Vaccination Insights

Show Notes

Daniel speaks with Dr. Sree Chaguturu, Chief Medical Officer, CVS Caremark about vaccine hesitancy — citing original research around common objections and physician best practices — as well as current vaccination rates, variants and boosters, and what we’ve learned as an enterprise from long term care (LTC) facilities and the federal retail pharmacy program.

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Dr. Daniel Kraft:
Clinicians of all types can play a role in helping emphasize the fact that we've had over half a million Americans die of covid and zero from vaccine. Have you noticed any interesting insights about what might be driving hesitancy and what let's say can doctors and other clinicians do on their one-to-one interactions?

Dr. Sree Chaguturu:
Storytelling matters, really personal stories about how you have gotten your own vaccine and it wasn't that bad and you feel safer. I mean, also in our own survey data, patients who are hesitant and we ask, "Who do you want to hear from?" They always say clinicians. Clinicians first. They are not looking to hear from politicians. They're not looking to hear from athletes or celebrities. They want to hear from you and me and our colleagues about what we personally think about these vaccines. They trust us.

Dr. Daniel Kraft:
Hi, I'm Dr. Daniel Kraft. Welcome to Healthy Conversations. I'm joined by Dr. Sree Chaguturu. We certainly live in exciting pandemic times. You and your team at CVS have been on the leading edge, particularly now that we've ended the critical stage of vaccinations, and I thought we'd start off with maybe the big picture. What are some of the bigger trends that you're seeing for clinicians in terms of covid related data and insights in terms of where we are in the pandemic's trajectory?

Dr. Sree Chaguturu:
We see this incredibly stunning decline over the last few months since the beginning of the year to now in March when we're having this conversation. Usually you would see some discordance if there was a change in trans with cases heading in a different direction than hospitalizations or death. But we're seeing a concordant decline across all three measures. That's really good.
What we see is that there's a change in mobility. We do less so of that in January and February, we're starting to see pockets of immunity, not necessarily that herd immunity that we're all looking for, but those pockets of immunity starts to inhibit community transmission in pockets. The seasonality of coronaviruses. There's a lot of data from other coronaviruses that show that there might be a potential seasonality. And the major piece that's changed is the introduction of COVID-19 vaccines. I'm really excited to talk about what we're seeing in the vaccine space, but I just thought it would be good for us to talk about and celebrate this decline that we're seeing across all these categories of COVID-19 transmission.

Dr. Daniel Kraft:
Yeah, definitely good news. Depends on which data we look at and from what part of the country or part of the world.

Dr. Sree Chaguturu:
Yes.

Dr. Daniel Kraft:
There's some debate about what can someone do once they're vaccinated or how do they interact with folks who aren't?

Dr. Sree Chaguturu:
After a patient has been vaccinated what are those messages? This is constantly evolving. So the CDC has recently put out their guidance that if you are vaccinated or if a patient is vaccinated, how can they interact with other vaccinated individuals or unvaccinated individuals or can they go visit their loved ones and skilled nursing facilities? There will be very personalized recommendations that we need to provide to our patients. I think we learn a lot by every conversation that we have with our patients about what works and what doesn't. I think we also learn a lot by talking to our colleagues about which ways we message to our patients.

Dr. Daniel Kraft:
You spend time inpatient at Mass General, you're interacting with pharmacists at your local CVSs. Are there lessons learned? I mean, most people don't go to the CDC website. They get things filtered.

Dr. Sree Chaguturu:
So at CVS Health, since the introduction of COVID-19 vaccines, we've been doing ongoing surveying of the population about what is actually of interest to you. If you are hesitant, what are the messages that really are important to you to get you over that hesitancy? What we find in our data, in our research is that people are really interested in the safety and efficacy of the vaccines. And so being able to very clearly articulate that these are relatively safe vaccines, we have a very clear understanding of the short-term side effects, we have very little reason to think that there would be any significant long-term side effects and these are highly efficacious.
And talking about the fact that these vaccines are relatively equivalent when it comes to hospitalizations and deaths, it's amazing how much our patients are looking to trusted sources on the internet. So if they see you with your videos online or having conversations, that really goes a long way because they'll share that with their own friends and colleagues and it's a great way for you as a clinician to amplify your messages as a trusted source. So a lot of different ways that we can tackle this, it's going to take all of these methods in concert to get us to the other side of the pandemic.

Dr. Daniel Kraft:
There's an info demo on top of that good and bad information, who to trust and where to get it, and I've seen even my own primary care practice does a very good job of sending out regular updates when things change. Whether it's where and when to get tested, when are vaccines going to be available, latest guidance, et cetera. There's new variants identified in UK, South Africa, a couple coming from Brazil. There's where I am based in California, a new California homegrown variant. How do you and CVS sort of track those and what do you think the implications are going to be for vaccines efficacy going downstream?

Dr. Sree Chaguturu:
As we all know, viruses mutate constantly, and so coronaviruses are well known to not mutate as frequently as other viruses, but yet we do have these variants that have arisen. And part of the reason that we're hearing so much about the variants is that we're now doing more genotypic analysis to be able to identify these variants.
This has been happening since the beginning of the pandemic. If you look at online resources like nextstrain.org, you can see a lot of the phylogeny trees that show since the beginning there's been these variants that have arisen. And we're going to continue to hear more about the variants as well because we're investing more as a country in surveillance. What the CDC is going to be doing is partnering up with laboratories to do a subset analysis where they're going to dive deep on genotypic analysis to look at variants and then upload that data to public data sets so that the scientific community can look at what is actually happening with the genetic variants.
Now, what are we seeing in terms of the three COVID-19 variants of concern? The VOCs, one from United Kingdom, one from South Africa and one from Brazil. And the way that I think about these variants is basically five questions. Does our current testing work? Do the current treatments work? Is the variant more transmissible? Is there more morbidity and mortality associated with it? And then do the vaccines work? Largely the testing and treatment seem to work for all of these variants with varying efficacy. What we're seeing is that across the UK and the South Africa variant, they are more transmissible and then we see that the UK variant is also likely more fatal. Now that Brazil variant that you mentioned, unclear if it's more transmissible or more fatal, but the major concern is there's a higher risk of reinfection. So what we're seeing on the vaccine efficacy is that in vitro you're seeing a slightly less antibody response against the variants than you see it a wild type or reference strain, but all of the vaccine-induced immunity is higher than natural immunity, so you have a cushion effect in terms of antibody response.
With the UK variant, it looks like all of the vaccines seem to be working pretty well. The Johnson & Johnson, the Moderna and Pfizer, but the South Africa variant appears to have some element of escape. But Moderna and Pfizer have both very quickly been able to put forth a new valent, a new vaccine construct that could protect against the South Africa variant. Now the question is exactly how would that actually be put forth into the marketplace and how would we as clinicians think about vaccinating in the setting of rising variants? It could be that you need to have a divalent vaccine, you're going to have to have a wild type plus a South African variant and you're giving a dose that has both. Or, and that's sort of what Moderna's looking at, do you give a booster with just South African variant or do you do a combined.
Pfizer's looking at, well, we see a dose response in antibody response to vaccines. So if one dose gives you X and two doses gives you 2X, why not just give three doses? And so they're actually looking at a three dose regimen that could boost your antibody response, potentially protecting you without having to develop the South Africa variant on widespread and give a South Africa boost. It's just using the current vaccine, but a three dose schedule. So the variants, I think the summary here is that they're of concern, but the industry is responding really quickly and we're going to have a better science in the upcoming weeks and months on what to do.

Dr. Daniel Kraft:
This has been discussed by others that in a form of the annual flu vaccine, where if variants keep evolving, the mRNA and other vaccine platforms could evolve to give you a new valency maybe every six months, every year depending on what the public health measures and testing are showing. Is that an expectation that might be a future path where we can end up with an annual COVID booster that addresses new variants?

Dr. Sree Chaguturu:
That's right, Dan. I mean the original participants in these trials with Pfizer and Moderna are being tracked for two years. And so they're going to be on an ongoing basis looking at antibody response in those patients and determining when do we see antibody response declining and therefore that will have implications of when we would need to do a booster. I'm kind of entering into this with the assumption that this is going to be every year or every other year that you would need some sort of booster. The question is it a booster every year or every other year or do you redo the entire schedule? So you need to do another two doses. I think by the end of 2021 we'll have a better sense of what that looks like.

Dr. Daniel Kraft:
And now of course we've got the new Johnson & Johnson single dose vaccine. It's sometimes thought to be maybe less effective, but again, there have not been head-to-head trials. What's your perspective on the J&J vaccine?

Dr. Sree Chaguturu:
I'm so glad you asked about Johnson & Johnson and if we try to put all of these trials up against each other, it's very difficult to do comparative effectiveness. So Johnson & Johnson, having started the trial later, and also their trial was essentially a third in the US, a third in Brazil in Latin America, and then a third in South Africa. And if we think about where these variants of concern are, the Brazil and the South African variant, they were testing their vaccine where these variants were. Moderna and Pfizer didn't have to contend with that when they were conducting their trial. Johnson & Johnson's overall effectiveness was 66% on moderate to severe, but a hundred percent in preventing hospitalizations and death. So if we think about what we're trying to do, prevent the stress on the health care system and prevent people from dying, Johnson & Johnson's trial data shows it's essentially perfect in terms of efficacy on those two measures.
So that one dose effectiveness is really a great option. For example, let's say it's a patient who's been hospitalized and you're trying to make sure that they're vaccinated before discharge, and so that might be a great way of using the Johnson & Johnson vaccine in a way where you might not have follow up.
In general I think as clinicians being able to continuously tell the story that whatever vaccine you can get is the best vaccine for you is really important because our goal is to as quickly as possible get as many people vaccinated as possible to prevent community transmission and having more vaccine choices in more vaccine locations is going to help us get to that goal.
There's a multitude of tragic figures in terms of the impact that COVID-19 has had on our country. We have a half a million people who have died from COVID-19, but when we look at the mortality rate by race and ethnicity, what we see is black populations had a 40% higher mortality rate and Latinos had a 20% higher mortality rate than white population.
And then when we look at vaccines and vaccine hesitancy, when you start to cut it by race and ethnicity, what you see is that there's higher hesitancy among blacks and Latinos compared to whites or Asians. And we've seen that in data that CVS Health has done, and we've published two white papers on this that showed hesitancy from November to January. And what we saw was a 10% increase among hesitancy in blacks and a 5% increase in hesitancy among Latinos in those time periods.
Our most recent data, internal data shows that it stabilized and softened a little bit, which is really good, and we're starting to build trust across all race and ethnicities. And at a state level, we then look by social vulnerability index at the zip code level to determine which stores that we're going to turn on to provide vaccination services. And we over-index for high vulnerable communities. And so we also have a workforce that is over 40% people of color. And so as vaccine continues to become more available, we're going to continuously grow our offsite clinics and hard hit neighborhoods as well as we partnered with Lyft to provide reduced or free transportation. We're a founding member of the Ad Council and the Black Information Network to ensure that our messages about the safety and efficacy are amplified. So using our stores, extending beyond our stores, education and trust are really important in addressing vaccine hesitancy and health inequities.

Dr. Daniel Kraft:
We need precision messaging and not just medicine to the right population. It has actually lots of roots. Everything from the Tuskegee experiments, et cetera, and clinicians of all types can play a role in helping emphasize the fact that we've had over half a million Americans die of COVID and zero from vaccine. Have you noticed any interesting insights about what might be driving hesitancy and what can doctors and other clinicians do on their one-to-one interactions?

Dr. Sree Chaguturu:
Storytelling matters, really personal stories about how you have gotten your own vaccine and it wasn't that bad and you feel safer. Also, in our own survey data, patients who are hesitant we ask "Who do you want to hear from?" They always say clinicians. Clinicians first. They're not looking to hear from politicians, they're not looking to hear from athletes or celebrities. They want to hear from you and me and our colleagues about what we personally think about these vaccines. They trust us. Just earlier today, I had somebody say it was the conversation that mattered and it was the personal conversation, not the stuff that they read, but the personal conversation that convinced them to get the vaccine. And that really heartened me.

Dr. Daniel Kraft:
Some clinicians are getting on TikTok or making YouTube videos, and again, you can make one specifically for your practice, make it fun and informational and match your population and meet them in different ways. My parents who live in the Washington DC Beltway area about a month ago scrambling to get them on a website and scheduled and finally refreshed enough times to find one appointment. What are some of the lessons you've learned?

Dr. Sree Chaguturu:
There are a lot that we've learned over the course of the past few months. We've participated in two major programs. The first is the Federal Pharmacy Partnership for Long-Term Care, where we've partnered with 40,000 skilled nursing facilities and long-term care facilities and have provided over four million doses across 70,000 plus clinics that we've done in these 40,000. And we're in the tail end of finishing that up.
So we learned the logistics. In addition, what we saw was the impact that the vaccines had. Essentially three weeks after that program started, you see a divergence in the number of cases and hospitalizations and deaths in the general population compared to what you see in skilled nursing facilities. And then with the second program that we're in, which is the Federal Pharmacy Partnership, we've partnered up with the federal government to get vaccines for our retail pharmacies that allows us to do general population vaccinations.
That rapid dissemination of knowledge, we actually built a lot of that lessons learned from testing because we were rapidly scaling out testing throughout 2020, prototype it in one store and move it out to all the other stores. On the vaccine distribution I think we're halfway through telling that story. I look forward to talking in a future conversation about the lessons learned in vaccine distribution. It was really challenging in the early days in terms of who got how much vaccine, but we're getting to a better spot where people are better able to predict how much demand that they have in any one hospital or clinic or mass vaccination. And then those lessons learned will be really important of how we distribute therapeutics and vaccines in the next pandemic.

Dr. Daniel Kraft:
And we're certainly in encouraging times competitors like J&J and Merck working together to increase the supply. When I got my Moderna shot, I got my little CDC card and it's written on paper. Where do you see this heading now with the idea of almost a digital yellow card for enabling travel, connecting to your passport or the fact that you might have tested negative that morning if you're not yet vaccinated? There's platforms like CommonPass, and I think even the Clear platform that works with TSA has elements, but there's almost too many of these platforms.

Dr. Sree Chaguturu:
Definitely. I mean, we're only going to see the role of digital and our ability to track our own health using digital platforms grow over time. As we think about this return to normalcy, there's going to be a coupling of testing and vaccine data that we will need to furnish for different use cases. You might be going to an event and the event might have people who are vaccinated able to stay closer together than people who might not be vaccinated or tested.
Given that there's going to be different use cases, they're going to be different platforms. For those people who are providing vaccination services, we're going to have to be able to play with multiple formats. I really don't think that you're going to see one dominant platform given the multitude of use cases.
So at CVS Health, we fully expect if you've gotten your services from us, you have a digital record from CVS Health that shows your vaccination, and not just COVID vaccinations, but all of your vaccines that you received from CVS. The growth in digital and the growth in these credentialing services will only continue.

Dr. Daniel Kraft:
I think it's going to help connect the dots to the point no matter where you got vaccinated, it might show up in your Apple Health kit or on your Android platform, you'll have the QR code, which enables you to jump on that plane or enter that event. You still need to take into consideration the sort of digital determinants of health and who has access to the digital versions versus paper, but tremendous opportunities there.
It's interesting now a lot of work has been going on about repurposing, let's say generic drugs to treat, let's say early COVID. Is CVS Health and with all its data and the ability to look at who's prescribing what often off-label, maybe not as part of a clinical trial, maybe able to pick up on some markers about other elements that might be effective. Whether it might be a patient's vitamin D level and risks to the fact that they might be on a particular neurologic drug that protects them in some way, that might help us give us insights for this pandemic or future diseases in general.

Dr. Sree Chaguturu:
The way to think about CVS Health is that we have three core businesses. We have our health benefits with Aetna, retail with CVS Pharmacy, and our pharmacy benefits manager, CVS Caremark. Each one of them has significant amounts of data. But what we see on the Caremark side, and that's where I am as the medical officer for CVS Caremark, we've seen throughout the pandemic rises in falls and geographic differences. It maps up to where you see hotspots. And sometimes what we saw was that the medications were moving sooner than what we saw in the epidemiologic data.
The other piece is that we could see increases in prescriptions, which we were able to work through to make sure that there wasn't any discontinuity in therapies, for example Kaletra. Early on there were some questions on whether or not Kaletra would have some antiviral effect against COVID, and so we wanted to make sure that patients who have HIV still had access Kaletra. There is a lot that can be done with this data that we haven't used in these ways before, but can help us in this pandemic and in future.

Dr. Daniel Kraft:
In the sense some of the silver lining of this horrible last year is that it's accelerating things. Sputnik was a catalyst for the space age, and COVID is a bit of a catalyst for a health age. And a lot of the new collaborations, new forms of getting vaccines developed, new forms of understanding how better to deploy therapies, vaccines, public health efforts, testing, tracing, isolation to PPE are all going to hopefully give us benefits across many disease paradigms.

Dr. Sree Chaguturu:
Well, if we think about how did we respond so quickly to SARS‑CoV‑2 is because of the lessons that we had from MERS and SARS‑CoV‑1. So I think you're spot on. The lessons that we learned from here, even if they don't get applied to SARS‑CoV‑2, there will be another reason for us to apply the lessons learned on testing platforms, therapeutics, vaccines to future pandemic. So I'm right there with you.

Dr. Daniel Kraft:
My friend, Dr. Larry Brilliant, who helped eradicate smallpox often frames COVID-19 as a practice pandemic, meaning the fatality rate is relatively low, and there certainly have been others that if they get out there in the next generation could be much worse. But now we're all sensitized as individuals, as communities to be [inaudible 00:22:25]. How do you collaborate with the competitors, the Walgreens and others of the world, maybe in sharing vaccines when one is short in one location or another? There have been some interesting surprising collaborations or learnings that have come even from competitors?

Dr. Sree Chaguturu:
We have been in constant contact with our colleagues across the health care spectrum. For example, long-term care facilities, and Walgreens was the other major pharmaceutical chain that was identified by the federal government to provide vaccinations in LTCs. And we worked together to figure out what does that actual day of clinic look like. I mean, it was all in our best interest to make sure that we got vaccines to the site, we got vaccines to the site safely. We made sure that we used them efficiently. That patients got the right consent forms, and that we were able to bring back any excess doses and use them appropriately. And as you've said earlier, it takes a village for us to get through this. And it is been great to have colleagues across the country to work with.

Dr. Daniel Kraft:
It's an interesting opportunity. I've certainly collaborated with folks I would've never met through the pandemic, and it's helped catalyze a lot of conversations as well as hopefully impact. But given your experience, we both trained at Mass General where sometimes things take a long time to shift, and what might be your vision for where health care might be in 10 years informed by the pandemic and some of your other related work?

Dr. Sree Chaguturu:
I think we're going to see an explosion of new platforms for diagnostics, especially in the point of care space. And then how does that couple with digital? And I think we're just going to see more and more mRNA platforms and therapeutics moving forward. Not only vaccines, but in other areas as well.

Dr. Daniel Kraft:
One of my favorite quotes from Bill Gates is we tend to overestimate what will happen in a year, underestimate will happen in a decade, and I think the next decade will make the last 10 years look slow.

Dr. Sree Chaguturu:
And I really feel optimistic about what the rest of 2021 has for us. So I just want to thank all of you who have been listening for all that you're doing and getting us to the other side of the pandemic.

Dr. Daniel Kraft:
Great. Well, thank you so much, Sree, for all the work you're doing, all your colleagues at CVS Health, and Caremark. It's certainly a team sport, a lot of innovation, a lot of collaboration globally. And again, we're all in this together and let's keep these healthy conversations going because as you mentioned, it's often those one-to-one communications between a provider and a patient or the family members that really help change perceptions.