WorkSTEPS Chief Medical Officer, Dr. Ben Hoffman, discusses the past, present, and future of COVID-19 on this episode of Workplace Injury Prevention - A Fit For Work Podcast, covering topics including the science behind vaccines, developing herd immunity, mitigation measures for the workplace, and the importance of perseverance as the light at the end of this pandemic's tunnel grows brighter.
WorkSTEPS Chief Medical Officer, Dr. Ben Hoffman, was recently featured on Workplace Injury Prevention: A Fit For Work Podcast to give his professional input on various aspects of the COVID-19 pandemic's evolution and the next steps that will lead us to a new normal. Listen below or at this link.
Timestamps by topic:
1:20 - How vaccines are made & how they work in the body
4:45 - COVID-19 vaccines & side effects
13:40 - Establishing herd immunity
19:20 - COVID-19 testing (past & present)
22:15 - COVID-19 screening in the workplace
26:15 - Next steps
A transcript of the episode is available below.
Workplace Injury Prevention - A Fit For Work Podcast: Questions answered and updates on COVID mitigation for the workplace
Curtis Kopotic: Welcome, friends, to Workplace Injury Prevention - a Fit For Work podcast where we are bringing the power of prevention to you. I am your host Curtis Kopotic and I am joined by my co-host, Ambjor Brown, and today we are joined by Dr. Ben Hoffman.
Ambjor Brown: Hey Curtis! Dr. Hoffman joins us again- he is going to give us a rundown on some updates regarding COVID-19.
Curtis: It's one of those things that we've all been talking about, we've brought it up occasionally, but I think this is a good little deeper dive as to where we are and where we are going. And some bright spots on the future ahead.
Ambjor: Definitely bright spots. And, you know, we last talked to him early on, he was gracious to kind of do an emergency podcast with us and just kind of give our listeners an idea on how they can kind of get through things, and at that time, Curtis, I never imagined that we would still be talking about this early on in 2021. Never in a million years. So, I'm just really grateful that he can give us some updates today and put a little bit of a light at the end of the tunnel for us.
Enjoy our COVID-19 update with Dr. Ben Hoffman.
Curtis: Well, thank you for joining us again, Dr. Hoffman, and trying to get an update on COVID and where we are now, and I think there's a lot of positivity in the air, but there's still a lot of unknown. The current thing is definitely the vaccine, that is on everyone's mind, so that will probably be a good place to start.
In general, how are vaccines made, and how do they work in the body?
Dr. Ben Hoffman: Okay, it's a good question because the way we're making some of these vaccines for COVID-19 are novel, they're different from what we've done historically. Historically, what we did was we made what are called "vector" vaccines, and what that is, it contains a weakened version of a live virus. It's usually a different virus than the one that causes the illness, but it has the genetic material from that virus in it, and then you insert it into this weakened version of the live virus, and you inject it into the body. That's typically the way that measles, mumps, rubella, hepatitis B, and other types of vaccines have been made. Typically, it takes a fairly long time to perfect that for any given vaccine, or for any given illness you're trying to prevent the person from getting.
However, in recent years, there's been development of a new type of vaccine called a mRNA - or a messenger RNA- vaccine. And what that is, it contains materials from the virus that gives our cells instructions for how to make a harmless protein that's unique to the virus. So, in this case, we're taking the RNA, which makes the spiked protein on the surface of this COVID-19 virus, and then they're injecting it into the body, and then the body recognizes and starts coding for that spiked protein and builds antibody to it. You're not injecting any of the live virus, or attenuated live virus, and the interesting thing about these mRNA vaccines is that they should be harmless because all you're doing is taking a little snippet of that RNA - which is like DNA, it's reproductive material - and you're injecting it into the body and then the body recognizes it as foreign and starts building antibody to it.
Curtis: That's really fascinating. Now, I remember - for me, biology was quite a few years ago - but for those who may not know, basically these proteins are kind of like the "key to the house" right? So that's what allows things into the virus cell. It basically is letting your body get access to be able to get into the virus to destroy it, if you will. Correct?
Dr. Hoffman: Correct. What we do is we take these little pieces of RNA, and we encase it in a little piece of fat, a little globule of fat, which allows it to make its way into the body. It's a unique way to do things and it's been shown to be very effective both in the experimental setting prior to COVID-19, and now when we've been doing empirical trials with the use of the multiple vaccines that are on the market. I can say that that type of new messenger RNA vaccine technology is what's being used for the Moderna and for the Pfizer. The other vaccines that are coming onto the market, like the Johnson & Johnson and AstraZeneca, are a little bit different. They're more of a traditional way of doing a vaccine.
Curtis: And now, that's kind of interesting that they are having different ways of administering- or that these vaccines, they're all accomplishing the same thing, their process of getting it done are different. Is there any advantage or disadvantage that people should be "hey, I'd rather have the Johnson & Johnson vs. the Moderna." Do you see any difference between those?
Dr. Hoffman: Well, Curtis, first of all, I want to mention that this is not unusual to have more than one method of vaccine to vaccinate people against an organism. For instance, the polio vaccine was an enormous landmark in vaccine development. It was developed by March of Dimes back in the 40s and 50s -which, by the way, took years to develop - that one was originally a live attenuated virus and then they moved it over to a different type of technology, and both of them were available. It's also true of the typhoid vaccine. The typhoid vaccine, there's both injectable vaccine and oral vaccine and they work different ways, and you can get both today.
In terms of their effectiveness, it appears as though all of them are similarly effective, but - we'll turn back to COVID-19 now - although in the United States, only the Moderna and the Pfizer have been approved. Shortly, the AstraZeneca vaccine will be approved. The AstraZeneca vaccine I believe was approved the last couple of days in the U.K. And then after that I believe Johnson & Johnson- and there's a series of Chinese vaccines, I think there's four or five different companies in China that are manufacturing vaccines, and they likely will seek approval outside of China for their use.
Ambjor: Then, I know a lot of people are talking about the side effects of the vaccine, or just vaccines in general as far as some people get a fever, some people kind of feel run down for a day. I know some friends of mine are worried that when they've gotten the flu vaccine, that they've actually gotten the flu with those side effect. Can you talk a little to the side effects for us, please?
Dr. Hoffman: Side effects are common with vaccines. A lot of it is sort of what I'd call idiosyncratic: there's no consistency from person to person as to what the type of side effects are going to be. So with these vaccines, one of the reasons you do clinical trials is to see whether or not there's any side effects, will those side effects be the transient ones that last a day or two, or ones that become rather severe. In certain cases some vaccines, historically, have led to even death and were withdrawn after the clinical trials.
What appears to be the case with the clinical trials, or what is the case with the clinical trials for the [COVID-19] vaccines that are currently either far into development - that is, phase 3 human trials or currently on the market - is that they have a potential of causing low-grade types of the facts, like maybe a low-grade temperature, fatigue, some arm pain, which, again, are transient. They last a day, maybe two, in a small percentage of the patients. Also headaches have been described with these vaccines.
Now, there was a concern that there have been reported a number of people that have more severe effects. They're severe allergic effects or some sort of neurologic complication. Now, these were done in the clinical trials. These were found to be the case in clinical trials, and one of the roles of the advisory boards that are independent of the vaccine manufacturer - typically vaccines go through multiple layers of review independently. They also start internally in the company and they're not independent, but then they move on to a hierarchy that goes up eventually into the regulatory bodies of the country; let's say in this case the FDA.
One of the challenges is you have to determine whether or not any side effects are due to them occurring randomly in any population, let's say 50,000 people, because if you're giving 50,000 people a vaccine, some of those people could have diseases or medical problems completely unrelated to the vaccine, so you have to determine whether or not these more complex medical problems were related to the vaccine or just randomly occurred and would have occurred without the vaccine. And it appears as though there have been no serious side effects associated with this vaccine, other than perhaps the rare origin responses we've seen.
I've also read an interesting fact: you may be aware of the fact that the government tracks every adverse vaccine side effect. They've been doing it for 30 or 40 years and there's a big registry of this, and in part because the government would assume some of the responsibility when a manufacturer makes a vaccine, they assume liability for the manufacture of that vaccine - or at least some type, not total liability, but I understand there is government support if something goes wrong - and there has never been, as long as the government has been tracking vaccines, that there has been an adverse side effect that's considered severe after 43 days. Now, it doesn't mean to say this current vaccine will set a new record, but history of a lot of vaccine research and subsequent vaccination of large populations of people, once you reach a certain date it's not likely to cause any severe side effects. We've passed that threshold in time.
Now, to fully answer your question, this whole issue is a bit more complicated in that there has been in recent years an anti-vaccination movement in parts of the world, particularly in the United States and the United Kingdom. It has happened for a number of reasons, but one of the reasons is that there was the belief that it was possible for vaccines, particularly these childhood vaccines we give to all our kids, would cause some sort of autistic spectrum type of illness, and I'm sure you've read about that. It was actually- the research for this was done by a researcher in the United Kingdom and there was extensive research that was done by him, and it was published. Subsequently, there has been a lot of review of that data, and his theories and his science have been debunked. They made up some of the data, the data was inaccurately analyzed, and it's been reviewed by many different independent panels, and this notion that a vaccine can cause autism has been debunked. That said, there's still people out there that don't believe it, but there has not been any compelling research to suggest vaccines could lead to these types of adverse side effects.
Lastly, what I want to say is that these messenger RNA vaccines, if you understand the science of how they're developed, taking little pieces of the RNA - again, RNA is like DNA - and that RNA sits inside this virus. It's almost like a golf ball that has a little bit of RNA it, and on the surface of that golf ball are receptors, we call them the spike receptors. There's a lot of different receptors on the surface, so it's like a golf ball with little spiked thorns sticking out. The reason they exist is because when a person inhales the virus, it sticks to the mucosa. They need those spike proteins to attach to the mucosa, and once they attach to your airway mucosa, they actually make their way through the mucosa, through those spike proteins, and they inject that whole piece of RNA into the body's cells. Then the body's cells- the machinery in the cells is repurposed to manufacture more of those viruses - that, the RNA - and therefore cause replication, reproduction of more of those little golf balls that are making it into your body and then all of the impacts of that occur.
When you review that science, there's really no way that that little piece of RNA that's being injected in the vaccine itself could cause disease. It's just- there's no biologic plausibility to it. Now, is it possible that we don't fully understand this? Yes, but I really don't think so. I think all of the scientists in the world believe that it's an effective way to make a vaccine and it's a safe way to make a vaccine. I suspect going forward, we'll primarily be using these mRNA vaccines.
Ambjor: Dr. Hoffman, that was so much good information, and I know that we've kind of focused these questions a lot on ones that we've been fielding on the job site, at home, with our friends and family, so I think we've got a lot of really good vaccine information from you. Thank you for that. My final vaccine question for you came specifically to me and it was somebody saying "I've avoided the COVID virus for the last nine months that we've been worried about it; why do I need to get a vaccine now? I haven't gotten the disease, I'll be fine."
Dr. Hoffman: Well, uh, that's one approach. [Ambjor laughs] ...I don't think it's a rational approach. I think that it's not rational because the thing is that the only way this little bug is going to go away is if we develop enough immunity in the population so that that bug, when it enters any given micro-environment, it has no place to go and it just dies off. It's really not living; it just has no place to go. So if you think about that, if you're in a room and in that room there are ten people, and if there are five people who have had [COVID-19] and five people who haven't had it, that COVID bug comes in and it's going to have five people it could possibly affect. As you reduce that number down to four people, three people, two people, one person- it's less likely that that organism is going to be able to infect anybody and it needs to infect somebody in order to continue with survival.
Now, the question is how many people in that room need to either infected naturally or vaccinated in order for that bug to say "eh, I'm going to go looking for some other susceptible people,"? Probably somewhere between six and nine out of that group, because the bug is going to float around the room and it may miss that one person and say "nah, I'm out of here" or just be dead. The answer to this question is, in the past, we approach higher rates of immunity in the population, whether it be from natural infection or vaccine, the greater the chance that individual doesn't need to get a vaccine. However, we're not seeing those rates in this population yet. I think arguably, maybe, 30% of the U.S. population has gotten it, so we still have seven people in that room that haven't gotten it. It's plenty of people, including the hypothetical friend, who could get it.
I think until it's really clear that there's immunity in that room - what we call "herd immunity," - or herd immunity in our community, our state, our country, then a person should still get vaccinated. I think it's not a wise decision [to not get vaccinated]. Most younger people, you know, as expected, do not seem to get as sick with this organism. Although, you may have seen yesterday that the congressman-elect who was forty died from COVID. There are younger people getting infected by this, and the new variant that's out there - this is no surprise, there's a new variant - that started in the U.K. and they broached it in the past couple of weeks, it's essentially that same RNA with a couple of changes in it. It appears to be more transmissible. Hopefully it won't be more virulent or lethal, but it seems as though it's probably more transmissible - transmissible meaning that instead of needing 100 viral particles to get sick, you only need 50 viral particles to get sick - so the chances of getting sick are greater.
However, the upside of that - and this has not been talked about in the news - is that in the world in virology, there's a general truth - a general truth, not an absolute truth - and that is as you increase transmissibility, the ease to become ill, you reduce lethality. As something becomes more transmissible, your chances of getting sicker from it than the one that was less transmissible is less likely. There's a reason for that, from a practical perspective it's sort of easy to understand. The sicker an organism makes you, the less likely you're going anywhere. So if you take SARS or MERS, that were highly lethal, they really made people highly sick, those people stayed at home. They couldn't go anywhere; they were too sick to go anywhere. Now arguably you could say "well, some of them had to make it to the supermarket so they could survive and they dragged themselves out of bed," but for the most part, with the increase in transmissibility, it means that you're not as sick, so hopefully this may actually be better. It still has to be proven, but again, this is a general rule in virology.
Ambjor: That is an interesting one, and you're right, that isn't something that is widely known, but it definitely makes sense.
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Ambjor: Shifting gears here a little bit- last time we talked to you it was very early on in the pandemic. Has there been any changes in regards to testing in the last six months or so that you could talk about?
Dr. Hoffman: Yeah, there's been enormous changes in testing since we last spoke. Currently, there are two ways to diagnose COVID reasonably, simply. One is the PCR, which is actually looking for the RNA inside of that little golf ball (see above) and there's antigen, which is looking for the spike protein.
Now, let's talk about the PCR for a minute. Up until a few months ago, the only way to get a PCR test was to have some probe stuck to the back of your nose and tickle your brain - people didn't like it - then put it into a little jar and it goes to the lab where anywhere from one to fourteen days later, it's very variable, you'd get a test result. It's an accurate way of doing things, except, unfortunately, it was very slow in many cases. The other way to do a PCR is now they have rapid test PCRs. They can just take some nasal swabs or even some mucus from the throat and they can put it onto a little cassette-looking thing and stick it into a little machine present in the office, and they can determine reasonably, not totally accurately, determine if the PCR is positive and the RNA is there. You can still get the laboratory-based one, or you can find a place that's doing rapid PCR.
Now, there's the antigen test. The antigen test has come onto the market, and these are what's called lateral-flow cassettes. They're similar to those little antibody tests that we were doing early on in the pandemic that had really serious accuracy problems. The easy way to understand how it works is that it's very similar to an at-home pregnancy test. You urinate on basically the same type of paper and there's something in that piece of paper that binds with the hormone that comes out in pregnancy that shows positive, and usually people go to the doctor to confirm it. So those little lateral-flow antigen tests are around. They're not expensive, they're very accurate if they're positive. They're 99% accurate if you have COVID. They're 90% accurate if they turn out negative. One out of ten negative tests that are done is an error, and that person is positive. So, they have that inaccuracy for people who are carrying the virus but it doesn't show positive.
Curtis: And that's very similar to pregnancy tests as well, it's just that there's not enough of the hormones to detect that it's there. Correct?
Dr. Hoffman: Yeah, or- you know, there's a rule in laboratory science: as you increase sensitivity, the sensitivity and specificity, as you increase one, the other is going to go down. There are no tests that are 100% sensitive, 100% specific. If the nature of the technology that you have to - and it is a screening technology - that you're always going to be looking for somebody that's positive, but you'd be willing to accept certain inaccuracy in that type of test, and that's just how you do screening. What you should do if you have a negative antigen test and the doctor or the clinician feels as though you have symptoms of COVID, meaning that the test showed negative but in fact, you lost your sense of taste and smell, you should always follow it up with a PCR to manage the false negative.
However, these tests are really good for surveillance and screening purposes. Where we've been using them in workplaces - they're inexpensive - to screen otherwise non-symptomatic people. While they're not 100% accurate, they're accurate enough to make it possible to reduce the chances that someone who is sick, or carrying the virus, comes into the workplace.
Curtis: Well, it sounds like the general idea is that there's no one single thing that is able to be helpful. It's not just wearing a mask helps, it's not just screening, it's all these different things together make for an effective combatant against it. I've been curious about this; it seem the measures that people take on worksites where they are doing screening, such as temperatures, questionnaires, mask or face coverings... Has anything changed in regard to what we first thought people needed to be screened for compared to what they are being screened for now? What are some of the more effective signs that are being screened for?
Dr. Hoffman: Well, Curtis, first of all, risk management is always about multiple layers of doing things. We may have spoken about this in the past, it's the Swiss cheese model. You can make people line up like six pieces of Swiss cheese, and you may be able to make it through the first hole, maybe the second hole, hopefully not the third-fourth-fifth holes - you have to layer risk management strategies on top of one another to reduce the chances of whatever adverse outcomes you are trying to find will occur.
In regards to what you're just mentioning, you're going to want to have access controls. Access controls would be somebody answering questions, and we all know those questions because they're asked to us multiple times a day now: have you been around anybody [with COVID-19], are you symptomatic, etc. Then taking somebody's temperature, then when they reach the workplace, keeping people away from one another. There's multiple ways of trying to enforce that. Some are easier than others depending on the work situation. Then the last layer after the separations in the workplace and disinfection would be testing, some surveillance or screening type of testing. I think if you have all those in place, I think you can approach zero chances - not having zero people in the workplace having COVID, but the chance of them transmitting it to somebody else in the workplace - approaches zero.
I can tell you from an empirical or experiential perspective, mine - we work with hundreds of workplaces - it has been effective. We have seen very little transmission at employers that have instituted all of those controls, that is, the layers of Swiss cheese. They have five or six layers there, and they have not been able to make it through to transmitting in the workplace.
Ambjor: Dr. Hoffman, kind of as a final summary of our COVID update today, what are some final words that you would have for our listeners? Some words of hope, or just some advice on getting us through to what our new normal is?
Dr. Hoffman: It's a good question and I've been writing about that - I don't know if you folks read my brief every week - but you know, we're at probably the next-to-last phase of this pandemic. We have turned the corner, there's no doubt about it. I think the most important thing is for people to not lose the stamina and the efforts that they have going. I see all around me that people have COVID fatigue. It's pretty significant. It's certain that people have said "you know, I can't deal with this anymore, I'm just going to go about my life," and I understand that, however, they may be going about their life but their exposures do impact other people. They could easily be non-symptomatic or minimally symptomatic as they're out and about, and they can infect a family member, a friend, a coworker. I think it's about stamina to take the last-, you know, we're sort of in a baseball game in our fourth overtime and everybody's exhausted, but we're reaching the end of this. These vaccines are going to work, and I think people need to believe the signs. I've worked with adult children and have told them "look, really, stay in your bubble. People can go out and do their things with their friends but they've got to be in your bubble. Stick to your bubble, and let's just get over this thing and hopefully, the light is here at the end of the tunnel. And get the vaccine!" That's really about all I can tell people. "Hang in there."
Curtis: Well I think that's great advice and encouragement to know that things are getting better. We are in that final stretch, I feel like, and taking that opportunity when it comes to you. So if you could just remind our listeners where they can view your weekly updates.
Dr. Hoffman: Go to worksteps.com and every week what we do is, during that week we are reviewing the world's literature on COVID-related issues, and there's usually anywhere from ten to twenty articles, each summarized, most of which you probably would not have seen, some which you've probably seen in the news, and our review of it goes into more detail. In the front of all that, I write a one to two-page letter summarizing some important points from that week or going over an important issue that is primarily employer-related, that employers need to think through. This past [week's brief] I sort of summarized the past year, really talking about if you're a leader in your organization - I'm not talking about the CEO, I'm talking about somebody that manages people and is dealing with all of the stuff these days - I gave some ideas on how to do it. It's based on an article in the Harvard Business Review about management in this period of time right now. We also go over things like travel restrictions, changes in EEOC requirements- it's usually what the hot topic is of the week and then the news. Just go to worksteps.com, you'll see a banner on the top.
Although I do my piece, which is really the letter at the top, there are several people that work on this all week long and I really want to recognize them for the hard work they've done. The newsletter is being read by 40,000+ people, so I think that we've been successful in trying to help people manage things.
Curtis: And that's great that you're getting those messages out, and anytime you do something weekly, that is a huge commitment, so thank you for doing that, and we really appreciate your time and giving us an update on where we are and where we're going. Thank you so much for your time.
Dr. Hoffman: You're welcome, and please have a happy new year, and feel free to get back in touch with me if you want to talk again in the future.