counter those messages. I'll be honest with you. I think that we, as physicians, got to get out there on social media and have our own voice out there. So, I think that's one big way we can affect change. Then also, informing public policies, so informing some of these plans that you were referencing earlier, both at the national level, and then at our state levels or state medical associations, that's another place where we can have tremendous influence.

Unger: Now, I'm just curious. Operationally and practically, how are you preparing for this shift at your own system?

Dr. Parodi: Well, that's a great question. So, by the way, this is a massive shift. I mean, you think about the mindset that we've been in over the last two years, and with all the changes in guidelines and changes in strategies. I think the last time we talked, we were still talking about maybe trying to contain this thing or eradicate it. Right? Then it was all about mitigating it. Now we're talking about living with it. So, that is a mind shift and it's not like a flip of the switch. So, it really is requiring conversations all the way down to the clinic unit level, and talking through people's concerns, and it runs the full gamut in spectrum. Some people are already done with this. They've already taken off all the masks. There are other people who are not comfortable with that at all. So, being able to talk through those things and then also talk through the reasoning about why things are different now, here in March 2022 as to March 2020.

Unger: Yeah. One of the things, obviously, as we've talked over the last two years, that characterizes this time is just the constant learning, new evidence, new science driving changes in how we approach this. Are you finding the people can still hang on with more learning about this mental shift?

Dr. Parodi: So, let's be honest. People are really fatigued. They're pretty tired here. I think they're also tired of the change from literally day-to-day, where the recommendations were flipping back and forth. So, one of the things that we've been doing is we've heard that and to commit to, we're going to try to normalize actually, the recommendations and we're not necessarily going for complete perfection with the latest paper that was printed yesterday as a pre-print. But, to follow what the generalized evidence is, and to try to stick with some general guidance, short of, again, something coming completely out of the blue. I think that's really important. I think people need some stability, recommendations. That has been some of the messaging that we've been providing both internally at Permanente but also to our public health colleagues, that we actually, can we try to stick with some recommendations for some longer period of time than we've had in the past?

Unger: Yeah, I'm sure. In the look back at this, the whole subject of message will be a very, a fruitful area to explore, since it's just been such a challenge over the course of these years. When you talk about the mental shift too, there is this element that needs to be put in context, which is about risk. I had a chance to talk to Dr. Paul Offit, the pediatrician last week. He's just written a book about risk and medical innovation, and one of the things that he said was just, people are really bad at assessing risk and they put too much emphasis on the risk of the treatment, as opposed to the risk of getting it. How, talk to me about how you're thinking about risk and how you're advising people on that now.

Dr. Parodi: So, let me give you an anecdotal example of this. So, I remember a meeting where we were talking about, can we be in-person, as opposed to being virtual? It was a meeting that, it's relatively important, and again, as much as we've got technology available, there's nothing like being able to be in the same room, read people, break bread, literally break bread. You actually eat together. There was again, a spectrum people who were, they're ready to do it and then there were other people who weren't. So, what we ended up doing is, I said, "Let's actually go through a little bit of an exercise," and everybody's fully vaccinated in the cohort we were talking about. We said, "What's the relative risk of you potentially catching COVID if have an in-person meeting?"

Then, "What's your relative risk of getting into a car accident? Are you driving today? Are you going to go someplace?" When we compared those two risks, people are like, "Oh, okay. I'm ready to come to that meeting". It's almost like, as human beings, we got to be able to contextualize risk because I think when you just throw out numbers and say, "It's one in 1 million or one in 2 million," you don't know what that really means. So, I think we actually have to get to levels of being able to talk to our patients, talk to the general public, in ways that it are much more consumable and understandable.

Unger: You mentioned earlier in the conversation, there's always kind of an asterisk after what we say, which is, provided there's not a new variant. Do you feel pretty prepared should there be a development on that, and about how to kind of shift quickly back into the pandemic mode or prevention mode to prevent something like this from happening again?

Dr. Parodi: So, I think that actually that is going to be one of the big learnings coming out of this whole experience, is that we need to be better prepared. I am encouraged, actually. I'm looking at this from like a national policy perspective that hopefully they're going to move something called the Prevent Act forward, which is actually to have a better prepared public health infrastructure, in making that investment in, from a standpoint of a large health system and in our physician practice at Permanente, we are definitely reevaluating, what do we need to have to be able to spring into action? We've got experience in this, again. We prepared, before all of this for our annual flu season.

Now we've got to be prepared for potential COVID ups and downs that are not tied to a season. So, that's actually has been some of the operational discussions that we've had. It's, okay. How can we turn on the isolation, turn on the search capacity, and do it, rather than doing it as an emergency response. It's part of actually our normal business-related response, our normal health care response, when something comes up,

Unger: That is going to be so important. Dr. Parodi, I just want to say thank you for your continued thought leadership over these couple of years and thanks to you and the folks at Permanente for all the work you've done to help us, hopefully, merge into this endemic period. That's it for today's COVID-19 Update. We'll be back with another segment soon. In the meantime, for more information on COVID-19, 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.