Podcast: After a year of COVID-19, vaccines making life better but it’s not over

Jim Dryden (host): Hello, and welcome to “Show Me the Science.” Conversations about science and health with the people of Washington University School of Medicine in St. Louis, Missouri, the Show Me State. As we continue to detail Washington University’s response to the COVID-19 pandemic, we’ve reached the one-year mark, both of the pandemic and of this podcast. And as we begin our second here, we’re catching up with our very first guest from our first episode. Dr. Steven Lawrence is an infectious diseases specialist who was heavily involved in trying to prepare for the pandemic as COVID-19 spread around the country and around the world. Back when we first spoke to him last March, we knew that the disease caused by the novel coronavirus could be serious, even deadly, but not a whole lot more.

Dryden (in 2020): With COVID-19, is there a symptom that’s a tipoff, or is it still so new that we just don’t know?

Steven Lawrence, MD: Unfortunately, we can’t tell just from the illness if it is COVID-19 or if it’s one of the many other respiratory viruses that are circulating now and every year.

Dryden: As lockdowns began last spring and toilet paper and hand sanitizer vanished from store shelves, people were on edge about this new and strange virus. Some of those nerves have subsided after a year, in spite of the fact that in terms of reported numbers of infections, it would seem that there are as many or more infections now as there were last March.

Lawrence: When we look at the numbers of diagnosed cases now compared to a year ago, back in March and April of last year, there is very little testing capacity. So we were only identifying the sickest of the sick patients and really the tip of the iceberg. There were many, many more. In fact, estimates were at least 10 times as many cases than what were identified by testing.

Dryden: Now, there’s not only more testing available, there also are vaccines, as well as some promising treatments for people who do become infected. Looking back, Lawrence says last March he really had no idea what we were in for.

Lawrence: Well, I think that there was so much uncertainty at that time. And we were so busy trying to craft an immediate response that we really didn’t have that much thought about how long it would be. However, the 1918 influenza pandemic, there were three waves of serious activity and some ongoing disease transmission in between those waves. And so many of us who had been thinking about flu for a long time recognized that it might be longer, where we would have some altered operations. But (it would have been) really hard to have imagined even back then that it was going to be more than a year.

Dryden: When we spoke last March, the lockdown was just beginning. And when I asked you what your greatest concern was, you talked about having the staff and the stuff to provide the care that patients were going to need.

Lawrence (in 2020): I think the most feared consequence of this epidemic is having a large number of sick patients presenting to our hospital and not having the staff, the stuff, basically equipment like ventilators, and the space to be able to provide care for everybody who needs it.

Dryden: And now, a year later, how do you think we did it, at least here in St. Louis and at Barnes Jewish Hospital?

Lawrence: In our region, we came close to our capacity when we were at our peak of activity in April of last year. But again, we were fortunate that all of the measures that were put into place were put into place probably just in time. And so, as scary as it was at the time and uncertain about how effective they would be, it’s turned out that those really draconian measures up front were necessary and just in time.

Dryden: A year ago, a lot of people were panicking a little bit. Just remember what the toilet paper isle looked like at the grocery store. And I think now we’re more relaxed. Some of those early issues have been resolved. But should we be relaxing? I mean, the actual number of cases seems to be at least as high, even higher than it was then.

Lawrence: Once anybody is living in a situation that’s different and scary and you’ve been in it for a while, you become more accustomed to it. And we fear most the unknown. And going into the lockdown phase from a year ago, there was a tremendous amount of unknown. How bad could it get? Would I become sick? And believe me, health-care workers were scared, too. That’s one reason why the scale of it, when you look back, why we maybe don’t have that sort of daily fear as much as we did a year ago. But another thing, too, that’s really important to remember is that when we look at the numbers of diagnosed cases now compared to a year ago, back in March and April of last year, there was very little testing capacity. So we were only identifying the sickest of the sick patients and really the tip of the iceberg. There were many, many more. In fact, estimates were at least 10 times as many cases than what were identified by testing.

Dryden: Now, I noticed a couple of things when I listened back that we didn’t talk about. One of those things was masks. The other was vaccines. And my hunch is that you probably think we did pretty well in one of those areas and maybe not quite as well on the other. But rather than presuming what you might say, I want to ask you.

Lawrence: Well, the vaccine story is going to be one of the world’s greatest public health triumphs, that you went from the worst pandemic in 100 years, a novel virus that had never been seen before. And within 12 months, we went from the first cases having been identified to having a vaccine, then safe, it’s effective. And millions of people getting the vaccine all within 12 months is nothing short of miraculous. It went as well as it possibly could have. And it is not, I believe at this point, an exaggeration to say that they are the game changers that will allow us to put this pandemic in the rearview mirror.

Dryden: What about masking? I mean, there was debate at the start about how effective it might be. I don’t think there’s really any debate anymore, at least among doctors and scientists and health-care providers. But masks became a wedge issue rather quickly.

Lawrence: The mask issue is probably a case study of things to learn and how to do it right and how not to do it. The early guidance did not have strong recommendations for needing masks. A year later, who would have thought that face masks would become a separate industry. So that infrastructure didn’t exist. And so when there was uncertain benefit and a certain risk of running out of critical PPE supplies for health-care workers, the early recommendation was that widespread mass use in public wasn’t necessary. Well, it was necessary. And the messaging, had we had better data, certainly could have reflected it. And we did get that data within a few months. However, some of the initial messaging may have led to confusion. The idea of mask wearing was not to take away any one individual’s liberating, it was to prolong the life of our neighbors and to allow them the chance for liberty and to protect their lives.

Dryden: I know, for myself, I didn’t get the flu this winter. I haven’t had a cold. Part of me is thinking maybe we should keep these masks.

Lawrence: So there are a lot of people thinking about the new normal. And I strongly believe and would urge others as well to think about the future as a new normal and not think about going back to normal. We’ve been given the chance to reset, and I think a lot of this is certainly what we’ve learned about pandemics. I think a lot of this, too, from a pandemic perspective and from a systemic racism perspective, there being fewer cases of flu has been a remarkable story. There are other respiratory viruses that have almost disappeared this winter because of all the measures that we’re doing — masking, distancing, limiting gatherings has led to by far the least active influenza season and most other respiratory viruses, too. Most every respiratory virus that we track, we’ve seen fewer and almost none in some instances than any season since we’ve been recording. Influenza each year is responsible for tens of thousands of deaths, and this year it’s been almost nonexistent. There may be some reasons to believe that some of the things that we’re doing now, maybe not to this extreme, but some of the things as far as having less frequent in-person meetings, being sure that nobody comes to work sick, which we’re all doing now, right? Those who are working in person may have to go through screenings and make sure that they’re not coming to work ill with symptoms. Even sometimes even consider wearing masks when together with a lot of other people in person when it’s necessary. These things combined, we may want to keep some of these to make our winter and respiratory virus seasons less impactful. I mean, who wouldn’t want to avoid a few colds a year? I mean, that sounds like a great idea. Obviously, we don’t want to have to live under the same types of conditions that we’ve been in, to this extreme. But some of these features might not be too onerous to continue on a limited basis during winter flu and cold virus season.

Dryden: There’s a saying in snow skiing and water skiing, that you really don’t want to get out ahead of your skis. And now, as some states are reopening and restrictions are being reduced or eliminated, I feel like maybe as communities or states or countries, maybe in some areas we’re getting out ahead of our skis. And I know it’s painful. A lot of people haven’t seen family members, some for a year now, haven’t had a chance to hug grandma, that sort of thing. And I wonder if as communities, there’s a danger that if we do get out ahead of our skis, so to speak, we may end up delaying those reunions even longer.

Lawrence: Yeah, we are at risk of getting ahead of our skis and especially in the next two to three months, while the vaccine is being ramped up and it’s still not available to everybody who needs one, which is everybody. We’ve got a few months yet where we can see a reversal of this decline in the last two months. It’s unfortunate, too. And I think one of the other lessons learned through this year is that as with so many other things that have become so polarized, there seems to be an argument in the media that there were two possibilities. That there was the approach that we must lock down, we can’t do anything, versus the approach of too many people are losing jobs and losing their livelihoods, and businesses must be open. So we’re not going to have any restrictions. And while there could be some little subtleties on the margins, there really have been two very polarized camps. And so it’s been a frustrating part of this. And another lesson learned that we could have done a better job across the country with, messaging the middle ground of taking rational precautions. We can start to slowly ratchet back these layers of mitigation that we’re using right now. But they’re layers, and we have to slowly peel them down one by one in response to declines in our transmission rates. And we have made a lot of progress in the last two to three months, which appropriately some of those layers are being peeled back right now. But any sort of mass abandonment of particularly universal masking right now is going to be potentially very dangerous.

Dryden: So we can assume, I guess, that in the next couple of months, more and more people are going to get vaccinated. But we’re also going to see the spread of new mutant variants of the virus from the UK, from South Africa, from Brazil, other mutant forms. What does that do to the concept of being protected either by vaccination or by prior infection with the virus this year?

Lawrence: It’s too soon to tell the impact. There are a few things we know. These viruses mutate, form new variants. This is something that happens all the time. Some of those variants may have a competitive survival advantage. In other words, they may be more efficient pathogens of human hosts and that may mean that they can transmit more easily as the B.1.1.7. strain that originated from the UK. That one is one that seems to have a competitive advantage. It is in most places where it’s been introduced becomes the predominant variant, and it’s starting to do that in the U.S. and is likely to continue to be so. But the impact on our overall trajectory is a little unclear. There is concern, it’s well-placed concern that the increased transmissibility of it could lead to a bump in our number of cases. It’s a bit of a race versus time if we can get enough people vaccinated so that there’s less sort of fuel for the fire of this new variant to be able to find new people to infect. If there are fewer people who are susceptible, then the impact of that new variant will be much less. But to date, the data that we have would suggest that vaccines do still have an impact at being protective even versus those other strains may be reduced from that, but still appreciable protection versus severe disease. So these variants are definitely important to monitor. However, it is not necessarily indicative that they are going to materially change the course of the pandemic. If we can continue to ramp up vaccine delivery and reach numbers closer to 70 to 80, 85% of the population being vaccinated, those variants then become less of a risk.

Dryden: Have we learned anything from this pandemic as it’s unfolded that can be applied to the next pandemic? Because I’m guessing there’s going to be a next pandemic.

Lawrence: There are so many things that we have learned. And also it’s humbling because many of us have thought about pandemics and have studied prior pandemics, particularly with influenza. Things that you think you know may not apply. And there will always be new things that pop up. So lessons learned include being able to collect and listen to the data and to have your eyes and minds open to be able to adjust quickly when new data emerge. One thing that has always been known with this sort of emergency management 101 is the importance of risk communications. We’ve known this forever, but despite knowing that, there were still many mishaps in effective leadership, not always having our leaders be clear, be transparent, say what you know, say what you don’t know, give clear guidance that is driven by data. These types of risk communication fundamentals were inconsistently used throughout the pandemic, and it is fair to say that had there been much more uniform leadership throughout this, that there would be far fewer deaths.

Dryden: Like many medical officials, Lawrence says that at the one-year mark, he feels optimistic. But he says we’re not out of the woods yet. With effective vaccines available, there’s a real chance to move past the pandemic. But he says people have to get the vaccine. And until most of us do, he says, the rules remain the same. Wear a mask, avoid large gatherings, wash your hands, and maintain safe social distances for at least a little bit longer. “Show Me the Science” is a production of the Office of Medical Public Affairs at Washington University School of Medicine in St. Louis. The goal of this project is to keep you informed and maybe teach you some things that will give you hope. If you’ve enjoyed what you heard, please remember to subscribe and tell your friends. Thank you for tuning in. I’m Jim Dryden. Stay safe.