Dr. Bob Wachter, chair of UCSF’s department of medicine, held Grand Rounds today with Dr. Caitlin Rivers, the founding associate director at the Center for Forecasting and Outbreak Analytics, and Dr. Ezekiel Emanuel, co-director of the Health Transformation Institute at the University of Pennsylvania. As you might have guessed, data, planning and health policy were front and center.
Leveraging data — if we can access it
Throughout the pandemic, we have become familiar with data models predicting how the virus would sweep across the nation, when surges would take place and more. Recently, the Centers for Disease Control and Prevention opened its own center to “use data and analytics and modeling to support outbreak response,” said Dr. Caitlin Rivers, the founding associate director at the Center for Forecasting and Outbreak Analytics.
When asked by Wachter why such a center hadn’t existed before, Rivers said that though the CDC has always used data and analytics to perform outbreak response, “when there’s a public health crisis, it’s really been the responsibility of academics to provide that surge capacity.” However, in recent years, she said, it has become apparent that the CDC needs to institutionalize that function.”
The lack of data and analytics from the United States in the pandemic was “glaring early on,” said Emanuel.. One of the biggest issues he sees is access to data, because the CDC can’t compel jurisdictions to report their data — a predicament Rivers called “a pinch point, especially in an emergency” and an opportunity for growth.
The center’s $200 million in initial funding was “good, but not sufficient” in Emanuel’s eyes. “This is a several billion dollar a year effort, I think, if we’re going to get enough data and do the right surveillance,” he said.
Rivers acknowledged a need to grow the U.S. public health data infrastructure, but also called the $1 billion for the Data Modernization Initiative “a great start.”
In response to Wachter’s inquiry about the tension between prevention funding and the fact that the last global pandemic was 100 years ago, Rivers said that the United States needs to make investments in prevention because threats will arise.
“If you look at what happened in the twenty-first century, it’s been SARS, Zika, the anthrax attacks, Ebola, covid — it’s about every two years that we have these major health threats that actually threaten our national security,” she said. “We need to start looking at it not as something that comes around once every hundred years, but the way that we talk about hurricanes or the military.”
Emanuel found Wachter’s question amusing given that it came from someone sitting on an earthquake fault line. “Look, it’s going to happen sometime,” he said. Knowing the tendency to underinvest in prevention should encourage us to look to places like South Korea and Taiwan, which responded to the SARS epidemic by hiring more epidemiologists and improving their ability to collect data instead of rushing to put it in the back mirror.
“We are a big country,” he said. “We have a lot of resources.” He also noted that the $1 billion in data funding only equates to $3 per American. He recommended investing closer to $30 or $50 per person.
Monitoring the current state of the pandemic has also gotten more difficult as home testing affects reported case counts. Today, the primary metric of measuring the status of the pandemic is hospitalization and deaths because they are “what we have,” Rivers said. Even reporting those numbers will become voluntary as soon as the nation’s covid declaration of emergency is ended.
“That’s an under-explored element of how our ability to track the pandemic is shifting,” she said. Both Rivers and Emanuel said that wastewater monitoring will likely play an important role in future pandemic surveillance, though it too will require more investment.
Future variants and political divides
Both panelists see a potential new wave of cases in the future, especially given the recent rise in cases in the United Kingdom from an Omicron subvariant.
“Personally, I don’t foresee a large wave, which I take a little bit of comfort in,” she said. “But with this virus, it seems like you never know because things are always changing.”
The saving grace is that as the weather warms up, more people will be spending time outside which could “squash” the surge, Emanuel said. He predicted the likelihood of a new surge and variant this fall is between 25 and 50 percent, but fears people will be unwilling to adjust their behavior even if there is a new surge.
Emanuel felt the Biden administration “did fantastically well” in its first six months, but he remains concerned about the widening political divide that revealed itself during covid.
“This was a serious, serious threat, and yet it just divided us further,” he said. “That, I think, is a very, very ominous commentary on where we’re at.”
While there is some debate in Congress over how state and local jurisdictions spent covid funds, he said we still need to spend more money — he estimates $100 billion over the next few years — at the federal level to beef up surveillance, test different kinds of vaccines and therapeutics, and improve indoor air quality.
Boosters and therapeutics
Wachter also inquired about the necessity of a fourth shot, referencing an Israeli study that showed the benefits of a second booster against symptomatic infection “waned to zero” after two months. While Rivers said she recommended getting a fourth shot to the older people in her life, Emanuel expressed concern and said we don’t understand the long-term risks of immune exhaustion and long term protection.
“We have the world’s best immunologists right here in the United States, but it does seem like we haven’t prioritized understanding this in a deep way,” he said, noting that companies providing the booster can’t be relied upon because they have financial incentive to encourage boosters every six months. He also expressed the need to study long covid and its effects given how serious the issue appears to be.
“We need to think of research preparedness as part of our pandemic preparedness,” Rivers added.
Similarly, Emanuel pushed for more research into antivirals, as we currently only have two — one of which has lots of restrictions, such as not being viable for pregnant women. While he is enthusiastic about the antiviral Paxlovid, he is worried about breeding resistance in the future.
“We need to get a multi drug regimen that can be taken relatively quickly with a positive [test] and have a big effect,” he said. Such a regimen would “make a very big difference” for those who are immunocompromised, those who haven’t responded to the vaccine and those who experience breakthrough infections, to name a few.
Rivers expressed concern about equitable access to therapeutics, noting that “therapeutics are one of the tools in our toolbox, but they don’t replace the pandemic strategy.”
See our previous Grand Rounds coverage here.