Anthony Harris, MD, MBA, MPH, has visited Infection Control Today^® (ICT^®) before during the course of the COVID-19 pandemic, where he discussed how private industry might want to hire infection preventionists, how much of a threat COVID-19 variants pose, and the promise of vaccines. Recently he spoke to ICT^® about vaccine mandates. This is a subject that Harris knows much about because he’s the CEO and medical director for HFit Health, a company that helps businesses with their infection prevention and control problems, including the challenges of imposing vaccine mandates on employees. Harris also spoke about the need for a vaccine for children aged 5 to 12 and how that should be mandated, vaccine hesitancy among health care professionals, and the danger still posed by COVID-19 variants, including the so-called monster variant, an iteration that would be more infectious than the Delta variant, and also immune to antibodies generated either through prior infection or vaccines. His advice for infection preventionists charged with trying to convince their fellow health care professionals to get the vaccine is to “just speak to the benefits” the main ones being that the COVID-19 vaccine prevents hospitalization and death.

Infection Control Today^®: Vaccine mandates are being challenged often in the form of lawsuits. How do you see that playing out?

Anthony Harris, MD, MBA, MPH: I see [vaccine mandates] prevailing, with the [Biden] administration’s documentation of precedence. We know that mandates such as this don’t exist in isolation. For any school age child that wants to attend public school, guess what? Be vaccinated. Likewise for universities, in many cases. If you’re living in a dormitory scenario. This is not a far cry from precedent that’s already been set. And we know that many clients and large employers that we work with are anticipating that this is going to go through. Even those scenarios, in particular from state to state [where] we see pushback, even from state OSHA [Occupational Safety and Health Administration], perhaps.… I’ve spoken with a number of state OSHA council members. And they said we’re going to maybe not enforce the penalty for companies that are not in compliance. But we’ll see how that shakes out in terms of their mandate to comply with, at a minimum, the federal mandate from an OSHA standpoint. Like you mentioned, a lot of moving parts. But we think that this is going to be something that will be with us in terms of a mandate for businesses that meet the criteria.

ICT^®: Are you concerned at all about the reaction among some health care professionals who have quit or resigned as a result of vaccine mandates? Did that surprise you?

Harris: I’m not too surprised. We know that there are very strong feelings on both sides of this issue, in terms of personal choice versus mandates. And we’ve seen this again play out with school aged children. Parents that have chosen to homeschool their children because they did not want their children vaccinated. It is something that is anticipated and a part of our sense of normalcy and the freedoms that we enjoy here in the U.S. It’s not alarming, but at the same time, on the flip side of it, it’s not alarming, too, that the majority of U.S. eligible individuals for the vaccine have been vaccinated. We’ll continue to see that number increase as we move forward because there will be ongoing pressure for individuals to be able to enjoy the normalcy that we used to enjoy—days of old, at this point—but certainly that’s going to look like a more vaccinated populace at a high level.

ICT^®: The two groups that seem to be most hesitant to get the COVID-19 vaccine are Republican men and African Americans. Does that surprise you? That opposition to vaccines is making some strange bedfellows?

Harris: We’ve seen this play out at this point in time for the last year and a half in regards to first, mask mandates and social distancing, and then vaccinations. And if we look particularly at the African American community, we know that there is a longstanding distrust of governmental mandates and projects so to speak, harkening back to the Tuskegee experiments. and that distrust carries on into generations today in these communities. And me living here on the Southside of Chicago, I see it firsthand. Where individuals will say, “Look, I’d rather disregard any attempt to get a vaccine until I see someone drop dead in front of me.” That’s the kind of proof in the pudding for them. Obviously, a high bar. But now we are seeing these communities

disproportionately affected by COVID-19. I think we will see an increase in the vaccinations amongst African Americans because of the impact that COVID-19 has had in these communities. When it comes to Republicans, again, you know, being pro-choice—if we want to use that language around vaccinations, maybe a little controversial—but at the end of the day, it is something that we have seen in politics. Albeit on opposite sides in regards of the particular issue that we’re talking about. But we know the data are the data. There are almost twice, if not almost two thirds, as many Democrats who are vaccinated currently in the U.S. than Republicans. And I hope that it is not for a lack of communication of accurate data. Information that’s going to help save lives, help save communities, help save families from potential devastation, when it’s a potentially preventable outcome. And so that’s what we are germanely concerned about in the political community, and our messaging for sure.

ICT^®: There was a recent study in the Journal of Infectious Diseases that says that children can be just as infectious as adults and that children could be the incubators of the next variant that pops up. When a vaccine for children arrives, do you think that there will be mandates that children get it?

Harris: Yes, hands down, because of the Delta variant and because of the Delta Plus variant that has several unique mutations.… We know that the airborne propensity for transmissions is increased because of Delta Plus, even above and beyond what we saw with Delta, and certainly with the Alpha strains that we experienced last year. Because of the burden of viral particles in a droplet, five microns or smaller, we believe that children will likely be a source of infection and reservoir for infection until they’re vaccinated. And even once they’re vaccinated—again, not to be the doomsayer—but just looking at the data, and the data I like is the data out of Israel looking at 39% efficacy for prevention of infection, certainly higher for hospitalization, 88% and 92% for severe illness. But only 39%. [That means that] 61% of people are still susceptible to transmit COVID-19 from an infection after being fully vaccinated. We need to drill down and understand that kids will likely fall into that same or similar profile in terms of ability to contract and transmit. And that is why we won’t get to the other side of this pandemic by way of herd immunity, but only to make the disease endemic. Albeit a far worse outcome endemic compared to a flu or other illnesses that we deal with on a regular basis.

ICT^®: Infection preventionists are often in charge of trying to educate their fellow professionals about the benefits of getting the COVID-19 vaccine. Any words of advice?

Harris: My best words of advice would be taking the approach that I’ve learned anecdotally through serving as the chief COVID-19 doc for our organization nationwide since March of last year. And that is let’s just speak to the benefits and lay the benefits out clearly. Anybody that says, “Hey, get vaccinated to help prevent infection” is not telling you the opposite side of that. Where you’re not going to see a tremendous benefit to the majority of people to prevent infection. Why do we get vaccinated? We want to prevent hospitalization and severe illness and death. And if we look at U.K. data, of their one dose policy that they had starting at the end of last year into this year for vaccination, we saw a dramatic difference between what they experienced from a mortality standpoint, with this latest rise in cases that we experienced starting back in August here in the U.S. and in the U.K. They had almost three times less of a death rate from the similar spike in cases and at some points in time they were higher than we were in terms of number of cases. But again, they experienced less mortality. That’s why we need to preach vaccination. We need to prevent the excess deaths that we’ve documented over and over in literature between what we’ve seen during the pandemic and what existed and was expected prior to the pandemic. Those are lives that could have been prevented in terms of loss. And that’s why moving forward, we want to be proactive to help prevent that loss.

ICT^®: Some health care experts have said that what keeps them up at night is the monster variant, a COVID-19 variant that’s more infectious than the Delta variant but that’s also immune to the antibodies produced either by prior infection or vaccines. How worried are you about that in light of the fact that most of the world hasn’t been vaccinated?

Harris: You’re right, and the monster variant may be amongst us already. Again, I mentioned the Delta Plus variant. We know that there were four mutations that occurred in the spike protein that actually moves the virus away from binding with our antibodies more fully as the Delta variant had done previously. It’s something that we’re seeing active. We have been through genetic drift. If we do see a genetic shift, meaning a more dramatic mutation that allows the coronavirus to escape our antibodies, then we’re going to be in a tremendous position to have a lot of devastation in those communities that haven’t had access to vaccinations. And I’ll mention, though, that there is a potential treatment that I believe may have a dramatic impact for those vulnerable communities. And yes, I’m talking about molnupiravir, the Merck medication [for which the company is] seeking emergency use authorization. The data on that is pretty darn good. And we saw in their studies that they ended their recruitment early because the results were so prominent in regards to decreasing death; not just death, but hospitalization, severe illness in those vulnerable individuals who have a pre-existing condition. And we know that Merck is gearing up to produce on an order of 2 million doses by the end of 2021. And a majority of those are going to help Third World countries that don’t have access to IV solutions. There is help on the way. There are a number of other nucleoside antivirals that are in the pipeline, and we hope they will be just as efficacious for preventing loss of life and severe illness. But we still have a lot of work to do in terms of getting the right treatment, and then hopefully preventing, through vaccination.

ICT^®: Does the fact that COVID-19 vaccine effectiveness wanes over time make it more difficult to mandate vaccination? People can turn around and say, “Look, it doesn’t even work.”

Harris: Right. It does make it harder to demand a vaccination, I believe, from the perspective of transmission prevention. And then we see also, in terms of even severe outcomes, if we were looking at the data, it wanes over time. Even the data that looked at boosters for Johnson and Johnson for the mRNA vaccines as well. We saw that waning over six months [causing] more breakthrough transmissions in those who are fully vaccinated. Anecdotally, large employers that we work with…. I spoke at a national safety conference in Austin recently, and after my talk, a gentleman came up—a safety professional, heads a large organization—and said, “Look, 70% of our cases that we’re seeing today are in fully vaccinated individuals.” That’s alarming. And so that is why we’re seeing Israel saying that because of the waning immunity for natural immunity, as well as acquired immunity, you need a third booster in order to be considered fully vaccinated. Three shots gets you fully vaccinated in Israel. We have yet to declare such a leap forward in the U.S., but I do anticipate—looking at the waning immunity in what we’re seeing—that that will likely be our scenario as well, in order to maximally protect the public from more devastation from COVID-19.

ICT^®: Doctor Harris is there something that I neglected to ask you that you think is pertinent and that you want your fellow health care professionals to know about vaccine mandates or anything about COVID-19?

Harris: From the infectious disease side, the companies out there that are going to be subjected to the mandate need help [in formulating] the best strategy to execute on their vaccine protocols, to execute on testing. This is a point in time that certainly I’ve never seen in my career—and even those who have been in this business twice as long as I have, for 40 plus years—have not seen the level of demand for our services as professionals in this industry. I want to cajole everyone to offer your best practices to organizations to help maximize their efforts to protect as many people as we can and to help them not just be compliant, but to be protected.

This interview has been edited for clarity and length.