U.S. Should View India as Cautionary Tale

Kevin Kavanagh, MD, saw how disruptive COVID-19 was going to be long before most other health care experts. Kavanagh, a member of Infection Control Today®’s Editorial Advisory Board, now sees promising signs, foremost among them the number of people getting vaccinated and the diminishing COVID-19 case counts. There are also things that worry him. Vaccine hesitancy, for one. In some areas of the country, only about 50% of health care workers have been vaccinated. He’s advocated that health care workers who refuse to get vaccinated should seriously consider not working in health care. Nursing homes need adequate numbers of well-trained personnel and they must be vaccinated, and infection preventionists should be at the forefront of encouraging that…. [I]nfection prevention is our key at encouraging vaccinations and setting up strategies to increase the vaccination rate in health care personnel.”Also, COVID-19 doesn’t have to kill you to make your life hell. Society places too much attention on mortality rates and not enough on what might be the effects of long-haul COVID-19. The latest studies about this don’t look promising. Kavanagh recently talked to ICT® about these matters and much more.

Infection Control Today®: Let’s start with the good news first, Doctor Kavanagh. What are some promising signs that you see?

Kevin Kavanagh, MD: Well, the good news is, is that COVID-19 rates are much lower than what they were over the Christmas holidays. They are down. In some areas, they’re continuing to decrease. And we have a workable vaccine that appears to be highly effective to the predominant variants in the United States along with the wild strain. And because of that, we have the tools needed to really snuff out this pandemic. And that is extremely encouraging. For us who are fully vaccinated, although we still have to take some precautions, we can get out and about and have—slowly—a more normal way of life. You can visit your relatives that are fully vaccinated, your grandkids. All of that can be done much safer than it could have been done several months ago. And with the rates low in many communities, that also adds to some of the safety. And so that is the good news.

ICT®: OK. Let’s hear it. What do you see as worrisome at the moment?

Kavanagh: Well, what’s worrisome is that some of the communities where rates are low—it’s not all of the communities…. We have large sections of the nation that are vaccine hesitant, they are not getting the vaccine. And this is going to be a setup for reinfections. For example, in Kentucky statewide, 41% of individuals have had at least one dose of the vaccine, and over 30% have had two doses. Well, that’s not enough to return to immunity with the new variants. If the new variants are both more infectious and more lethal than the wild-type virus, and you haven’t approached a

Kevin Kavanagh, MD

50% mark in your immunity in your communities, you’re really set up for reinfections. And we have nobody to blame but ourselves. We have appointments in Kentucky for vaccinations, which are not being kept. We have empty slots for appointments. We have some vaccination clinics that are walk-in clinics and have virtually no one there. And this is predominantly in rural areas. Then you have other sections of Kentucky and, of course, of the United States, where they’re achieving a good level of vaccination. But unfortunately, as a country as a whole, if we don’t control this virus everywhere, it’s going to continue to spread. It’s going to continue to be endemic. And really, we could wind up like India, and it’s just horrific over there. And I need to add that by far, the thing that is most concerning is that even health care workers do not have a high rate of vaccination. In many of the rural areas, it’s around 50%. And that is unacceptable. You can’t get the general public in these rural areas to become vaccinated, if the health care workers themselves are not getting the vaccine. We need to do that to get control of the virus, to get it so we can get case tracking again. If we get hit by a variant that is vaccine resistant, we will have the knowledge, the available resources in order to control spread. We’ve got a way to go. And if you look at what’s going on in India, they had close to 250,000 cases, 3500 deaths, and by some estimates, they’re only counting maybe one out of every 30 individuals. That’s vastly undercounted. And this is extremely disturbing because India has the double mutation variant. That’s the variant that has two escape mutations. And that is a variant we do not need to get into the United States and have it spread. Infection preventionists need to be out there beating the drum: First in their facility, they need to get everybody vaccinated. Because that will then set the example for others. It’s hard to convince a patient to become vaccinated when they were just escorted to the room with a nurse who did not have the vaccine. And with the variance, even the E484K variant, you can become infected if you have the vaccine. Now, you may not get severely sick. Hospitalizations are markedly down if you’re vaccinated. Asymptomatic carriage is quite high, so people tend not to show symptoms. But you can still spread the virus to others who do not have the vaccine yet. And some people, as you know, can’t get the vaccine. They have significant health problems, or the vaccine isn’t going to be that effective for them because they’re immunocompromised. You need to get the vaccine. And I should add that this problem of long COVID: That is also confounding. We focus too much as a society on whether or not you live from the infection rather than long-term consequences. And right now, best evidence is indicating that 10% to 30% of individuals with mild to moderate COVID-19 will continue to have some symptoms many, many months after the illness. And those symptoms may be permanent. A recent study from the VA looked at over 70,000 individuals. And they tracked these individuals from 30 days to six months post-COVID. Now they were over the acute phase. None of them were hospitalized. They had a 59% increase in fatalities over those patients who didn’t have COVID. And that would equate to eight deaths per 1000, which would almost double the fatality rate from the wild COVID virus. I really think that we need to take this seriously. Just because you get a mild infection doesn’t mean you’re out of the woods, doesn’t mean you’re not going to have long-lasting health problems. You do need to get vaccinated because you want to avoid severe infections with these severe variants. But right now, the prevalent virus in America is the UK variant and the wild type. And for those two viruses, the vaccine—if you get both doses—is highly effective. Let’s go out and get vaccinated. Drive the case numbers down low enough. Our public health staff can contact trace and isolate the other more dangerous variants. And it starts in the hospital with hospital staff becoming vaccinated.

ICT®: What you’re talking about is right in the wheelhouse of infection preventionists because they are often part of vaccination efforts in hospitals. How do you convince somebody who’s hesitant to do something? It’s more or an art than a science, right?

Kavanagh: Well, it is. You may have to make sure that people who aren’t vaccinated maybe not have contact with high-risk and immunocompromised patients. You may also need to provide incentives currently, because these vaccines are under an emergency use authorization. They are not approved by the FDA, but it’s an EUA by the FDA. It’s very difficult to mandate, but certainly you could be giving incentives for people to get vaccinated. I mean, Krispy Kreme is giving a free doughnut to everybody in the United States that has a vaccine. I think it’s one donut every day. That may be worse than COVID. I don't know. Just as an aside, you can put on a lot of pounds on Krispy Kreme doughnuts. But no, it’s not worse than COVID. I’ll take that back. But we really do need to provide incentives for people to get vaccinated and I think that’s key. And then if they’re not vaccinated, they need to really be placed in an area where they’re not going to put high-risk patients at risk. Hospitals, that’s easier to do. But for example, nursing homes, we have a very high rate of unvaccinated health care workers. In Kentucky, the one severe outbreak we had in a nursing home was from an unvaccinated health care worker who brought COVID in. And even vaccinated patients got sick. And this was one of the E484K variants. This is just key. We absolutely need to vaccinate individuals. And in nursing homes, I think it should be mandatory that if you’re not vaccinated, you really need to find another job. Morally, you should do that. I know you will hear, “Well, we can’t find people to work in nursing homes.” But frankly, who wants to work in nursing homes with their history of COVID-19 and a bunch of coworkers that aren’t vaccinated? I think establishing a safe workplace is the first step you do to try to get a good trained and adequate staff at nursing homes. And, again, infection preventionists should be at the forefront of encouraging that. So first, medicine needs to really get their act in order. And infection prevention is our key at encouraging vaccinations and setting up strategies to increase the vaccination rate in health care personnel.

ICT®: When you mention incentives, I immediately think about money. Would offering a health care worker a $1,000, $2,000, or $3,000 bonus perhaps act as a good incentive? Or does that open up a whole new can of worms with those who’ve already gotten the vaccine resenting that they didn’t get the bonus?

Kavanagh: Well, and that’s true. You have to look at people who have already been vaccinated. But they’re talking about on the federal level of giving tax incentives to people that have become vaccinated. And I think that will help. And certainly, I do think that facilities will be seriously looking at if someone gets COVID-19, and they’re not vaccinated and refused a vaccine, are we going to be stuck with paying for time off, hospital costs, disability, etc.? And that’s something that an employer is going look at hard. You may have a right to not get a vaccine. But do you have a right then to inflict the consequences of that? Financial, both exposure to patients and families? Do you have that right to inflict that on others? Those are some things that are going to be hard questions, but certainly in a health care setting, such as a nursing home, and such as hospitals, vaccinations are imperative. And right now, the tools that we have at hand are both education and providing positive incentives. For nursing homes, I would go a step further and really try to isolate individuals who aren’t vaccinated and keep them away from the nursing home residents. Because they are high-risk. Some of the nursing home residents are immunocompromised. And a vaccine may not take. They need to be protected and they are entrusting their lives in the same individuals that aren’t becoming vaccinated and putting their lives at risk. It’s just morally not the correct thing to do.

ICT®: We talked about tax breaks on the federal level in health care settings. You could have a bonus program where if you can show the card that you’ve gotten vaccinated, you get a certain amount of money. With no card, you don’t get a certain amount of money. Maybe that would help sway some people?

Kavanagh: Definitely. Definitely. I think that’s very true. The other thing that can be done is giving them time off. That is absolutely critical. If they get vaccinated, they may have a few days that they’re down or sick. Or if they don’t, they then have some time to themselves. There are ways that facilities can do this without inflicting a lot of financial burden on the facility and at the same time get a protected workforce that won’t be becoming sick and disabled, let alone infecting other patients with COVID-19.

ICT®: As you know, Doctor Anthony Fauci [director of the National Institute of Allergy and Infectious Diseases and one of President Biden’s medical advisors], has been nicknamed, in some quarters, “Doctor Doom.” Obviously, a pejorative. As I mentioned many times, you’ve been ahead of the curve when it comes to COVID-19. You were one of the first experts to say that this will change everything. Do you worry sometimes that it’s a burden to carry these sorts of messages? Do you feel that people will unjustly label you a killjoy?

Kavanagh: Well, I think, in some respects. But we’ve been doing this now for over a year. And after a while, when your predictions have come true, people then start to listen, and you get less and less of a pushback. And when I say predictions, they’re really just what any scientifically educated person would think is going to happen with the pandemic. It’s not really hard to come to these conclusions. And currently, if you sound the alarm, people may say in the United States everybody’s fine. You’re just a reactionist. But with the news coming from India, in seeing what’s going on over there, they realize that we still need to exercise caution. And if we didn’t take the steps we did last year, we certainly could have wound up just like India. India is an example of what happens if you depend upon the theory of herd immunity. And it is a disaster. And that’s what could have happened over here. And I should add that India, because of malaria, a lot of patients take hydroxychloroquine over there. And that doesn’t seem to have helped much either. About the only thing that has kept us on the right path, in my opinion, has been scientific messaging. And no one has done that better than Doctor Fauci. If you want to put your faith in somebody, I’d put my faith right now in science and in someone who has a good track record, such as Doctor Fauci. And I think that’s key. India is a good example of what we could have been, and avoided. And we have Doctor Fauci to thank and so we shouldn’t be disparaging him at all.

ICT®: OK, Doctor Kavanagh. Do you want to circle back to what you think is promising?

Kavanagh: Well, yes. I do think that right now, if you're vaccinated, you still avoid large crowds outdoors. And certainly, you wouldn’t want to rub up to someone that has COVID-19. But you can get out and about now. You can see your grandkids, your family. You can do some traveling to family members. Of course, you want to make sure that they’re vaccinated too and start to get back to a normal life. All of this is possible at this point. And so that is just key. That I think is very, very important to do. And if we do get vaccinated—and we encourage others to—then we may continue to have improvements in our life, and we will have avoided the fate of India. It’s all up to us. And right now, we should really enjoy the reprieve that we’re having, especially if you’re vaccinated. Still doing things safely. And at the same time, let’s make ourselves cognizant that we still may have further fights to do with both this virus and future pandemics.

This interview has been edited for clarity and length.