AJA Medical Committee Unwilling to Commit Due to Uncertainties
On December 11, the Food and Drug Administration (FDA) issued an Emergency Use Authorization for Pfizer-BioNTech’s COVID-19 vaccine, the first to gain any sort of approval; a week later, Moderna received the same status. With 95% effectiveness in clinical trials — and even stronger protection against severe infection — both vaccines appear to offer a fairly straightforward path towards herd immunity. As the end of the COVID-19 pandemic approaches, the temporary “new normal” of COVID-19 precautions will slowly recede. AJA and its Medical Committee will have to determine the timeframe of lifting restrictions in school.
While they use different actual molecules, both vaccines utilize a first-of-its-kind mRNA technique. Conventional vaccines inject a significantly weakened version of the virus, allowing the immune system to fight off the half-dead pathogen by making the antibody, and then storing that antibody for future use if it were to encounter that pathogen again.
“As the end of the COVID-19 pandemic approaches, the temporary ‘new normal’ of COVID-19 precautions will slowly recede. AJA and its Medical Committee will have to determine the timeframe of lifting restrictions in school.”
These mRNA vaccines work differently. They contain instructions for the body itself to create an imitation of the “spike” protein the SARS-CoV-2 virus uses to latch onto the cell. The immune system can then destroy that disconnected spike protein-replica, even while no actual viral cells have entered the body at all.
However, as Dr. Josh Guttman explained, a novel response to a novel coronavirus — including historically-fast vaccine development — has its drawbacks. Despite the overwhelmingly positive infection prevention data, the scientific community faces more uncertainty than normal in pinning down some of the more secondary effects. Dr. Guttman, a member of AJA’s Medical Committee, specializes in Emergency Medicine at Emory University and Grady Memorial Hospitals.
Because of this uncertainty, Dr. Guttman, AJA Head of School Rabbi Ari Leubitz, and fellow Medical Committee member Dr. Amy Wolkin, an epidemiologist at the Centers for Disease Control (CDC), were unable to offer up specific benchmarks for unwinding current COVID-19 protocols, even when pressed repeatedly.
Population Scale and Transmission Muddy Threshold Estimates
Rabbi Leubitz and Dr. Guttman both emphasized the vaccination rate in the “AJA community” — meaning parents and teachers — as a determining factor for reducing risk, which could lead to relaxing mask-wearing and distancing. They said that community numbers would play a larger role than the corresponding figure for the state, or even local counties. However, Dr. Guttman would not answer “definitively” where that percentage might fall, saying he “prefer[s] not to guess” and would “have to see numbers and trends in the right direction.”
Two major factors stood in the way of setting a benchmark for rolling back COVID-19 restrictions: how the vaccine will fare in a larger population, and how effective the vaccine is in stopping transmission (as opposed to preventing infection, the data point measured in the trials).
Although more than 70,000 people took part in either the Moderna or Pfizer trials with an impressive effectiveness rate, Dr. Guttman wasn’t comfortable assuming those vaccines would work exactly the same way in an entire population of more than 300 million people. He said that because of small variants in the way each individual’s DNA makes proteins, “everyone is a little bit different, [and] just because the vaccine makes my body make antibodies that prevent infection doesn’t mean it will do the same to yours.”
The other outstanding uncertainty involves transmission, which is also a key reason why Dr. Guttman doubts that even individuals who are fully vaccinated will be able to walk around without following protocols (such as masking and social distancing) before the broader restrictions are eased up as the school approaches herd immunity.
Because of the new mRNA technology used in the COVID-19 vaccines, there has not been enough testing to conclusively prove, in a controlled study, that a vaccinated person cannot pass on the virus even if they themselves are not infected.
However, an absence of evidence doesn’t necessarily indicate whether a claim is true or false, just that it hasn’t been proven or disproven yet. In a “Frequently Asked Questions” column in the New England Journal of Medicine, Harvard Medical School Professor Dr. Paul Sax wrote, “There are several good reasons to be optimistic about the vaccines’ effect on disease transmission.” He cited data from the clinic trials and other studies that indicate that asymptomatic carriers (which a vaccinated person would be) transmit less of the virus. Dr. Sax also considered it biologically unlikely that “a vaccine [would] prevent disease and not also prevent infection,” stating, “If there is an example of a vaccine in widespread clinical use that has this selective effect — prevents disease but not infection — I can’t think of one!”
Dr. Guttman of the AJA Medical Committee was less optimistic. He did agree, “I can’t imagine it won’t prevent transmission to a certain degree,” but he argued that more data is required. For his part, Dr. Sax did recommend continuing precautionary protocols for the time being.
A preliminary study from the Sheba Medical Center in Israel seems to indicate that the Pfizer vaccine (at the very least) confers “sterilizing immunity,” which would prevent transmission in addition to infection, but it is still too early to draw conclusions from those initial findings. Dr. Guttman wasn’t sure when there would be sufficient data to conclude if the vaccine stops transmission (one way or the other), but he expected it would be published soon.
“Because of the new mRNA technology used in the COVID-19 vaccines, there has not been enough testing to conclusively prove, in a controlled study, that a vaccinated person cannot pass on the virus even if they themselves are not infected. “
With these pieces of unsettled science — community effects and vaccinated transmission — Dr. Guttman and Rabbi Leubitz hesitated to commit to a specific vaccination-rate timeframe.
Vaccinated Individuals in a Vulnerable Herd
Even if and when it is clear vaccinated people do not — or very rarely — transmit the virus still presents complicating factors.
For an individual who is vaccinated before the school reaches the to-be-determined benchmark, the considerations may be similar to the currently-mandated behavior of a previously-infected person. Right now, someone who previously tested positive is required to follow the same restrictions as somebody who has never been infected. (It should be noted that the CDC claims reinfection is rare, but possible.)
From a public health perspective, according to Dr. Wolkin, having certain groups of people acting in different ways complicates matters and makes precautions more difficult to follow and enforce.
Rabbi Leubitz channeled the Judaic concept of “lo plug,” avoiding a separation that would just cause confusion. “One of the things that makes it very easy in our school to do masks is that everybody does it without any [exceptions]… so it’s very clear this is just what we do, [and] it makes it easier on students,” he said.
Rabbi Leubitz also brought up difficulties in obtaining documentation to prove vaccination or prior infection. He explained that with established vaccinations against measles, for example, state law allows him to demand proof from students and teachers; given the evolving circumstances, he was uncertain if he had a similar ability to require documentation of COVID-19 vaccination.
Rabbi Leubitz further expressed a desire to avoid putting a “target” on the back of students and teachers who choose not to get vaccinated — “for good or bad reasons.” He said it “opens up a can of worms.”
For Once, We Don’t Have to “Think of the Children”
Per current state regulations, teachers are set to be vaccinated in “Phase 1B,” before most of the general public. As such, there will almost inevitably exist a timeframe in which teachers are vaccinated, but most parents are not. Therefore, AJA’s community-wide standards won’t have been met, so school-wide standards will not have been relaxed yet. (Students, who fall in the youngest age brackets, will be at the back of the line once they are eligible.)
Most seasonal influenzas impact the population with a “u-shaped” curve, disproportionately impacting the youngest and the oldest (see below). While COVID-19 has wreaked havoc on the elderly, children have been almost entirely spared. According to an American Academy of Pediatrics (AAP) report on January 14, while more than 2.5 million children have been infected with the virus in the United States, just 191 have died of it, a minuscule number for a country with about 75 million children.
With this in mind, while Dr. Guttman was careful to specify some high-risk children, he confirmed that “household adults and teachers are the main concern” when assessing in-school precautions.
Because of this dynamic, Rabbi Leubitz speculated that there exists “a distinct possibility” that after all teachers (and faculty) have been vaccinated, “that would be a good time to consider rolling back the COVID protocols in the building.”
Dr. Guttman took a different approach. Even while acknowledging the limited risk to children, he argued that if children are infected at school from their classmates, they risk spreading it to parents and grandparents who are more susceptible.
Dr. Wolkin further rejected the premise that children are mostly unaffected by COVID-19, pointing out that while very few children suffer severe cases, some do. During an interview, she noted that multiple children were hospitalized at that time at Children’s Healthcare of Atlanta. According to the AAP report, about 10,000 children have been hospitalized at one point or another over the course of the pandemic.
Where Do We Go From Here?
Although millions of Americans have already been vaccinated, don’t expect any near-term changes. Everything Rabbi Leubitz and members of the Medical Committee told Palette was prefaced with, in essence: “We haven’t sat down and made any policies, so this is all subject to change.” On multiple occasions, Rabbi Leubitz clarified he was musing on the spot, as opposed to declaring thought-out and finalized policy.
“Even while acknowledging the limited risk to children, [Dr. Guttman] argued that if children are infected at school from their classmates, they risk spreading it to parents and grandparents who are more susceptible.”
A lot will depend on the vaccine’s capability to stop transmission, and Rabbi Leubitz and Dr. Guttman emphasized that community infection rates will remain a factor even heading into the post-vaccine world.
On multiple occasions, Medical Committee members refused to be pinned down on any specific numbers or dates, deflecting with “We will know more… when more data is collected.” Dr. Guttman and Dr. Wolkin declined to specify when they anticipated that data would become available.
To give some sort of timeframe, Dr. Guttman did say “it is unlikely we will change protocols through this school year.” He detailed, “The vaccine needs to be available to all adults in order to reach any level of herd immunity.”
Rabbi Leubitz initially struck a more optimistic tone, guessing that teachers could be vaccinated by March or April. However, since Rabbi Leubitz spoke to Palette in December, vaccine distribution in the United States has failed to hit some of its expectations. As late as December 13, officials hoped for 40 million distributed doses by the end of December, but as of a month later on January 28, only 25.6 million shots have been given, per Bloomberg’s tracker.
“On multiple occasions, Medical Committee members refused to be pinned down on any specific numbers or dates…”
Even if President Joe Biden continues the current pace to hit 100 million vaccines distributed in his first 100 days in office, less than a third of the country vaccinated is unlikely to trigger herd immunity. Furthermore, eligible students will find themselves at the very end of the line as low-risk individuals — and that’s only for some sophomores, juniors, and seniors. Moderna’s original authorization only covered adults 18-years-old and older, and even Pfizer’s dip into adolescents only went down to age 16. While the manufacturers have signaled they intend to conduct trials for younger children (12 and older) relatively soon, it will be a while before vaccines are approved for most middle school (and some high school) students.
Beyond that, Dr. Guttman wouldn’t commit to eliminating all protocols before all children can be vaccinated, despite the lower risk. He said, “It’s possible, but it’s way too early to tell,” a sentiment Dr. Wolkin concurred with. Vaccines likely will not gain FDA approval for young children by the end of 2021.
As teachers receive vaccinations in the next stage, it would seem some aspects of COVID-19 protocols are ripe for change. However, from conversations with Rabbi Leubitz and two members of the AJA Medical Committee, it appears that might not be the case.
As Dr. Wolkin noted, different members of the Committee possess diverse backgrounds, and factors that contribute to policy decisions include “science, what’s happening in the community, and personal behaviors.” While she approaches topics with a broad, population-level public health background, she acknowledged physicians like Dr. Guttman might have an individual patient-first attitude. Furthermore, she noted that Rabbi Leubitz has both a broad and focused perspective of schoolwide dynamics, and all that entails.
“As teachers receive vaccinations in the next stage, it would seem some aspects of COVID-19 protocols are ripe for change. However, from conversations with Rabbi Leubitz and two members of the AJA Medical Committee, it appears that might not be the case.”
Moving forward, these different priorities will sometimes contradict, and the merits will have to be weighed on a case-by-case basis. Regardless of how COVID-19 precautions are eventually rolled back — and Dr. Guttman had all confidence that it will happen at some point — it isn’t going to be in the immediate future. As Brown University Professor Emily Oster noted, this distorted “pandemic life” will end “not with a bang, but with a whimper” of gradually easing restrictions, to repurpose the words of the poet T.S. Eliot. At this point, nobody is willing to venture when that whimper might be heard.