Paul Offit on Vaccine Science, COVID's Future, and the Anti-Vax Movement

— "You're seeing a real pushback against the kind of weapons that are needed in public health"

  • author['full_name']

    Jeremy Faust is editor-in-chief of app, an emergency medicine physician at Brigham and Women's Hospital in Boston, and a public health researcher. He is author of the Substack column Inside Medicine.

  • author['full_name']

    Emily Hutto is an Associate Video Producer & Editor for app. She is based in Manhattan.

In part 1 of this exclusive video interview, app editor-in-chief Jeremy Faust, MD, and Paul Offit, MD, director of the Vaccine Education Center at Children's Hospital of Philadelphia, discuss the science of vaccines, the future of COVID, and the politics of the anti-vax movement.

The following is a transcript of their remarks:

Faust: Hello, Jeremy Faust, editor-in-chief of app.

We are joined today by Dr. Paul Offit. Dr. Offit is a professor of pediatrics at CHOP, Children's Hospital of Philadelphia. He's the co-inventor of the rotavirus vaccine and he serves on the Vaccine and Related Biological Products Advisory Committee for the FDA. His new book is entitled, .

Dr. Paul Offit, thank you for joining us.

Offit: Thank you.

Faust: Let's start with the conversation about vaccines and science, and then we'll go over to some public health issues that you talk about in the book.

The first thing I'd like you to help people understand is actually a biological thing that you talked about in the book, which is that there's a difference regarding whether a virus can be eradicated depending on its incubation period. Can you just explain that for people who either didn't go to med school or who went to med school a while ago?

Offit: Sure. So if you take a virus that has a long incubation period, like measles for example, if you're vaccinated or naturally infected, you'll develop antibodies in your bloodstream which will protect you against mild disease for 3 to 6 months until those antibodies start to come down. But you'll also develop memory cells, memory B cells, memory T helper cells, memory cytotoxic T cells, which are generally long-lived and sometimes lifelong.

For a long incubation period disease where it takes 10 days, 14 days to first develop symptoms, you actually don't need antibodies in the circulation, you just need memory cells that can then, in the case of B cells, make antibodies. That, usually, is plenty of time when you have a long incubation period to activate those cells, to get them to differentiate – in the case of B cells make antibodies – to prevent even mild disease.

So for that kind of disease, you can actually eliminate it from the face of the Earth. Smallpox is a long incubation period disease and so we've eliminated it. Polio, we're getting close to eliminating it -- another long incubation period disease. And measles, we eliminated measles from the United States in 2000. It's come back in large part because of falling immunization rates, but that's that.

For short incubation period diseases like SARS-CoV-2 or influenza or respiratory syncytial virus or rotavirus, there what you can do is when you immunize, you can induce antibodies, which will then protect you against mild disease for a while. You'll also induce these memory cells, which will protect you against severe disease because it takes a while to develop severe disease. But, you're not going to be protected against mild disease for long.

I was fortunate enough to be part of a team at Children's Hospital of Philadelphia that created the rotavirus vaccine. Rotaviruses don't really evolve away from protection induced by vaccination or natural infection. All viruses mutate, but they don't really evolve away from recognition by antibodies induced by vaccination or natural infection.

So what we've done with that disease is essentially we've eliminated hospitalizations in this country, but the virus still circulates. That virus doesn't create variants. It still circulates in the community, and it still causes mild disease, you probably have 95% immunization rates.

Even if 100% of people in the world were vaccinated against COVID and the virus didn't mutate or didn't evolve, you still would see that virus circulating because it's a short incubation period disease. You're going to get mild disease again and again and again. We never made that clear early in this pandemic.

Faust: In terms of this virus, I struggle with whether or not I should or we should be thinking about it as a garden variety coronavirus that just happens to be new and happens to be worse prior to immunity. Is that how you think about it? And if so, what's going on with the seasonality? Because clearly every year now we see a peak in the winter months, but unlike some of these other viruses -- as you say in the book -- it doesn't just go away in the summer.

Offit: Right. So there are four strains of circulating so-called human coronaviruses, and for the most part they're winter diseases. We'll see them in our hospital accounting for maybe 10% to 15% of children who are hospitalized with respiratory symptoms.

One of those viruses entered the human population in the late 1700s, another of those viruses entered the human population in the late 1800s. So I think it's fair to assume that this virus, SARS-CoV-2, will be with us for decades, if not longer.

Will it, as you argue, will it sort of settle into a seasonal pattern as these others did and become primarily a winter respiratory virus -- join the pantheon of winter respiratory viruses, like not only the human coronaviruses, but influenza, respiratory syncytial virus, human metapneumovirus, parainfluenza virus, etc? We'll see.

It hasn't clearly defined itself as a seasonality yet, but if you had to make a guess -- and you should never make a guess about this virus because you're always wrong -- I would say that it probably would settle into being a winter virus.

Faust: Alright. Let's talk a little bit about vaccine politics. The anti-vaccine movement has been with us for a long time, but it seems to me that in the past decade or two, it made a shift from primarily being a feature of the fringe left to actually going to the other side. For example, in terms of religious exemptions to other vaccines, only two states, I believe you said, had said no religious exemption, and it was Mississippi and West Virginia.

So in fact, I used to think of vaccine hesitancy and anti-vaxxing as from my original neck of the woods, the Bay Area, these crunchy liberals who believe in natural stuff. Now, it's sort of gone the other way. What happened there?

Offit: I think there's never been a politics to the anti-vaccine movement. I think on the left it was, as you note, this sort of all-natural "don't inject me with anything with a chemical name." And that outbreak of measles in Southern California in 2014-2015 that spread to 25 states, that was a phenomenon of the left, if you will. There has always been this sort of libertarian "government off my back; don't tell me what to do." But you're right -- it has swung wildly to the right.

The anti-vaccine movement has never been better funded. There was recently an article in the Washington Post talking about how much money has poured into the coffers of groups like RFK [Robert F. Kennedy] Jr.'s Children's Health Defense or Del Bigtree's Informed Consent Action Network. They are better funded than they've ever been. They're certainly far better funded than the people who are trying to communicate facts about vaccine safety and efficacy.

It's a tough time, and you're seeing a real pushback against the kind of weapons that are needed in public health, whether it's isolation or quarantine or vaccines or masking. In some ways, I think we may be less prepared for the next pandemic than we were for this one.

Faust: You also write about Dr. Ala Stanford, who is a really perfect embodiment of another thing that happened in the pandemic, which is that the Black population initially [had] a little bit of hesitancy around the vaccine, but due to efforts like Dr. Stanford's, actually the opposite happened: you have a huge interest in the Black community. There's a trust there that I think might be a win.

So do you think that that's what's happened here? That because this virus hit Black communities and other communities of color so hard, the vaccine was seen as something to be lauded and accepted, rather than a continuation of like prior suspicion about medical research and all of the earned baggage there?

Offit: I think she was one of the bright and shining lights that occurred during this pandemic. I have known Ala for a little while and just feel honored to know her. She's a hero to me.

So here's a woman, an African American surgeon at Temple University, who really took it upon herself to form something called the Black Doctors COVID Consortium with her own money. She then went into North Philadelphia, primarily a Black and brown community, and sat in people's living rooms and just tried to explain to them why it was important for them to get a vaccine. And if they said no, she would come back. And if she said they said no again, she would still come back. She got 50,000 people in that community to be vaccinated.

There should be a thousand Ala Stanfords, because I think if we're going to really combat this misinformation and disinformation, I think it has to occur at that level. I don't think it can really be at the federal level or the state level. I think it has to be at the local level, so you go into an ultra orthodox Jewish community in Brooklyn and explain why it's important to be vaccinated or a Somali American population in Hennepin County, Minnesota and explain why it's important to be vaccinated. But you have to find out who the people are that they trust, because I think there's been an enormous loss of trust during this pandemic.