200 Million Vaccines and Counting: Emory’s Dr. Carlos Del Rio on Effort To Target Vaccine Resistance

Dr. Ca rlos D el Rio - 20210419RiosXM

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Marianne O’Hare: Welcome to Conversations on Health Care with Mark Masselli and
Margaret Flinter a show where we speak to the top thought leaders in
health innovation , health policy , care delivery and the great minds
who are shaping the health car e of the future. This week Mark and
Margaret speak with Dr. Carlos Del Rio Executive Associate Dean at
Emory University School of Medicine and Foreign Secretary at the
National Academy of Medicine. Dr. Del Rio is a renowned infectious
disease thought leade r with a long bench of research around HIV AIDS
and now COVID , Dr. Del Rio is concerned the next phase of
vaccinations , planning of supply , more reluctance to get the vaccine
w ill pose challenges for full containment of COVID - 19.

Lori Robertson checks in , the Managing Editor of FactCheck.org , she
look s at misstatements spoken about health policy in the public
domain , separating the fake from the facts, and we end with a bright
idea that’s improving health and well - being in everyday lives. If you
have commen ts please e - mail us at [email protected] or find us
on Facebook , Twitter , or wherever you listen to Podcast and you can
also hear us by asking Alexa to play the program. Now stay tuned for
our interview with Dr . Carlos Del Rio here on Conversations on Health
Care .

Mark Masselli: We're speaking today with Dr. Carlos Del Rio , Executive Associate
Dean of the Emory University School of Medicine, Distinguished
Professor at the Division of Infectious Disease and Profe ssor of Global
Health at the Rollins School of Public Health.

Margaret Flinter: Dr. Del Rio is Co - Director of the Emory Center for AIDS Research, Co
Principal Investigator of the Emory CDC Clinical Trials Unit, and he's
also the Foreign Secretary of the Na tional Academy of Medicine. Dr.
Del Rio, we welcome you to Conversations on Health Care today.

Dr. Carlos Del Rio : Happy to be with you.

Mark Masselli: Well, that's great. And I think we all know that the U.S. vaccinations
are accelerating, b ut there are s ome headwinds. We recently learned
that the FDA is still analyzing the risk factors with the J&J vaccine. And
many are concerned that this might lead to or might add to some
vaccine hesitancy. And we've seen in our own health system, a slow
number of peopl e were starting to cancel out, as a result, we really
welcome your views on the J&J delay and what recommendations you
expect to see from the FDA panel moving forward?

Dr. Carlos Del Rio: Well, I think I think there are a couple of issues. Number one, the
vaccine induced thrombocytopenia and thrombosis that we're seeing,
both fir st with the AstraZeneca vaccine and now with the J&J vaccine

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is interesting, because it's occurring with two adenovirus vector
vaccine s . And therefore it makes us think that somethi ng is related to
that vector. It also is very, we're not seeing the similar thing with the
mRNA vaccine s . The other thing is that it seems to be a side effect
that is more common in women and particularly in younger
individuals under the age of 50. So what could happen here in the U.S.
with J&J is a little bit what happened in Europe with the, you know,
the regulatory agency, the European Medicines Agency, which is the
FDA equivalent, is they have said, look , this is still a very useful
vaccine, the side ef fect is very uncommon, but in certain groups i t s
more common than others. So don't use this vaccine on people under
the age of 50. And, and may be that the Johnson and Johnson decision
here in the U.S. is very similar. Will they also say, this is not a vac cine
for young women? Maybe it can be okay for men, but not for women.
I think we need to see what a little further analysis of the data shows.
But I want to emphasize that, you know, for the U.S. , we can, you
know, it'd be nice to have this vaccine especi ally J&J because it's a one
dose vaccine. But we have plenty of the other vaccines .

I'm more concerned about, about the impact this has globally,
because AstraZeneca, in particular, was a very important vaccine
globally. And I want to emphasize that this i s still a very useful
vaccine , i t ’ s still an effective vaccine, we shouldn't discard it, and the
side effect is there. But what is very rare, and when you have a
pandemic that has ki lled globally 3 million people. We have to take
that into perspective. And we have to say, well , you know, at some
point in time, the vaccine benefit outweighs the risk , and that is the
case.

Margaret Flinter: Well, Dr. Del Rio, it's almost hard to imagine thinking back over these
last few months, that very soon we're going to b e in a place where the
supply of vaccines probably exceeds the demand for vaccine here in
the United States, which is a huge accomplishment, but it would be a
better accomplishment if it wasn't in fact, in part due to the fact
there's still so much vaccine hesitancy and vaccine resistance here in
the United States, and I wonder if you could comment on the degree
to which this what seems to be quite entrenched vaccine resistance
among a significant portion of the population is going to impact our
ability to really bring this pandemic under control in the United
States? And are you working on any creative strategies or new
strategies that you think might help overcome those pretty
substantial pockets of resistance and hesitancy?

Dr. Carlos Del Rio: Well, you k now, the problem is that the so called, you know, that
what you're mentioning is pockets of resistance are all very different,
right? It's almost like, you know, ice creams of different flavors are
not one thing in co mmon. And, you know, in African - America ns, for
example, there's concerns about the speed of the development of

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vaccines. There's also concerns about, you know, mistrust in the
healthcare system, and issues of racism and other things that we've
seen . Among Hispanics, we're seeing, for example, a lot of people are
very concerned that, you know, they're going to get deported if
they're undocumented, that this is going to lead to them having to,
you know, to reveal that they don't have a social security number,
they don't even know if you look at m ost places, this doesn't even tell
you that the vaccine is free in many places, when you sign up . It tells
you that, you know, you have to enter your social security number
and your insurance number. And that may make some people who
aren't insured unlikel y to sign up for the vaccine without knowing that
it's free. And you don't need to have that .

We're also seeing a significant a hesitancy among rural white
evangelical people. And again, you need a different approach. So I
think in each community, you real ly have to get down to the
community, you have to trust, you have to work with trusted
messengers within that community. So I think there's not one
universal approach. I think the other thing we need to do is we also
have to do listen to people , and I thin k this is going to be a labor of
love. This is not you know, the people that are rushed to get
vaccinated, are vaccinated, they want to get vaccinated . It’s the
people that, you know, you can take the horse to the water, right , but
you can’t make it drink it, you have to just take your time, you have to
answer people's questions. And what I've learned from doing several
forums and meeting with community and meeting with people in
healthcare and other places, is people have questions that they want
to answer directly. And I would say they have personal questions.
Many times, young people or you know, young women in particular
are worried about fertility, because they read misinformation that this
vaccine impedes your fertility. People talk about, you know, is this
going to impact my DNA? What are the long term side effects? So I
think you need to answer each one of those questions.

The other issue, is that a big group of the population unvaccinated are
those young, you know, between the ages of 20 and 40. And for many
of those individuals, they're like, you know, this disease is a nuisance,
but it's unlikely to kill me. So why should I get a vaccine, and we need
to explain to them that there's still reasons to get vaccinated. Among
those reasons is not to trans mit to others not to get infected and
transmit to others. But also to remind people that, although rare, are
dying from COVID, even when you're young, is still a possibility.

Mark Masselli: Well that’s really good advice. And, and while we have sort of a l ocal
strategy that we have to impl ement, it's a global pandemic , you know,
the U.S. is as lucky as you said, we're, we're vaccine rich, we have
ample amounts of Moderna and Pfizer , b ut other countries are not so
fortunate. There's a shortage, a global shor tage of vaccines. And this

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is against the surge that's happening in India , in Brazil. What if you
could just talk about the global supply chain issues and really connect
the dots because we can solve the problem here. But if we don't solve
it everywhere, t his pandemic and its various mutations in the like, will
wash up against our shore again .

Dr. Carlos Del Rio: Well, they'll be here, right, because we're all interconnected , and we
still – I think it's really important for Americans to understand that the
pandemic will not be over until it's over globally , and I think the U . S .
has a very important leadership role to play in getting vaccines to the
rest of the world. Over the last several years, during the last
administration, we really gave up our leadersh ip role in global health ,
and we have to retake it. Right now, that board is being filled by
China, by Russia, which are giving their vaccines and many places in
Latin America are actually actively using the vaccines from China and
from Russia, and some of those vaccines, particularly I'm concerned
about some of the Chinese vaccines may not be as efficacious as some
of the other vaccines. In fact, I would rather take the AstraZeneca
vaccine, which I think has much higher efficacy or the Johnson and
Johnson . But we haven't been there doing that and I think we need to
get our vaccines supply to the world and again it's , this is not about
charity. This is really about solidarity. But this is really in our best self -
interest as Americans because as you say, if w e don't control the
pandemic in other places around the world, we're not going to be
controlling the pandemic here.

Margaret Flinter: Well, again, back here in the United States while we see certainly a lot
of variation in terms of control, we are seeing s ome states that are
beginning to feel like they've made the progress, they need to really
relax some of their restrictions right here in our own State of
Connecticut, that will be happening in the month of May. I'm
wondering what your thoughts are on that. I know, there's got to be
some apprehensions about relaxing anything, when we're still in the
middle of the pandemic. But if a state is doing well, if the majority of
their high risk populations are vaccinated, is this the time to allow the
restaurants to open and go back to kind of business as usual? And
maybe I'll just add on to that, of course, because every day, there's
something new, the question has come out about do you need masks
when you're outside at all at this point, and mayb e you could tackle
that for us?

Dr. Carlos Del Rio: You know, they're all really tough questions , and I think like
everything in this pandemic, we're entering uncharted territory in
which we have about 50% of the population vaccinated, especially the
high risk population , an d the question is, do you just let the virus run
loose? I mean, I worry about what is happening in Michigan, right,
where a lot of young people are infected, we had a rapid spread of
the B117 variant, which is highly transmissible, and we're seeing ICU s,

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h ospitals overwhelmed with young people. So I don't want some of us
to be , the rest of the country , to be Michigan .

Now, why has Michigan done that way and Florida or other places
have not? I frankly don't know . I think it's very hard to understand ,
and we can make a lot of hypotheses. Some people say, well, in
Florida, you're mostly outside versus in Michigan, that is still cold,
most people are inside. I don't know. I think there's interesting
hypotheses. But the couple of things that I would say is we've learned
in this pandemic that super spreader events can happen , and once
you have a super spreader event, you have rapidly dissemination. So I
think that while you're opening up, I would love to see those likely
super spreader events to not happen, or the y happen to continue to
happen in a mask ed way. For example, if I was going to go to a
concert where 5 , 000 people are going to attend, I would wear a mask.
If I'm going to be out in the park walking with my dog , I don't think I
need to wear a mask. I mean, it's – so it's – and that makes it really
hard job because it really requires people to sort of assess and
evaluate risk in ways that quite frankly, we're not used to doing. I
mean, we're not, we normally don't do that . We cross the street. I
mean, this m orning, I woke up , I got in my car, and every single thing
we do, we're not there sitting saying, Well, you know, should I take
the freeway , should I take the street because the chances of me dying
on the freeway when I'm 70 miles an hour are a lot higher, if I have an
accident with the chance of dying when I'm in the street at 35 miles
an hour .

I don't make those decisions , risk - benefi t decisions, on a regular basis,
yet [inaudible 00:13:19] making decisions , and I worry that that
people will make the wro ng decisions, right and there will be a big
event that will become a super spreader event. I think that we need
to monitor community transmission , and the key is when you start
getting community transmission below 10 cases per 100,000
population. I think I 'm a lot more comfortable saying it's time to relax
more things than when we say they're still 50 cases per 100,000
population, in which case, I worry about opening things up . So you
really need to look at what is your local transmission, and what is your
local vaccine coverage , and I think if you take those two things into
consideration, you can make better decisions.

Mark Masselli: That's great advice. We're speaking today with Dr. Carlos Del Rio
Executive Associate Dean of the Emory School of Medicine . D r. Del
Rio, your research has been focused in on HIV and AIDS. You're
collaborating with one of our colleagues here at the Community
Health Center, Dr. Marwan Haddad in AIDS research . But according to
a report from the Kaiser Family Foundation, we've lost some ground
in the fight on AIDS. Talk about the impact the pandemic has had on
this and other infectious disease and the challenges and concerns that

Dr. Ca rlos D el Rio - 20210419RiosXM

you have.

Dr. Carlos Del Rio: Well, I mean, other concerns are not only an infectious disease but
are rea lly in everything, right? I mean, we have essentially we went
into a stop of care, and many, many places has shifted into what they
do . So many places that do non - essential service , and I would say,
people see community HIV testing as a non - essential servi ce or
community STD testing as a non - essential services, those services
have stopped. As a result of that, I think we're doing okay, giving
continuous care, and viral -- antiretroviral therapy to people already
diagnosed, but we're missing new diagnosis. I think we're not going to
see until several years from now the true impact of what the
pandemic has done. But I'm worried that our plans to end the HIV
epidemic and to really control transmission, which relied a lot, very
similar to COVID, relied a lot on a lot of testing, Linkage to Care,
treatment, treatments, prevention, I think a lot of those things have
been impacted. As a result of that, we're going to see a stalling of this
effort . We're seeing the same thing with substance abuse, quite
frankly . We'r e seeing an increase in cases of substance abuse as a
result of not having access to buprenorphine to methadone
substitut ion and to many other programs.

So I think overall, the impact of the pandemic goes beyond COVID,
right? It goes to really into a vari ety of different areas. As a result of
that we're seeing – when we talk about excess mortality caused by
the pandemic, we're not just talking about people that died from
COVID, we're talking about excess mortality from other diseases that
got impacted as a result of COVID.

Margaret Flinter: Well, Dr. Del Rio, in your long and remarkable and impactful career,
you've certainly been witness to the ravages of infectious disease on
vulnerable communities and one of the things that you've tried to do
is to increa se diversity in c linical research trials, which ha s been
lacking over the years . The president has certainly looked to the
nation's federally qualified health centers as one vehicle, perhaps for
addressing the health equity gap in the United States. I wond er if
you'd like to comment on how we might leverage the role and the
might of our nation's community health centers, which care for 30
million people to address health inequity, both in health outcomes,
but also in inclusion and health research? Is there a role for the
Community Health Center movement to play in that area?

Dr. Carlos Del Rio: I clearly think it is . I mean, Community Health Centers have been a
very important part of providing care to vulnerable populations. I
think one thing that I would lo ve to see is access to care , to become
not a – to really be something that everybody has. I mean, we
continue to be in a country where your ability to access medical care
is dependent on whether you have an employer that provides

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insurance, and other thing s that I think the fact that nobody likes
government run health insurance until you get to be 65. And then it
somehow everybody loves government run health insurance . We
need to understand that access to care is really important . I think this
pandemi c and others have shown us that. We've learned, for
example, in HIV Ryan White transform ed the way we do HIV care
because you provide access to care that payer buys for self . So we
need that I think as the number one . Health equity, we'll start by
making sure th at everybody has access regardless of their ability to
pay, or where they work or wh at they do.

The second thing is I think that when you talk about research and
equity in research, I really think that the only way to do that
effectively is to work with t he community and to gain the trust of the
community because for people to participate in research, they have
to trust you. I've learned over time that that trust doesn't happen
from one meeting. It happens over time. It happens really from
people knowing w ho you are, what you do, and how what you're
doing is benefiting them. I mean, many times I've had research, when
I've talked at meetings to community, the question is, why should I do
this, and when you – if you cannot answer the question to a
participant of why should I do this, then simply you don't have their
trust and you don't have the ab ility to communicate with them.

So Community Health Centers are places where people trust their
providers frequently and where they think that it's a safe place , and if
you have a trusted place and a safe place, it 's a good place to do
research.

Mark Masselli: Well, I think that's a great point. We're part of Dr. Carlos, All Of Us
Precision Medicine Initiative at the NIH and really gaining trust of
vulnerable communit ies is the North Star and making sure that there's
inclusion . We now want to shift over and talk a little bit about the
mRNA technology behind Pfizer and Moderna vaccines, seems to hold
a lot of promise for potential interventions in cancer and other
infec tious disease and possibly HIV. I'm wondering if you could talk
about the next wave of scientific discovery and anything you're seeing
practically now that crosswalks over from both mRNA CRISPR
technology that's been in the f orefront of many conversations.

Dr. Carlos Del Rio: You know, there were a lot of people very skeptical and didn't really
know if the mRNA technology was going to work. I think the success in
COVID as a way to deliver an antigen will really be transformative in
the field of vaccinology b ecause I mean, I think, flu and other vaccines
will become much more sort of plug and play with mRNA technology
than they do with the current technology. I mean, you need eggs, you
need long time to develop a flu vaccine , so I do think that we will see
di fferent vaccines develop . We got to remember that mRNA

Dr. Ca rlos D el Rio - 20210419RiosXM

technology initially was developed actually and was being tested for
vaccines for cancer, for example, fo r melanoma, and other diseases.

So I think it's a vehicle to deliver an antigen and present it in such a
way that produces a good response. And I think this is going to change
drug delivery for many other diseases. I do think also that as a result
of COVID, we're learning s omething that I find interesting is how
we're looking at research in repurpos ing drugs and some of those may
not be effective. But I think there's a lot of interest in understanding
the way you can repurpose drugs to use to treat other diseases. And I
think we will see a lot of that happening going forward in which
people are going to design. I think the trials like for example,
SOLIDARITY or RECOVERY , or other big studies that have been done
either by WHO or by the B rits , again are going to transform the way
we evaluate medications in diseases.

Margaret Flinter: Well, that is very exciting. We've been speakin g today with Dr. Carlos
Del Rio, Executive Associate Dean at the Emory University School of
Medicine. You can learn more about his research on infectious
disease including COVID - 19 and HIV by going to vaccines.emory.edu.
or foll ow him on Twitter @CarlosdelRio7. Dr. Del Rio, we want to
thank you for your extraordinary and dedicated leadership in tackling
the world's grea t infectious disease challenges, for your commitment
to public health and thank you for joining us today on Con v ersations
on Health Care.

Dr. Carlos Del Rio: Delighted to speak with you.

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Mark Masselli: At Conversations on Health Care we want our audience to be truly in
the know when it comes to the facts about healthcare reform and
policy. Lori Robertson is an award winning journalist and Managing
Editor of FactCheck.org, a nonpartisan, nonprofit consumer advocate
for voters that aim to reduce the level of deception in U.S. Politics.
Lori, what have you got for us this week?

Lori Robertson: What are the facts behind the pause in the use of the Johnson and
Johnson COVID - 19 vaccine? On April 13, the CDC and FDA
recommended the pause “ out of an abundance of caution ”, the
agency said after six cases of a very rare blood clot among the 7.2
million people who receiv ed the J&J vaccine. The other vaccines
authorized in the United States by Pfizer - B io NT ech and Moderna
aren’t affected. More than 180 million doses of those vaccines have
been given with no reports of this syndrome. They use a different
type of vaccine tech nology than the J&J vaccine. The six cases are
women ages 18 to 48. One woman died and one is in critical
condition. They had severe headache, abdominal pain, leg pain, or
shortness of breath 6 to 13 days after receiving the J&J shot. While

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the cases are v ery rare if you got the J&J vaccine within the last two
weeks and develop those sympto ms, contact your doctor.

Peter Marks, D irector of the FDA ’s Center for Biologics Evaluation and
Research said in a press conference that the CDC and FDA acted
quickly be cause the usual treatment for blood clots, a drug called
heparin “ can actually cause tremendous harm or the outcome can be
fatal ” . So the agencies want health care providers to be aware . A CDC
advisory committee is reviewing these six cases further. The ra re
blood clot is called cerebral venous sinus thrombosis or CV ST which
occurs annually in 2 to 14 people out of 1 million in the general
population. The concern however is that these six cases of CVS T ,
which represent less than one in a million of those va ccinated with
the J&J vaccine also had low levels of blood platelets. Dr. Paul Offit,
Director of the Vaccine Education Center at the Children's Hospital of
Philadelphia and a member of an FDA vaccine advisory committee
said recommending the pause is a sig n the vaccine monitor systems
are working, and that the agencies discovered and took action on a
“ very, very rare side effect post approval ”.

And tha t's my fact check for this week. I'm L ori Robertson, Managing
Editor of factcheck.org.

Margaret Flinter: F actCheck.org is committed to factual accuracy from the country's
major political players and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact that you'd
like checked e - mail us at www.chcradio.com , we'll have
FactCheck.org's Lori Robertson check it out for you here on
Conversations on Health Care.

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Margaret Flinter: Each week Conversations highlights a bright idea about how to make
wellness a part of our c ommunities and everyday lives. Baltimore,
Maryland has one of the highest emergency medical call volumes in
the country , and it results in a significant number of patients being
taken to the ER for conditions that could have been treated outside of
the ER . The University of Maryland Medical Center and the Baltimore
City Fire Department teamed up in the hopes of reducing unnecessary
ambulance tri ps and hospitalizations.

Dr. David Marcozzi: How do we all start to address health issues more comprehensively
tha n simply calling 911 , being transported to an emergency
department when that is not an optimal care for p atients nor benefits
the system.

Margaret Flinter: They created a new pilot program which pairs doctors and nurses at
the hospital level with paramedic s in the field bringing medicine right
into the patient's home.

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Dr. David Marcozzi: A nurse practitioner or physician is partnered up with a paramedic ,
and we monitor the 911 system and have completely synchronized
with that system so that 911 low acuity c alls, we augment the
Baltimore City EM S system so that we co - dispatch a paramedic and
either nurse practitioner or doctor to the scene of low acuity calls,
have them logged in at scene through EPIC , ask the patient whether
they would like to be treated a t scene . If they consent , we then enroll
them into our program, register them there just like a mobile urgent
care center. We then treat them at scene, discharge them with the
same exact paperwork we discharge them from the hospital from the
emergency depart ment with prescriptions as needed and then we
follow up with them within 24 hours to mak e sure they got what they
need.

Margaret Flinter: Dr. David Marcozzi of the University of Maryland Medical Center says
that this mobile integrated healthcare community paramedicine
program has a two pronged goal. One, reducing unnecessary trips to
the ER by deliverin g right care at the scene, two, bringing a
coordinated paramedicine team including doctors and nurses into the
homes of patients being released from the hosp ital to ensure that
their recovery is supported for better outcomes. The pilot also seeks
another goal to keep vulnerable patients being released from the
hospital healthier with paramedics doing frequent follow ups over a
30 day period to ensure that pati ents are compliant with their
medicines are getting enough to eat and thus greatly reducing the risk
of re - hospitalization.

Dr. David Marcozzi: It ’ s eye opening to once you understand the challenges when we
discharge a patient or when patients are seen for low acuity issues
p eople face just at home to navigate the insurance industry, the
multiple providers they're supposed to follow up with, the diagnostic
testing that they may have to get an MRI, then the follow up back to
their primary care, the challenge s that individuals face certainly here
in Baltimore, and we're exploring, could we do this for longer or is
there a better way once we hopefully empower folks to transition to
maybe a lower resource intensive setting so that we can kind of
transition them to potentially another health support infrastructure
for THS Transitional Health Support for the 30 day follow program.
Our data demonstrates that the patients who are followed in our
program utilize and are admitted to the hospital significantly less and
utilize their health care primary care services significantly more. That
translates into lower cost to the system from a physician billings
construct, from a hospital construct, and oh by the way from an EMF
construct because you know what happens? Those p atients typically
c all 911 to get to the hospital.

Margaret Flinger: Dr. Marcozzi estimates that the two year pilot will save the University
of Maryland Medical Center at least $4 million, and the fire

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department expects to save just under 2 million. But m ost
importantly, he says the patient outcomes are markedly improved.
The mobile integrated healthcare community paramedicine program
rethinking how paramedicine is deployed in the field, reducing
unnecessary emergency room trips , and by the way, making sur e that
the emergency responders can respond that much more quickly to
the true emergencies. Now, that's a bright idea.

[ Music ]

Mark Masselli: You've been listening to Conversations on Health Care. I'm Mark
Masselli.

Margaret Flinter: And I'm Margaret Flint er.

Mark Masselli: Peace and Health

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Marianne O’Hare : Conversations on Health Care is recorded at WESU at Wesleyan
University, streaming live at www.chcradio.com , iTunes, or wherever
you listen to podcasts. I f you have comments, please e - mail us at
[email protected] or find us on Facebook or Twitter. We love
hearing from you. This show is brought to you by the Community
Health Center .

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