Theo, an 18-month-old in rural Nebraska, walks with his father in their backyard. For many toddlers, the barriers to accessing COVID-19 vaccines are many, such as few locations giving vaccines to very young children.
It’s Theo’s* first time in the snow. Wide-eyed, he totters outside holding his father’s hand. Sarah Holmes feels great joy in watching her 18-month-old son experience the world, “His genuine wonder and excitement gives me so much hope.”
In the summer of 2021, two months after Theo was born, Holmes, a behavioral health provider in Nebraska lost her grandparents to COVID-19. Both were vaccinated and thought they could unmask without any risk. “My grandfather was a veteran, and really trusted the government and faith leaders saying that COVID-19 wasn’t a threat anymore,” she says.” The state of emergency in Louisiana had ended and that was the message from the people they respected. “That is what killed them.”
The current official public health messaging is that regardless of what variant is circulating, the best way to be protected is to get vaccinated. These warnings no longer mention masking, or any of the other Swiss-cheese layers of mitigation that were prevalent in the early days of this ongoing pandemic.
The problem with the prevailing, vaccine centered strategy is that if you are a parent with children under five, barriers to access are real. In many cases, meaningful tools and changes that would address these obstacles are lacking, such as offering vaccines at more locations, mandating masks at these sites, and providing paid leave time to get the shots.
Children are at risk
Data presented at the most recent FDA advisory panel on COVID-19 vaccines showed that in the last year infants under six months had the third highest rate of hospitalization. “From the beginning, the message has been that kids don’t get COVID, and then the message was, well kids get COVID, but it’s not serious,” says Elias Kass, a pediatrician in Seattle. “Then they waited so long on the initial vaccines that by the time kids could get vaccinated, the majority of them had been infected.”
A closer look at the data from the CDC also reveals that from January 2022 to January 2023 children aged 6 to 23 months were more likely to be hospitalized than all other vaccine eligible pediatric age groups.
“We sort of forced an entire generation of kids to be infected with a novel virus and just don't give a shit, like nobody cares about kids,” Kass says. In some cases, COVID has wreaked havoc with the immune systems of very young children at his practice, making them vulnerable to other illnesses, he said. “And now we have kids that have had COVID two or three times, and we don’t know what is going to happen to them.”
Jumping through hurdles
Children under five were the last group to have an emergency use authorization (EUA) granted for the COVID-19 vaccine, a year and a half after adult vaccine approval. In June 2022, 30,000 sites were initially available for children across the country. Six months later, when boosters became available, there were only 5,000.
Currently, only 3.8% of children under two have completed a primary series, according to the CDC. An even more abysmal 0.2% under two have gotten a booster.
Ariadne Labs, a health center affiliated with Harvard, is trying to understand why these gaps exist. In conjunction with Boston Children’s Hospital, they have created a vaccine equity planner that maps the locations of vaccine deserts based on factors such as social vulnerability indexes and transportation access.
“People are having to travel farther because the sites are just few and far between,” says Benjy Renton, a research assistant at Ariadne.
Michelle Baltes-Breitwisch, a pharmacist, and her two-year-old daughter, Charlee, live in Iowa. When the boosters first came out she expected her toddler could get it close to home, but her husband had to drive Charlee four hours roundtrip.
This experience hasn’t been uncommon, especially in rural parts of the U.S. If parents wanted vaccines for their young children shortly after approval, they faced the prospect of loading babies and toddlers, famous for their calm demeanor, into cars for lengthy rides. The situation continues today. Mrs. Smith*, a grant writer and non-profit advisor who lives in Idaho, is still unable to get her child the bivalent booster because a two-hour one-way drive in winter weather isn’t possible.
It can be more difficult for low wage earners to take time off, which poses challenges especially in a number of rural counties across the country, where weekend hours for getting the shots may be limited.
Protect Their Future (PTF), a grassroots organization focusing on advocacy for the health care of children, hears from parents several times a week who are having trouble finding vaccines. The vaccine rollout “has been a total mess,” says Tamara Lea Spira, co-founder of PTF “It’s been very hard for people to access vaccines for children, particularly those under three.”
Seventeen states have passed laws that give pharmacists authority to vaccinate as young as six months. Under federal law, the minimum age in other states is three. Even in the states that allow vaccination of toddlers, each pharmacy chain varies. Some require prescriptions.
It takes time to make phone calls to confirm availability and book appointments online. “So it means that the parents who are getting their children vaccinated are those who are even more motivated and with the time and the resources to understand whether and how their kids can get vaccinated,” says Tiffany Green, an associate professor in population health sciences at the University of Wisconsin at Madison.
Green adds, “And then we have the contraction of vaccine availability in terms of sites…who is most likely to be affected? It's the usual suspects, children of color, disabled children, low-income children.”
It can be more difficult for low wage earners to take time off, which poses challenges especially in a number of rural counties across the country, where weekend hours for getting the shots may be limited. In Bibb County, Ala., vaccinations take place only on Wednesdays from 1:45 to 3:00 pm.
“People who are focused on putting food on the table or stressed about having enough money to pay rent aren't going to prioritize getting vaccinated that day,” says Julia Raifman, assistant professor of health law, policy and management at Boston University. She created the COVID-19 U.S. State Policy Database, which tracks state health and economic policies related to the pandemic.
Most states in the U.S. lack paid sick leave policies, and the average paid sick days with private employers is about one week. Green says, “I think COVID should have been a wake-up call that this is necessary.”
Maskless waiting rooms
For her son, Holmes spent hours making phone calls but could uncover no clear answers. No one could estimate an arrival date for the booster. “It disappoints me greatly that the process for locating COVID-19 vaccinations for young children requires so much legwork in terms of time and resources,” she says.
In January, she found a pharmacy 30 minutes away that could vaccinate Theo. With her son being too young to mask, she waited in the car with him as long as possible to avoid a busy, maskless waiting room.
Kids under two, such as Theo, are advised not to wear masks, which make it too hard for them to breathe. With masking policies a rarity these days, waiting rooms for vaccines present another barrier to access. Even in healthcare settings, current CDC guidance only requires masking during high transmission or when treating COVID positive patients directly.
“This is a group that is really left behind,” says Raifman. “They cannot wear masks themselves. They really depend on others around them wearing masks. There's not even one train car they can go on if their parents need to take public transportation… and not risk COVID transmission.”
Yet another challenge is presented for those who don’t speak English or Spanish. According to Translators without Borders, 65 million people in America speak a language other than English. Most state departments of health have a COVID-19 web page that redirects to the federal vaccines.gov in English, with an option to translate to Spanish only.
The main avenue for accessing information on vaccines relies on an internet connection, but 22 percent of rural Americans lack broadband access. “People who lack digital access, or don’t speak English…or know how to navigate or work with computers are unable to use that service and then don’t have access to the vaccines because they just don’t know how to get to them,” Jirmanus, an affiliate of the FXB Center for Health and Human Rights at Harvard and a member of The People’s CDC explains. She sees this issue frequently when working with immigrant communities in Massachusetts. “You really have to meet people where they’re at, and that means physically where they’re at.”
Equitable solutions
Grassroots and advocacy organizations like PTF have been filling a lot of the holes left by spotty federal policy. “In many ways this collective care has been as important as our gains to access the vaccine itself,” says Spira, the PTF co-founder.
PTF facilitates peer-to-peer networks of parents that offer support to each other. At least one parent in the group has crowdsourced information on locations that are providing vaccines for the very young and created a spreadsheet displaying vaccine locations. “It is incredible to me still that this vacuum of information and support exists, and it took a totally grassroots and volunteer effort of parents and physicians to try and respond to this need.” says Spira.
Kass, who is also affiliated with PTF, has been vaccinating any child who comes to his independent practice, regardless of whether they’re one of his patients or have insurance. “I think putting everything on retail pharmacies is not appropriate. By the time the kids' vaccines were released, all of our mass vaccination sites had been taken down.” A big way to help parents and pediatricians would be to allow mixing and matching. Any child who has had the full Pfizer series has had to forgo a bivalent booster.
“I think getting those first two or three doses into kids should still be a priority, and I don’t want to lose sight of all that,” states Renton, the researcher at Ariadne Labs. Through the vaccine equity planner, he has been trying to see if there are places where mobile clinics can go to improve access. Renton continues to work with local and state planners to aid in vaccine planning. “I think any way we can make that process a lot easier…will go a long way into building vaccine confidence and getting people vaccinated,” Renton says.
Michelle Baltes-Breitwisch, a pharmacist, and her two-year-old daughter, Charlee, live in Iowa. Her husband had to drive four hours roundtrip to get the boosters for Charlee.
Michelle Baltes-Breitwisch
Other changes need to come from the CDC. Even though the CDC “has this historic reputation and a mission of valuing equity and promoting health,” Jirmanus says, “they’re really failing. The emphasis on personal responsibility is leaving a lot of people behind.” She believes another avenue for more equitable access is creating legislation for upgraded ventilation in indoor public spaces.
Given the gaps in state policies, federal leadership matters, Raifman says. With the FDA leaning toward a yearly COVID vaccine, an equity lens from the CDC will be even more critical. “We can have data driven approaches to using evidence based policies like mask policies, when and where they're most important,” she says. Raifman wants to see a sustainable system of vaccine delivery across the country complemented with a surge preparedness plan.
With the public health emergency ending and vaccines going to the private market sometime in 2023, it seems unlikely that vaccine access is going to improve. Now more than ever, ”We need to be able to extend to people the choice of not being infected with COVID,” Jirmanus says.
*Some names were changed for privacy reasons.
A string of the code that comprises a DNA molecule, pictured at Miraikan, the National Museum of Emerging Science and Innovation in Japan.
New Alzheimer's Therapies
Mary Carrillo, Chief Science Officer at the Alzheimer’s Association
Alzheimer's Association
One of the biggest health stories of 2021 was the FDA’s accelerated approval of aducanumab, the first drug that treats the underlying biology of Alzheimer’s, not just the symptoms. But, Alzheimer’s is a complex disease and will likely need multiple treatment strategies that target various aspects of the disease. It’s been exciting to see many of these types of therapies advance in 2021.
Following the FDA action in June, we saw renewed excitement in this class of disease-modifying drugs that target beta-amyloid, a protein that accumulates in the brain and leads to brain cell death. This class includes drugs from Eli Lilly (donanemab), Eisai (lecanemab) and Roche (gantenerumab), all of which received Breakthrough Designation by the FDA in 2021, advancing the drugs more quickly through the approval process.
We’ve also seen treatments advance that target other hallmarks of Alzheimer’s this year. We heard topline results from a phase 2 trial of semorinemab, a drug that targets tau tangles, a toxic protein that destroys neurons in the Alzheimer’s brain. Plus, strategies targeting neuroinflammation, protecting brain cells, and reducing vascular contributions to dementia – all funded through the Alzheimer's Association Part the Cloud program – advanced into clinical trials.
The future of Alzheimer’s treatment will likely be combination therapy, including drug therapies and healthy lifestyle changes, similar to how we treat heart disease. Washington University announced they will be testing a combination of both anti-amyloid and anti-tau drugs in a first-of-its-kind clinical trial, with funding from the Alzheimer’s Association.
AlphaFold
Olivier Elemento, Director of the Caryl and Israel Englander Institute for Precision Medicine at Cornell University
Cornell University
AlphaFold is an artificial intelligence system designed by Google’s DeepMind that opens the door to understanding the three-dimensional structures and functions of proteins, the building blocks that make up almost half of our bodies' dry weight. In 2021, Google made AlphaFold available for free and since then, researchers have used it to drive greater understanding of how proteins interact. This is a foundational event in the field of biotech.
It’s going to take time for the benefits from AlphaFold to transpire, but once we know the 3-D structures of proteins that cause various diseases, it will be much easier to design new drugs that can bind to these proteins and change their activity. Prior to AlphaFold, scientists had identified the 3-D structure of just 17 percent of about 20,000 proteins in the body, partly because mapping the structures was extremely difficult and expensive. Thanks to AlphaFold, we’ve now jumped to knowing – with at least some degree of certainty – the protein structures of 98.5 percent of the proteome.
For example, kinases are a class of proteins that modify other proteins and are often aberrantly active in cancer due to DNA mutations. Some of the earliest targeted therapies for cancer were ones that block kinases but, before AlphaFold, we had only a premature understanding of a few hundred kinases. We can now determine the structures of all 1,500 kinases. This opens up a universe of drug targets we didn’t have before.
Additional progress has been made this year toward potentially using AlphaFold to develop blockers of certain protein receptors that contribute to psychiatric illnesses and other neurological diseases. And in July, scientists used AlphaFold to map the dimensions of a bacterial protein that may be key to countering antibiotic resistance. Another discovery in May could be essential to finding treatments for COVID-19. Ongoing research is using AlphaFold principles to create entirely new proteins from scratch that could have therapeutic uses. The AlphaFold revolution is just beginning.
Virtual First Care
Jennifer Goldsack, CEO of Digital Medicine Society
Digital Medicine Society
Imagine a new paradigm of healthcare defined by how good we are at keeping people healthy and out of the clinic, not how good we are at offering services to a sick person at the clinic. That is the promise of virtual-first care, or V1C, what I consider to be the greatest, and most underappreciated, advance that occurred in medicine this year.
V1C is defined as medical care accessed through digital interactions where possible, guided by a clinician, and integrated into a person’s everyday life. This type of care includes spit kits mailed for laboratory tests and replacing in-person exams with biometric sensors. It’s built around the patient, not the clinic, and provides us with the opportunity to fundamentally reimagine what good healthcare looks like.
V1C flew under the radar in 2021, eclipsed by the ongoing debate about the value of telehealth more broadly as we emerge from the pandemic. However, the growth in the number of specialty and primary care virtual-first providers has been matched only by the number of national health plans offering virtual-first plans. Our own virtual-first community, IMPACT, has tripled in size, mirroring the rapid growth of the field driven by patient demand for care on their terms.
V1C differs from the ‘bolt on’ approach of video visits as an add-on to traditional visit-based, episodic care. V1C takes a much more holistic approach; it allows individuals to initiate care at any time in any place, recognizing that healthcare needs extend beyond 9-5. It matches the care setting with each individual’s clinical needs and personal preferences, advancing a thorough, evidence-based, safe practice while protecting privacy and recognizing that patients’ expectations have changed following the pandemic. V1C puts the promise of digital health into practice. This is the blueprint for what good healthcare looks like in the digital era.
Digital Clinical Trials
Craig Lipset, Founder of Clinical Innovation Partners and former Head of Clinical Innovation at Pfizer
Craig Lipset
In 2021, a number of digital- and data-enabled approaches have sustained decentralized clinical trials around the world for many different disease types. Pharma companies and clinical researchers are enthusiastic about this development for good reason. Throughout the pandemic, these decentralized trials have allowed patients to continue in studies with a reduced need for site visits, without compromising their safety or data quality.
Risk-based monitoring was deployed using data and thoughtful algorithms to identify quality and safety issues without relying entirely on human monitors visiting research sites. Some trials used digital measures to ensure high quality data on target health outcomes that could be captured in ways that made the participants’ physical location irrelevant. More than three-quarters of research organizations, such as pharma and biotech, have accelerated their decentralized clinical trial strategies. Before COVID-19, 72 percent of trial sites “rarely or never” used telemedicine for trial participants; during COVID, 64 percent “sometimes, often or always” do.
While the research community does appreciate the tremendous hope and promise brought by these innovations, perhaps what has been under-appreciated is the culture shift toward thoughtful risk-taking and a willingness to embrace and adopt clinical trial innovations. These solutions existed before COVID, but the pandemic shifted the perception of risks versus benefits involved in these trials. If there is one breakthrough that is perhaps under-appreciated in life sciences clinical research today, it’s the power of this new culture of willingness and receptivity to outlast the pandemic. Perhaps the greatest loss to the research ecosystem would be if we lose the momentum with recent trial innovations and must wait for another global pandemic in order to see it again.
Designing Biology
Sudip Parikh, CEO of the American Association for the Advancement of Science and Executive Publisher of the Science family of journals
American Association for the Advancement of Science
As our understanding of basic biology has grown, we are fast approaching an era where it will be possible to design and direct biological machinery to create treatments, medicine, and materials. 2021 saw many breakthroughs in this area, three of which are listed below.
The understanding of the human microbiome is growing as is our ability to modify it. One example is the movement toward the notion of the “bug as the drug.” In June, scientists at the Brigham and Women’s Hospital published a paper showing that they had genetically engineered yeast – using CRISPR/Cas9 – to sense and treat inflammation in the body to relieve symptoms of irritable bowel syndrome in mice. This approach could potentially be used to address issues with your microbiome to treat other chronic conditions.
Another way in which we saw the application of basic biology discoveries to real world problems in 2021 is through groundbreaking research on synthetic biology. Several institutions and companies are pursuing this path. Ginkgo Bioworks, valued at $15 billion, already claims to engineer cells with assembly-line efficiency. Imagine the possibilities of programming cells and tissue to perform chemistry for the manufacturing process, inspired by the way your body does chemistry. That could mean cleaner, more controllable, and affordable ways to manufacture food, therapeutics, and other materials in a factory-like setting.
A final example: consider the possibility of leveraging the mechanics of your own body to deliver proteins as treatments, vaccines, and more. In 2021, several scientists accelerated research to apply the mRNA technology underlying COVID-19 vaccines to make and replace proteins that, when they’re missing or don’t work, cause rare conditions such as cystic fibrosis and multiple sclerosis.
These applications of basic biology to solve real world problems are exciting on their own, but their convergence with incredible advances in computing, materials, and drug delivery hold the promise of game-changing progress in health care and beyond.
Brain Biomarkers
David R. Walt, Professor of Biologically Inspired Engineering, Harvard Medical School, Brigham and Women’s Hospital, Wyss Institute at Harvard University
David Walt
2021 brought the first real hope for identifying biomarkers that can predict neurodegenerative disease. Multiple biomarkers (which are measurable indicators of the presence or severity of disease) were identified that can diagnose disease and that correlate with disease progression. Some of these biomarkers were detected in cerebrospinal fluid (CSF) but others were measured directly in blood by examining precursors of protein fibers.
The blood-brain barrier prevents many biomolecules from both exiting and entering the brain, so it has been a longstanding challenge to detect and identify biomarkers that signal changes in brain chemistry due to neurodegenerative disease. With the advent of omics-based approaches (an emerging field that encompasses genomics, epigenomics, transcriptomics, proteomics, and metabolomics), coupled with new ultrasensitive analytical methods, researchers are beginning to identify informative brain biomarkers. Such biomarkers portend our ability to detect earlier stages of disease when therapeutic intervention could be effective at halting progression.
In addition, these biomarkers should enable drug developers to monitor the efficacy of candidate drugs in the blood of participants enrolled in clinical trials aimed at slowing neurodegeneration. These biomarkers begin to move us away from relying on cognitive performance indicators and imaging—methods that do not directly measure the underlying biology of neurodegenerative disease. The identity of these biomarkers may also provide researchers with clues about the causes of neurodegenerative disease, which can serve as new targets for drug intervention.