California periodically touches base on the SARS-CoV-2 pandemic with John Swartzberg, a UC Berkeley Public Health Clinical Professor Emeritus and an international authority on infectious diseases and vaccinology. In October, Dr. Swartzberg was hopeful that forthcoming vaccines would be at least 70 percent effective; as it turned out, they far surpassed that figure, with both the Moderna and Pfizer vaccines approaching 95 percent efficacy. As the vaccine rollout continues, with varied success worldwide, we spoke with Dr. Swartzberg to get his take.
This interview has been edited for length and clarity.
A lot has changed since we last talked in late October. Could you give us some perspective on where we are now?
I have to say that it blew my socks off when it was announced in early November that Pfizer’s vaccine demonstrated 95 percent efficacy, followed shortly thereafter with the announcement that the Moderna vaccine offered essentially the same level of protection. And when the first vaccines were released around Thanksgiving, I started to feel that we finally had a way out of the pandemic. Nevertheless, fully half of all the deaths attributed to SARS-CoV-2 have occurred since November 1. The months since then have been deeply traumatizing. Also, that light we saw at the end of the tunnel in early December with the vaccine release was dimmed a bit by the vaccine rollout.
It was fumbled. I had a discussion with a senior person at the California Department of Public Health who said that public health agency economists determined the 50 states collectively needed about $8.4 billion for effective vaccine distribution and vaccination programs. But under Trump, the federal government only provided $400 million. The states simply didn’t have enough money to train people and put together reliable systems for vaccine transport and vaccination venues. And in California—and also in other states—this followed three decades of public health underfunding. So that created a perfect storm for the virus. The ability and capacity of state public health agencies to respond was greatly diminished, and the federal government proved to be actively destructive to the public process. There were some other issues—California, for example, tried to make the program socially equitable, and essentially succeeded in just making it excessively complicated. But the main problems were inadequate funding and the fact that the [Trump] administration politicized the Centers for Disease Control and the Federal Drug Administration. These agencies were once tremendously respected, and they’re not as trusted as they once were. Moreover, the White House was actively disseminating misinformation. This all created a certain inevitability for a botched rollout.
How would you assess President Biden’s response to the pandemic so far?
I think we finally have an administration that takes this problem seriously. Their approach is science-based, and they’ve unleashed the CDC and FDA from horrible politicization. They’ve also realized that you need to devote a lot of money to this pandemic, and they’re trying to secure it. It may not be apparent to people who aren’t following this as an academician, but there are many signs that things are appreciably better than they were three or four weeks ago. I think the public will start to see real fruits from these efforts by the end of the month, and March will be better than February. Not everything will be worked out by March, but I anticipate things will be running very smoothly by April.
While people are getting vaccinated, there have also been significant bottlenecks. In many states, it seems almost impossible to make an appointment—even for senior citizens or people with underlying health conditions. How long will this situation continue?
There’s still a problem with supply, but it is getting better. Right now, we’re closing in on 1.5 million vaccinations a day, which is even better than the goal Biden originally set of one million a day during the first 100 days of his administration. And we should be closing in on two million a day by the end of the month. On February 26, the FDA will get an opinion from its advisory committee on the Johnson & Johnson Janssen vaccine, and all indications are its recommendation will be favorable. That should be followed by FDA approval in early March. The J&J vaccine is also one dose versus two for the Pfizer and Moderna vaccines, it’s easier to produce, and it doesn’t have the stringent cold requirements of the other two vaccines. It can be shipped frozen at standard temperatures, and when it’s thawed, diluted, and put into vials for use, it can be kept in a regular refrigerator for up to three months. That’s going to improve supplies dramatically. J&J will ramp up as soon as they get approval, and they will be producing a lot of vaccine by April. So by sometime in April we could well hit a sweet spot where all the major logistical problems are worked out. We’ll have a robust and dependable supply of vaccines, and when that happens we won’t have any age or other special priority requirements for getting an inoculation. At that point, the major challenge will be convincing people who are vaccine-hesitant to get vaccinated.
Didn’t the Johnson & Johnson vaccine demonstrate less efficacy during trials than the Moderna and Pfizer vaccines?
There’s no real easy answer to that. True, its numbers weren’t as high in early trials. Pfizer and Moderna were 94 to 95 percent efficacious, and J&J’s overall effectiveness came in at 72 percent—but that is still quite good. And we also have to accommodate the fact that the Moderna and Pfizer trials were conducted during the summer. There was far less infection then, than in the fall and winter, when J&J ’s trials were conducted. Case loads during the J&J trials were astronomically high. Also, there were few known SARS-CoV-2 variants in the summer compared to the winter. In short, it was just a very different environment for the J&J vaccine, one in which it’s very challenging to demonstrate relative efficacy. Finally—and perhaps most critically—we have studies on around 80,000 people who have taken one of these three vaccines, and none have died from a SARS-CoV-2 infection. Some became ill, but not one died. So my bottom line message is that the J&J vaccine is very good, and is probably comparable to the Pfizer and Moderna vaccines. The important thing is to get vaccinated—with any of the approved vaccines.
You mentioned variants—how worrisome are they? Could they undermine all mitigation efforts?
They are concerning, and they could prove a setback. But I’m not worrying too much about them. We knew variants would be an issue when this pandemic began. This virus constantly mutates, constantly produces variants, but for myriad reasons few variants survive.
Right now we’re concerned about three major variants. The D614G variant emerged in Europe and was more transmissible than the original virus, and in six months it became the dominant strain globally. B117 is the United Kingdom strain that quickly became the dominant strain there. It’s 40 to 50 percent more transmissible than the original strain and was responsible for the UK’s horrific surge in December and January. It’s now in the U.S., mostly Florida and Southern California at this point. Of greater concern is B1351, the South African strain that seems as transmissible as B117 but appears less affected by the immune response induced by vaccines. And the same is true for P1, a Brazilian variant that’s mainly in the Manaus region at this point. It’s very similar to B1351. Now, our vaccines are still active against these strains—just not as active as we’d like. The good news is that we’re able to quickly produce booster vaccines to cover these strains, but that process would, of course, delay a return to normal.
So we’re at a critical juncture. We have these more transmissible strains, but we’re also seeing a downward trajectory in infections. So for the next six to eight weeks, we have to do everything we can to keep that decline heading in the right direction. We have to ramp up vaccinations, double down on vigilance, and maintain masking and social distancing even after vaccination. The only way to defeat this virus is by denying it hosts to infect. So we have to vaccinate as many people as we can as rapidly as possible, eliminating or at least greatly reducing the virus’ ability to spread and produce variants. And we have to persevere through this COVID fatigue that affects us all. We have to find the strength to maintain the non-pharmaceutical interventions—masks and distancing—that make a huge difference.
Looking to the future, will it ever be possible to eliminate SARS-CoV-2, as we have smallpox? Or will it always be with us?
Eradicating this virus is a very unlikely scenario. In the future, we’ll probably deal with it as we do with influenza. The influenza virus produces variants far more quickly than SARS-CoV-2, which is why we have to change vaccines every year. We don’t know yet how often we’ll need to adjust SARS-CoV-2 vaccines, and then re-vaccinate with a booster. One year? Two or three years? For the immediate and intermediate future, coexistence seems inevitable. With vaccines, some of us may get sick, but at least we won’t die. But at the same time, this virus has induced some cultural changes that can be seen as positive. Colds and influenza cases were greatly reduced this year because of COVID precautions. As a society, I think we’re generally living more cautiously. Masks, hand-washing, and social distancing have become normalized behaviors. And that’s going to serve us well in future pandemics. Because there will be future pandemics. Also, there’s a shift toward greater funding for public health now underway, and that’s directly due to COVID. The pandemic also highlighted the social and racial disparities that exist in our health care system, and it’s driving calls to remedy the inequities. And finally, the pandemic greatly accelerated scientific and medical progress. Because of SARS-CoV-2, I think we’re 10 to 20 years ahead in vaccines and viral therapeutics than would have been the case otherwise.