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A Word from the Experts

Breakthrough infections in people who have gotten their COVID-19 shots are very rare. But here’s why Rick Bright wants the CDC to restart the sequencing of all viral strains.

The virologist questions why the CDC isn’t sequencing all breakthrough COVID-19 cases, disputes the idea that the virus has to become endemic, and thinks this is the moment to be ‘impactful’

Rick Bright is now out of government and serving as senior vice president of pandemic prevention and response at the Rockefeller Foundation.

eLesor photo illustration/Getty Images| iStockphoto

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Rick Bright is no stranger to pandemics.

The virologist and immunologist has worked under four presidents, in different leadership roles at the Centers for Disease Control and Prevention, the National Institutes of Health, and most recently as the director of the Biomedical Advanced Research and Development Authority, which is responsible for giving federal dollars to ramp up production of COVID-19 vaccines and treatments.

It was in his role there that Bright alleged retaliation from Trump administration officials after he resisted efforts to make unproven COVID-19 treatments like hydroxychloroquine available to Americans, according to a whistleblower complaint filed last spring. (The case is still pending.)

A year later, he’s at the Rockefeller Foundation, running a new pandemic prevention institute. Bright’s got positive things to say about the Biden administration’s handling of the pandemic — he was part of Biden’s COVID-19 task force — but he also has concerns about some of the latest policies put forth by the CDC, particularly about how the public-health agency is monitoring breakthrough infections among the vaccinated.

“Those are, in my opinion, the most important viruses that we should look at,” Bright said, during an interview on May 11, “because those are the viruses [that] are infecting people who are supposed to be protected.”

Beyond those immediate concerns, Bright wants to see a better strategy for getting rid of the virus altogether. “We don’t have to let it become endemic,” he said

eLesor: How would you rate the current genomic surveillance strategy in the U. S.?

Rick Bright: I’ve worked in pandemic response for decades. Every time something bad happens, we just never seem to appreciate that it’s going to happen and how bad it’s going to be. Every time we get through it, we always say, ‘we’re going to do all these things and make it better [and] make sure it never happens again.’ And we don’t do it. There’s this cycle of panic, and then regret, and then forget.

One of the things that has always struck me as I’ve worked through these responses in the past, to MERS and Zika and SARS and Ebola and SARS-CoV-2, is we never know when to start. We never have a good starting signal. Because we’re not doing enough surveillance. We have the capability now to do the [genomic] sequencing, but we’re just not doing enough of it, and we’re just not doing it smartly.

When you ask how I’d rate what the U.S. government has been doing in this area, we’ve been just flying blindly for a long time. We didn’t value testing in the early days to get testing available and out in the community. And then we didn’t value real knowledge of the genomic sequencing so we can detect and track the virus [and] how it’s changing.

Any virologist knows the threat of viruses mutating and changing as they spread. We see that with flu. We see that with HIV and other RNA viruses. There is no credible scientist that would say that this virus would not mutate and change over time, especially after adding immunological pressure by vaccinating people. By January of this year, we may have been [sequencing] less than 1% of the viruses in the U.S. We might be to the 3%-to-5% range [now]. But we’re not doing it smartly. It’s not about just more. It’s about what viruses to sequence, from what people or what population, so we can really answer those top questions.

I saw a report by Bloomberg that really gave me pause. And that was that the U.S. CDC has made a determination to not sequence all of the viruses from the vaccine breakthrough cases. Those are, in my opinion, the most important viruses that we should look at. Because those are the viruses infecting people who are supposed to be protected. Those are where the virus variants are going to appear, where mutations might occur, and the viruses there are already escaping immunity. That is where I would focus.

eLesor: I did not see that report. Did the CDC say why they were choosing not to do that? Was it a matter of resources or time or coordination?

Bright: What it said in the story was (the) CDC said that they’ve looked at a few of those viruses already and didn’t see anything interesting. And they didn’t think it was worth the time to do the rest of them.

[Editor’s note: A CDC spokesperson confirmed the change, saying the public-health agency only investigates vaccine breakthrough cases “that result in hospitalization or deaths,” as of May 1.”The goal is to figure out why, after being fully vaccinated, would someone get sick enough to be hospitalized or die,” the spokesperson said. Breakthrough cases in people who have already been vaccinated are considered very rare — of the roughly 95 million people who have been fully vaccinated in the U.S., there were 9,245 cases of breakthrough infections, as of April 26.]

eLesor: What else do you think should be a priority when it comes to genomic surveillance in the U. S.?

Bright: We need to make sure that we’re sequencing [virus samples] that represent a diverse population and a geographical population. It doesn’t mean give a lot of money to big cities, and let’s get 1 million more viruses out of New York City, and not have any come up from Kansas and Oklahoma and Nebraska. We need to see where this virus is. We need to look at those vaccine breakthrough cases. We need to look at the viruses from immune-compromised populations, those who we call “long shedders” because the viruses live in [some] people a long time because their immune system is not not tackling it. This could be HIV-positive patients, patients undergoing cancer treatment or therapy, etc.

I would look in what we call the underserved or underprivileged populations who don’t have access to daily health care, whose lives are likely much more volatile and who have a number of other chronic diseases. Those are hotspots for virus replication, long-term shedding, and virus mutation. Those are going to be your dark spots where you’re most blinded. We have money now in the United States to do this, to turn on those lights, and really intensely look at those viruses in those groups to see if and how it’s changing.

eLesor: Can we use genomic surveillance to monitor the emergence of new viruses, as in could we have used this type of technology to detect SARS-CoV-2 at the beginning?

Bright: We have [to have] the genomic data with the epidemiological data and the metadata. I don’t need to know the person’s name and home address or anything personal about them, but it’d be great if we had the ability to…infer more information about what’s causing or driving those changes. If we have other signals that we can capture in the air or in the wastewater, to hone in on where something might be emerging, or new viruses or pathogens are emerging, then we can have the CDC and epidemiologists focus on those areas to get more information.

Our Pandemic Prevention Institute is collecting all of those various signals and aggregating them and analyzing them with some very unique ways to determine that a signal we received could be from a bacteria, could be from a virus, [or] could be from a fungus. You can share that signal with everyone in an equitable way, with politicians, public health advisers, entities that can do something about it — like put a travel restriction in place, or warn individuals to wear a mask or social distance, or trigger the production and development of drugs and vaccines and diagnostics. At the same time, we could give that information to individuals as well, to empower individuals, who right now have to wait on their government. They’re beholden to different political perspectives, as we saw in this pandemic, to titrate that out or put a different spin on that information for our population.

eLesor: Do you think the U.S. is ready to be smarter about public health issues? Or do you think it’s possible that funding can become a challenge in five years or 10 years?

Bright: We have an opportunity right now to do something impactful. And certainly there is no shortage of money with the American Rescue Plan. [Editor’s note:The Biden administration has provided several hundreds of millions of dollars in funding for COVID-19-related genomic sequencing since the start of the year.]

I’ve been in the government long enough to say I’ve seen money flow during crises — there were lots of supplemental dollars for Ebola — and when the crisis is contained, or goes away, then the money either sits and doesn’t get used. The first discussion of every next crisis is, ‘wow, can I tap into the money left over from that previous crisis, or do I have to wait?’ And they’re like, ‘but that old crisis might come back. You can’t tap that. You asked for too much money in the last crisis. ‘

It’s just money talk. The government makes partners with industry during the crisis, and then the crisis ends, and the money dries up, and the industry closes down that capability. During a crisis or a threat, we throw money to academic centers, and entrepreneurs, and innovators. And then when the threat moves, and the attention moves, the wind changes, and the money goes away, and all that innovation dries and rots on the vine.

We have a new mindset in this administration, in leadership and our various agencies. The public will have support. There is sufficient funding flowing. But I think we still need to have a meeting of the minds of some really smart people at the same table in public and private and philanthropic entities to determine what is the best strategy, to have the biggest impact and sustain it going forward so we can address shortfalls in public health, ensure that we have a thriving entrepreneurial innovation enterprise and ecosystem, and ensure that the money built to expand our manufacturing capacity and facilities and the workforce to address this threat doesn’t go away.

We have an opportunity to use what we’re building in the United States [and] leverage it to help the rest of the world. It’s an opportunity to have a global perspective and not just a nationalistic perspective.

eLesor: You’ve mentioned the possibility of surges or small outbreaks. There’s a lot of talk about what happens if this virus becomes endemic. What role do you see genomic surveillance playing in an endemic world?

Bright: We can choose which way we want to handle this virus. I believe we do great harm with influenza. We propagate influenza because we’re chasing next year’s influenza virus, with a vaccine that was designed against influenza viruses that were circulating one to two years ago. The influenza vaccines are partially effective. When you’re partially effective, you’re just driving that virus to continue to change.

We can either treat SARS-CoV-2 like we treat influenza, and let it happen and slowly chase it and slowly push it and continue looking in the rearview mirror. That’s one way. Or we can get a lot of this information through genomic sequencing and use artificial intelligence to analyze this virus in a unique way. We can see all the variants emerging. We can catalog those variants. We can test the ability of those variants to see how well they will grow and spread. And we can also look at how well the current vaccines work against the variants.

We have an option, I believe, at creating a vaccine that is universal in nature, broadly reactive, and can stop this virus, and we don’t have to let it become endemic. The key to doing that is we have to make sure we vaccinate the world. We cannot allow pockets of the world to exist, where the virus can still continue to evolve or change or recombine with other viruses and have a new hybrid version of the virus come out. So we have to blanket the world’s immunity. But we have to get really smart about what that immunity looks like. So the vaccines that we make today can either drive the change, drive further mutation of the virus to continually outsmart the vaccines, or the information we have today can be used to make a really smart forward-leaning vaccine to stop the virus in its tracks.

[Editor’s note: Bright previously worked for Novavax Inc. NVAX, which is developing a late-stage COVID-19 vaccine. He has no financial ties to the company.]

eLesor: Would we need a vaccine that’s 100% efficacious then?

Bright: It would not need to be 100% effective. I’ve seen results or reports around 70% to 90% effective. [Editor’s note: The vaccines developed by Pfizer Inc. PFE, -1.70%, Moderna Inc. MRNA, -1.62%, and Johnson & Johnson JNJ, -1.96% that are currently authorized in the U.S. were all at least 70% efficacious in the clinical trials conducted here.] But the trick is that you have to vaccinate everyone. You have to also vaccinate 70% of the population with a 70%- to 90%-effective vaccine to blanket the world.

There will always be people who won’t get vaccinated for whatever reason. There are a few people who can’t get vaccinated for whatever reason because of their underlying health. And there will always be people that the vaccines just don’t work in. There’s space in nature for those pockets. But then you have to make sure you have an effective vaccine that is forward-leaning, can block the virus, and then you blanket the rest of the world. You can stop something like this and push it back to the Batcave or jungle or wherever it came from.

This Q&A has been edited for clarity and length.

Read more A Word from the Experts interviews:

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• How 6 feet became 3: Meet an ER doctor behind the research showing kids are still safe in school with new social-distancing standard

• It’s a ‘question of time’ before another virus jumps from animal to human, says co-inventor of flu treatment Tamiflu. Preventative therapies are needed.

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