Dr. Goosby 'Not Freaked Out' About Variants

This is Part Six of our Q&A with President Biden COVID Task Force advisor, UCSF's Dr. Eric Goosby.

Synapse: What are your thoughts on how new coronavirus variants will impact the current situation with trying to get the pandemic under control? How realistically concerned should we be about them?

Dr. Goosby: So the U.K. one took about, oh, maybe four weeks to become the dominant COVID strain transmitted in the U.K. It has been in the United States for probably two to three weeks shy of the September outbreak in the U.K. that brought it to their island. It will dominate here because it selectively attaches more efficiently.

So the inevitable outcome of that with time will be that it’s the dominant form. As you know, viruses — that’s how they survive, is that they keep mutating, and they mutate every time they go through a generation — and they do about six generations a day in a twenty-four period.

So you multiply six generations by the number of people infected each day, and you can see that you’ve got billions of viruses mutating out there all the time.

And you can’t predict what change that mutation confers in giving a selective advantage to survival, transmission, or virulence.

Then, what that does is that when every population that’s followed with genomic surveillance is done, U.K. is the — probably Belgium is the most heavily surveyed country, but it’s tiny — the U.K. is the next, based out of robust surveillance systems all over the island and in Ireland and Scotland. They’ve done it for years.

So they’re looking for viruses in general, and when COVID happened, they zeroed in on that. But we undoubtedly have many variants that are in the United States.

We aren’t doing genomic surveillance, which is a problem. Under Trump, that surveillance was not stood up for the genome. There’s not a lot you do with it; it’s really an after-the-fact thing.

But it does give vaccine manufacturers the jump when the mutation actually changes a site on the virus — in this instance, on the virus itself, on the spike protein — that the vaccine doesn’t recognize. And the recognition of COVID is made up of six different areas on the spike protein, and the U.K. mutation changed one of them.

One out of the six. It drops recognition that can be measured a little bit. But you’re at 95% vaccine efficacy, so it drops it down to probably the high 80s. Still way above 50, which is a very effective vaccine. So it won’t impact that. The South African variant has two out of the six abnormalities and is more of a threat. Because of that, antibodies may not effectively identify and clear the virus.

And we’re worried about that as we would be about all of the mutations, in that mutations are going to continue to happen forever.

We need to stand up the surveillance system in the United States more robustly than it is now, and we’re doing that. And Moderna is already going to start — as will Pfizer, I’m sure — developing an alteration in the subsequent batches of vaccine that accommodate the South African two-spike protein changes that we are worried about.

They’ll make a vaccine that targets other areas on the spike. So that sounds like I could be pretty worried about it, but you know, this is how viruses are. Every virus you can name goes through this evolution. It rarely changes our ability in a vaccine.

The flu is a good example of one that changes every year. And we have to re-batch it. So it’s nothing I’m worried about that we feel we can’t handle.

We aren’t positioned with the surveillance in the United States, but we will be. We’re well-positioned elsewhere to do it. Quite frankly, there are enough research labs in the world to check any question of a new outbreak variant by just getting the blood — getting a sample of the virus and moving it to where the capability is.

There’s now that capability in Sub-Saharan Africa, Southeast Asia, Eastern Europe, in a way that it’s approaching developed world access if you have transportation ability. It’s something we’re going to have to learn to deal with; it’ll be part of our life in continuing to make effective vaccines for COVID. And we know the science to be able to do that. So I’m concerned, but I’m not freaked out about it.

I think we’ll be okay with this as long as we stand up the surveillance capability that allows us to keep the manufacturers ahead of the mutation.

Synapse: What are your perspectives on the differences among various countries’ handlings of the virus, in terms of their governmental responses? For the countries that contained the virus more effectively, what are the key things that their governments did?

Dr. Goosby: I think early is key, and what I mean by early is — as early as you can mount your response, which would be testing matched with contact tracing, to be deployed at a high volume right with a positive test. So you preclude the crescendo number of infections moving to exponential growth if you catch it.

The United States moved into exponential growth, and that was it. Contact tracing is overwhelmed when you have that many people.

So you’ve got to lock down to bring the total number of cases down to a number per day that you can contact trace efficiently, totally, so that within twenty-four hours, you have spoken to everybody who you think was exposed and told them, so their behavior change starts within two days from their exposure. If you do that, you will contain it. If you don’t do that, you might as well not bother!

So a lot of contact tracing — huge energy effort went into it — that was doomed never to have an impact.

The thing that countries did differently — you know, if you look at Singapore, Hong Kong, South Korea — you have a country that when the numbers were tiny, less than a hundred, had their contact tracing in place and were actively on it, and were effectively identifying and removing people from continued spread.

They did it beautifully. And when it came back, they did it again. If you don’t do it, and let the numbers get too high, you can’t catch it. You can’t restart. You’re stuck.

You then have to go into a lockdown so that all virus transmission is blunted and extinguished, so that you can reboot another start. If you don’t allow that to happen, you are in the situation that the United States is in.

And our closures and re-openings did not match case findings with re-openings, so we were at a point where we were staffed and ready to case-find everybody, contact trace them, and then containment rings sprang up every time you had a positive test.

When you get an imbalance there, you’re stuck, and we’ve been stuck for months in the United States. Too high numbers — the numbers are too high to re-contain. We’ve got to push it back down, re-contain it, then turn the volume up on case findings. It’s a primitive response.

The other concomitant effort is — vaccinate people! Because that’s essentially moving our population through what happens with herd immunity, but by using a vaccine to facilitate that. And we will eventually catch up with that. I think it is absolutely the most impactful intervention — to accelerate and prioritize vaccination. Do everything else, but it’s going to stop with vaccination, not any of the other things.

The other things are responding once it’s already out. The vaccination is going to stop the initial crescendo that occurs with early infection in a community, and so vaccination is the light at the end of the tunnel. It’s what we don’t have with TB and HIV, and why those keep festering.

And with the flu, you have a vaccine that doesn’t last. The antibodies don’t stay with you for the next year.

A new variation, a new mutation comes out, and the antibodies that you made in 2020 don’t work for the flu of 2021.