Assessing A Turbulent Year in Infectious Disease: Dr. William Schaffner, Professor of Preventive Medicine at Vanderbilt University School of Medicine

Lindsey Smith

Hi, I'm Lindsey Smith, welcoming you to Raise the Line from Elsevier, an ongoing exploration about how to improve health and healthcare.

Unfortunately, this has been an especially busy year for infectious disease experts who have been tracking controversy over federal changes to vaccine policy, a resurgence of measles, an unusually rough flu season, and most recently the outbreaks of hantavirus and Ebola.

That's why we're grateful today to be joined by Dr. William Schaffner — one of the country's most frequently quoted medical experts on infectious disease, vaccination, and public health — who can help us sort through these consequential topics.

Dr. Schaffner is Professor of Preventive Medicine in the Department of Health Policy as well as Professor of Infectious Diseases at the Vanderbilt University School of Medicine. He is past medical director of the National Foundation for Infectious Diseases, and that organization's liaison to the CDC Advisory Committee on Immunization Practices.

Among many honors, Dr. Schaffner has been recognized by the American College of Physicians, the Infectious Diseases Society of America, and the American Public Health Association. Doctor Schaffner, thanks so much for joining us today.

Dr. William Schaffner

It's a pleasure, Lindsey.

Lindsey Smith

So I'd love to start with you. What first got you interested in medicine?

Dr. William Schaffner

I became interested in medicine as a child when my family doctor arrived at our house with the proverbial black bag and took care of me and my brother. I'm the first in our family tree who decided to become a doctor. It was a magical beginning. I have no idea except that that's my memory.

Lindsey Smith

That's an awesome story. And I like that your family doctor inspired you at a young age. Your path took you somewhere pretty remarkable, though. Early in your career, you worked for the CDC. What was that job like and do you still draw on that experience today?

Dr. William Schaffner

Short answer is I absolutely do, every single day. So back then, the draft selective service was in force, and through a number of happenstance associations, I was told that I could apply for a commission as an officer in the United States Public Health Service rather than serving in an armed service such as the Army, Navy, or Air Corps.

So, I applied, and to my great delight and a bit of a surprise, I was accepted and was assigned to, because I had an interest in infectious diseases, to what was then known as the Communicable Disease Center. There were two kinds of assignments. You could stay at the home office, as it were, in Atlanta, where the CDC is located, or you could be assigned to state or local health departments where you would work locally and then could be on call by the CDC. I selected the latter because I wanted to be out where the action was, and I was assigned to the State Health Department in the state of Rhode Island, whereas I like to say, wherever the outbreak was, I could be home for dinner. It's a small state. I had an absolutely wonderful experience there.

The CDC also selected me on one occasion to go on an epidemic aid mission to the country of India in alliance with the World Health Organization to evaluate the malaria eradication program in India, which brought me to very distant rural areas of India investigating that program. So I had a wonderful domestic experience and also a wonderful international experience with the CDC. 

I came back to Vanderbilt to finish my residency. I've been here ever since and I have stimulated and encouraged students to also have public health experiences, whether locally or internationally, and I've continued to work in the epidemiology of infectious diseases.

Lindsey Smith

Wow, the CDC experience sounds like an awesome experience for you, especially the epidemic aid mission in India. So, in addition to your time as an employee, you've interacted with the CDC for years on vaccine policy and you've sharply criticized recent actions on vaccines by the current administration both in terms of process and recommendations.

Can you help us understand what the most significant changes have been and what your concerns are today?

Dr. William Schaffner

Well, Lindsey, I was a former member of the CDC's Advisory Committee on Immunization Practices. And when I rotated off that, I became what's called a liaison representative. That is, you are accredited to the ACIP by a professional organization. The liaisons participate fully in the discussions that lead to recommendations as to how vaccines are to be used. But we don't vote, only the full members vote. But nonetheless, you're part of that whole environment.

I was part of it for well over thirty-five, even forty years. And so when a year ago the ACIP members were all let go, fired, actually, and the liaisons all equally discharged, the committee was reconstituted with people who seemed to be professional vaccine skeptics or even anti-vaccine people, many of them. And when they began debating issues of vaccine safety that seemed to be completely unsupported by data, that was very disappointing. 

So yes, I expressed my disappointment that this remarkable structure that helped guide the way vaccines were used in this country for sixty-plus years had been so perverted. That distressed me greatly and continues to do so.

Lindsey Smith

That's a really clarifying explanation and a bit sobering at the same time. I think it's clear that these aren't minor shifts, but changes with real consequences. And we're already seeing some of those consequences play out, perhaps most visibly with measles. Let's stay on measles for a moment here. S,o the US hasn't seen measles transmission at this scale in decades. Are vaccines the only answer here, or are there other interventions and tactics we can pursue at this point?

Dr. William Schaffner

Well, the issue is a bit complex, but the solution is seemingly simple, but also complex. The solution obviously is vaccination. Measles vaccine is remarkably effective and wonderfully safe. Every vaccine has rare adverse events, so when I say safe, I mean safe in the general sense. No vaccine, no drug is perfect and has no adverse effects, but those associated with the measles vaccine are indeed very rare and the vaccine has been used in the millions upon millions upon millions of doses globally. It provides — when you get your two doses — a durable immunity that we think is lifelong. Can't hardly do better than that, to prevent a really serious illness that can threaten the life of young children and adults if they're unvaccinated. So getting everyone to accept vaccine is seemingly simple.

But there are people who are literally anti-vaccine for some reason. I can't reach them. But there are many people who don't know anything about measles and know less about vaccines. They're vaccine hesitant or vaccine skeptical. That middle group of people, those are the folks whom we can reach. We have to listen to them, we have to respond to their interests, their questions, their concerns, and then not only provide them facts, but make them feel comfortable, make them feel reassured.

You see, the behavioral psychologists have taught us that although information is fundamental, behavior change comes with a change in attitude. Information goes to your brain, but your attitude goes to your heart. How do you feel? And you have to feel comfortable and you have to trust in your healthcare provider.

We're going to have to learn to regain and extend that trust and to make people feel comfortable and reassured that what they're doing for themselves and for their children is in everyone's best interest.

Lindsey Smith

Let's play that back for just a second. So you mentioned that the measles vaccine is the answer and is safe overall, but there's also another piece to this puzzle: education, trust, communication, and a behavior change piece here as well. 

Measles wasn't the only respiratory illness making headlines, though. This past flu season, was described as unusually severe. Can you help us understand what drove that and what lessons we're drawing from it?

Dr. William Schaffner

Well, the severity of the past season is driven by really two things. The first is there was something of a change, a mutation in the influenza virus that made it able to evade some of the immunity in our population that had been accumulated through past experiences with the influenza virus itself and with vaccine. The second thing is that the vaccine was not a perfect match with the changed influenza strain. Nonetheless, the vaccine still provided a great deal of protection against most severe disease.

This is a bit of a paradox. Influenza vaccine, even at its best, is not so good at preventing milder disease, but does prevent substantial numbers of hospitalizations, intensive care unit admissions, and as I like to say, it prevents a lot of admissions to the cemetery, also.

Lindsey Smith

That makes a lot of sense regarding the change in mutation and the vaccine matched to the strain. And I appreciate you connecting the dots. It's helpful to understand the why behind a season like that, not just the headline. 

Let's go ahead and turn our attention to Ebola. There is a troubling Ebola outbreak in Africa, which continues to grow with over 800 confirmed cases and 180 deaths as of today, June 15th, when we're recording this.

Why do you think this has been so difficult to contain and what course do you expect it to take?

Dr. William Schaffner

The outbreak of Ebola has been difficult to contain because, first of all, it occurs in the eastern Congo, a part of the Congo that has not experienced Ebola in the past. So the people and the healthcare providers in that part of the Congo didn't have the experience of the people in the western Congo and in other parts of West Africa where Ebola has occurred before. So it was new to them. 

Number two, Ebola occurred in an extraordinarily remote area, hard to get to for the World Health Organization and others. Number three, there's political turbulence in that area, making the response even more difficult. And very importantly, it's caused by a strain, the Bundibugyo strain, for which we don't have a vaccine. And so there is not an immediate, rather easy to implement intervention, public health intervention that we can use to curtail the outbreak. So workers have to go in and speak with the local leaders, educate them, and try to educate the populace in behaviors that will interrupt transmission.

And here the critical issue is how you care for people who are very, very sick and who have just died. Because Ebola is transmitted not when you're mildly ill very much, but when you're very ill. Your body becomes essentially a test tube full of the Ebola virus. And when people are very sick, they get a lot of direct personal medical care, hands-on care. That's how the virus can be transmitted to the caregivers, the caregivers at home and the caregivers in the healthcare institutions. 

Also after they've died, the cultural practices ingrained over generations that revere the dearly departed indicate that the body must be cleansed. The body is often touched in reverence and can even be kissed and as you can imagine, those are exactly the kinds of activities that will transmit the virus to the person who is being reverent. And so these ingrained cultural practices have to be interrupted. This is very, very difficult.

I have to add one other thing. Once again, our country's withdrawal from the WHO and the USAID withdrawal of resources, probably contributed to the delay in diagnosis and now the ongoing difficulty of getting resources to that somewhat remote part of Africa.

Lindsey Smith

So you mentioned past experience, location remoteness, political turbulence, the Ebola strain, intervention, and cultural practices all highlight why this response has been difficult. I want to talk about another outbreak, a very different one, to get your take on the hantavirus outbreak. It seems to have stabilized, with only thirteen known cases and no new deaths reported in over a month, according to the World Health Organization. But do you see any ongoing risks to the public and what have we learned from this outbreak?

Dr. William Schaffner

Well, Lindsey, you can hear the smile in my voice, because I agree with you -- the hantavirus outbreak is coming to a close.  I would not expect further cases related to that group of passengers on the cruise that was affected by this Andes strain of the hantavirus, which can be transmitted person to person, but not very readily. So I think those folks who were exposed, we're coming to the end of their incubation periods, we haven't seen any new cases, and so far, so good. 

There are always lessons that could be learned, that should be learned, from any outbreak response. We always like to do an after-action report. However, particularly we in the United States often have a short memory, and with changing administrations, I have to admit this, the risk is these lessons are not always, shall we say, carried over. I think we, along with the World Health Organization, get a good solid B in response to the hantavirus outbreak. I think it was hyped a bit more than was necessary. I think from the beginning the experts, myself included, thought that we shouldn't get too excited about this. We can control this. This is not that big a deal.

But all that considered, I think we've done all right and I think the passengers who were exposed will soon be going on to their lives normally. Thank goodness.

Lindsey Smith

That is really reassuring to hear that it has stayed contained and hopefully we can remember to take those lessons learned from that outbreak. With all these big news stories, people might have missed that there's a new strain of COVID called XFG. What can you tell us about it in terms of how severe it is and anything else that we should know?

Dr. William Schaffner

We’re in a good but not perfect place with COVID. Obviously, we're not where we were when COVID struck, where the world's population was completely susceptible, and we had some really pretty severe strains of the COVID virus running around, causing terrific amounts of illness and deaths. Since then, over 95% of the US population, the latest data show, have had an experience with COVID. We've either been infected or had vaccine or both. So we are much better immunologically prepared than we were. Number two, the virus strains that are circulating now are not as virulent. They're not as apt to cause serious disease. 

Now that said, COVID has not disappeared. We still have people hospitalized with COVID in my own medical center every season and they share two characteristics. One is they're in a high-risk group, by and large, older, immunocompromised, have chronic medical conditions, and they are not up to date with their latest COVID vaccine. Because once again, the COVID vaccine will help prevent serious disease. These new modifications of the virus, these mutations that we see, are all like cousins. They're rather readily transmissible, but they appear not to be more severe. But nonetheless, they should be taken seriously. 

And once again, as with the influenza vaccine, I'll say it again with the COVID vaccine: we wish a larger proportion of the population would take advantage of the vaccine because both the influenza vaccine and the COVID vaccine can substantially reduce the impact of serious illness in our populations. Even though the vaccines are not perfect, they're really pretty good.

Lindsey Smith

That's really useful context. Thank you for shining some light on this. And all of this — you mentioned encouraging those to go out and get those vaccines — raises a bigger challenge that you've navigated for a long time, which is how we actually communicate about threats to the public and what they should be doing in addition to these threats. So you were a prominent public health communicator long before social media took hold and this more recent decline in trust toward government and health sources. Has that changed your approach to communication and what concerns you most about today's media environment?

Dr. William Schaffner

You know, if you had asked us pre-COVID, just on a survey, what's the single most important of all the interventions you do when an outbreak occurs, when you have a pandemic, how would you rank the interventions? What are they? What's the most important? And I think most public health authorities would have put communication first, second, and third. Big surprise to most people. 

A lot of other people would have said that the clinicians would focus on you've got to get the beds out there, you've got to care for the patients. Others would have said distribution of vaccines and therapeutics and the like. But communication is the most important so the public understands what's going on. We didn't do that ideally with COVID. As I said, with hantavirus, it was hyped too much. We're still not clear enough in our communications about Ebola. 

So you've got to provide information repeatedly in a fashion that the average person understands and will have trust in the information and how it's transmitted. And we in medicine have to get better about not only producing facts, but doing so in a way that comforts and reassures and explains to the average person. And then we need to do that repeatedly.  I try to participate with journalists in getting that sort of comforting as well as understanding out to the general public.

With my gray hair, I'm not really into social media and so I have to recruit — we all have to recruit — many younger people to do the same thing, to communicate through social media, which is much more challenging than the regular media because there's so much misinformation and even disinformation in social media and trying to sort all that out is very, very challenging. 

Also, your response has to be extremely rapid and large institutions are not that rapid in their response. And even better, getting out ahead of a lot of information, getting it out quickly before the anti-folks or the hesitant folks or the misinformation folks get out there. So I think that's the challenge for the generation that comes after me. You've really got to get engaged with the social media environment.

Lindsey Smith

Communication is so important and I think it speaks to just how much the job of a public health communicator has evolved over time, even if the core mission hasn't. There is a constant battle against misinformation that we have seen.

I want to turn our attention now to knowledge gaps. Elsevier is an education company and we're always looking to fill knowledge gaps. Is there a topic you think we should make a video about that deserves more attention?

Dr. William Schaffner

Well, if I wish there were a video out there, it would be one that would provide an educational experience for medical students, in fact, healthcare students of all kinds, about how to interact with patients who express vaccine hesitancy, how to school them in what is frequently done wrong, and then show them how to do it better, to get the confidence of the patient in accepting vaccines and other aspects of medical care — the so-called motivational interview. And then to introduce that into the education of all healthcare professionals and indeed physicians and healthcare workers already in practice. That would be a terrific asset. And then we would have to get some sponsors to actually get that information out, that video out so that people could watch it and learn from it.

Lindsey Smith

That's a great suggestion — how to educate providers on dealing with patients with vaccine hesitancy. And I'm jotting it down. That's exactly the kind of gap we are always trying to close. So let's look ahead a little bit. I'd like to direct this question at a lot of the students and early career health professionals that are listening in. I want to ask you what's your advice to them about meeting the challenges of this moment and building a career in medicine?

Dr. William Schaffner

I'm so fortunate in that I've had this career in medicine. It's been a calling for me. And I'm further fortunate in that I have some regular contact with people who have chosen to go into medicine in all of the medical disciplines.  I revel in their enthusiasm, their commitment, their excitement about the science that's developing. Their desire to go in and help both individual patients — to lay on hands and heal the sick, to comfort the afflicted and those who are sorrowing — and also those who are interested in extending the benefits of medical care to large populations to do public health, right? Locally, nationally, and indeed internationally. I just encourage them all the time. 

The opportunities are exciting and are even more exciting. And so all of these fields are opening up the opportunity to really intervene to make the next generation healthier than the previous generation. That is always there. Every researcher, every public health person is an optimist. They're working to extend the benefits of the knowledge and the medical care opportunities and interventions that we have equitably with justice to all segments of the population and to make the next generation healthier than the previous.

Lindsey Smith

There are so many opportunities and different fields for medical professionals to explore. Thank you for the thoughtful advice. We are fortunate to have voices like yours to learn from. Before we wrap up today's episode, is there anything we didn't get to today? Something you were hoping that I would ask you that I didn't?

Dr. William Schaffner

This has been warming and delightful. It's been a great pleasure for me to be with you, Lindsey, and I think we've done a good job. But as you know, I'm particularly interested in promoting the use of vaccines because vaccines prevent disease, and I think the prevention of disease is medicine's most noble goal. So I always conclude with one of my aphorisms: disease bad, vaccines good.

Lindsey Smith

That is a great note to end on. Dr. Schaffner, thank you so much for your time and for helping us make sense of such a consequential year.

Dr. William Schaffner

My pleasure. Thank you.

Lindsey Smith

And that does it for today's episode. Dr. Schaffner, thank you for helping us make sense of the ever-changing infectious disease landscape. Your clarity on these topics has been invaluable. I'm Lindsey Smith. Thanks for checking out today's show. Remember to do your part to raise the line and strengthen the healthcare system. We're all in this together.