, MD, PhD Dean for the National School of Tropical Medicine Co-Director, Texas Children's Hospital Center for Vaccine Development Baylor College of Medicine

KATHLEEN PAGE, MD Associate Professor of Medicine, Division of Infectious Diseases Co-Director, Center for Salud/Health and Opportunities for Latinos Johns Hopkins University

RISHA IRVIN MD, MPH Assistant Professor of Medicine, Division of Infectious Diseases Program Director, Generation Tomorrow at the Center for AIDS Research Johns Hopkins University

2/2/21 Session Objectives

• Compare and contrast the COVID-19 vaccines already available and under study • Describe the relationship of the anti-vaccination movement to current COVID- 19 vaccination efforts • Compare and contrast current COVID-19 vaccination rates to SARS-CoV-2 infection, hospitalization, and death rates among white versus Latinx populations in the U.S. • Name at least one component of the efforts underway to enhance COVID-19 vaccine access and equity among the Latinx and Black communities in Baltimore and beyond Clinical Vignette #1

• 45 year old woman with insulin dependent diabetes presents to clinic for routine follow- up. • Her provider asks if she is interested in receiving a COVID-19 vaccine • The patient tells the provider she saw on Facebook that the vaccine worsens diabetes, and so is not planning to take it • The provider states this is not accurate, and reviews the number of people in the clinical trials with diabetes • The patient shares they don’t know how much they can trust studies. They are close to the people who posted about the vaccine on social media and trust them. Clinical Vignette #2

• 72-year-old Black man visited your office last week for a routine, scheduled follow-up appointment • He asks whether he can have the COVID-19 vaccine. • When told that your office does not have the vaccine and that there is a website he can visit for more information, he reports that he does not have a computer. • He does have a smart phone, but has not considered using it for this purpose. • He travels by bus to office visits. COVID-19 Vaccines and the Rise of AntiScience

@PeterHotez

Peter Hotez MD PhD

Texas Children’s Hospital Endowed Chair in Tropical Pediatrics

Dean, National School of Tropical Medicine at Baylor College of Medicine

University Professor,

Hagler Institute of Advanced Studies, Texas 1 A&M University COVID19 and the G20 Nations

• 100 million cases • 2 million deaths

6 SARS CoV2‐COVID19 Vaccine Approaches

Anthony Fauci, NIAID, NIH Presentation to National Academies

7 • First Wave (2020) Op Warp Speed Vaccines – (mRNA) – Pfizer (mRNA)* • 2nd Wave (2021 Q1‐2) – AstraZeneca‐Oxford (Adenovirus) – Novovax (Protein Particle) – J&J (Adenovirus) • 3rd Wave (2021 Q2‐3) – Sanofi Pasteur (Recombinant Protein Insect Cell) – Merck & Co (Live VSV) – Baylor‐BioE (Recombinant yeast protein)* • *Not officially part of OWS Which one doc?

• ANS: • Take whichever one you can • All work by inducing virus neutralizing antibodies • We don’t know durability of protection • But potentially get boosted with a 3rd dose

9 COVAX and COVID-19 in Latin America, India, Africa

10 Global Coronavirus Vaccine Initiative

11 Coronavirus, Spike Protein, RBD CoV-2-RBD219-N1-C1

12 Developing Low-Cost COVID19 Vaccines YEAST: Pichia Pastoris

Yeast Hepatitis B Vaccine: Bangladesh, Brazil, Cuba, India, Indonesia

NEW PLAN: SARS CoV2 RBD 1 Billion Doses Clinical Testing 2020

13 Summary of our major milestones

• Biological E is scaling up • The vaccine and its production cell production and clinical testing bank were developed at Texas of a recombinant protein Children’s CVD. vaccine for COVID-19 • It was licensed non-exclusively to • Phase 1 and 2 – in five sites in BioE through an agreement India • The vaccine or a closely related • The vaccine prototype incudes high levels of • Receptor-binding domain VNA in mice, NHPs and protective (RBD) of the SARS-CoV2 immunity spike protein expressed in yeast (Pichia pastoris) • Alum • CpG from Dynavax

14 Potential Advantages of CoV-2-RBD219-N1-C1

• Ease of production, scalability: 1.2 billion doses • Refrigeration 4 C • 40-year track record of safety based on recombinant hepatitis B vaccine • Potentially suitable for children and infants, widespread vaccine acceptance • Low cost: US$1.50 per dose

15 15 Combating Anti-Science

16 https://peterhotez.org/combating‐antiscience/ THE ORIGINS: 23 Years of ‘’ Wakefield et al 1998

17 2019 WHO and “Vaccine Hesitancy”

80,000 measles cases 2018, 90,000 measles cases 2019

18 2019: Measles Returns to America 20 years after its elimination

Measles returned in 8 of the 15 hotspots areas we predicted in 2018

19 Vaccine Hesitancy in USA

20 Vaccine Scientist, Pediatrician, Parent of Adult Daughter with Autism, and the “OG Villain”

21 Early Fetal Brain Development: Large Scale Exome Sequencing and Autism

• 102 genes implicated in risk for autism spectrum disorder • All but one expressed in the cortex • Expressed early in brain development • Regulation of gene expression or neuronal communication • Most are expressed and enriched early in excitatory and inhibitory https://www.cell.com/cell/pdf/S0092‐ neuronal lineages 8674(19)31398‐4.pdf • Most affect synapses or regulate other genes • Neuronal cytoskeleton (Biorxiv) • Some ASD genes alter early development broadly, others appear more specific to ASD

22 “Moving Goalposts” of the Antivaccine Movement in America

Autism Health HPV MMR Freedom Autoimmunity Thiomerosal Medical Infertility Spacing Freedom Alum Chronic Illness

23 Origins of the Health Freedom Movement in Orange CA

24 Expansion of “Health Freedom” to Texas

25 Texas “Health Freedom” Anti-science • Health Freedom Protests • Vaccines • • Contact Tracing https://www.nytimes.com/2020/04/1 8/us/texas‐protests‐stay‐at‐home.html • Masks https://www.freedomfortexas.com/

https://www.nbcnews.com/news/us‐news/europe‐s‐coronavirus‐ death‐toll‐nears‐100‐000‐lockdown‐protests‐n1187301

26 Targeting Ethnic and Racial Communities By Antivaccine Groups

2017 2018‐19 2019 Somali Orthodox Jewish African American Community Groups Communities Minnesota NY NJ Harlem, NY

27 Vaccine Hesitancy

• 2 studies identified same 2 groups as vaccine hesitant:

• KFF • “Republicans” • African Americans

• Social Science Med • “Trump Voters” • African Americans

28 COVID-19 Meets the American Antivaccine Movement

• General Assertions • Specific for mRNA • Op Warp Speed Vaccines • Vaccines are rushed • Infertility • Vaccines not tested for • Autoimmunity safety • GMH: Genetically • Pharma and US Govt Modified Humans conflicts • 5G • Thalidomide • Severe Allergy • Sudden Deaths

https://www.sciencedirect.com/science/article 29 /pii/S1286457920300885?via%3Dihub Globalization of American Anti-Science Western Europe and Russia Hotez PJ (2021) PLOS Biology

• Globalization of US Health Freedom • Antimask Antivaccine rallies in W. Europe • QAnon and Political Extremism Far Right • Historical Legacy of the Stalin “Great Purge” • Putin and Weaponized Health Communication

30 The Epic Struggle

21st Century Forces Poverty, Climate Change, Vaccines War, Political Collapse, Urbanization, Antiscience

31 Tips for Addressing Vaccine Hesitancy for Providers Vaccine Equity for the Latinx Community

35 February 2, 2021 Immigration Policies

Cooling DACA Driver’s license Policies Sanctuary cities

Deportations Warming Criminalization of immigrants Exclusion from safety net Policies Public charge

February 2, 2021

How is vaccine coverage so far? White Latinx Vaccines Hesitancy vs. Vaccine Access

covidlink.maryland.gov/content/vaccine/ Phase 1

Healthcare Workers

• 25% of direct care workers for elderly and people with disabilities is foreign born (around 1 million) (Lee C. et al. Sep. 18, 2020 Health Affairs)

• Estimated 225,000 undocumented health care workers (Jawetz T, Center for American Progress, September 28, 2020) Phase 1A

• Adults aged 75 years and older. • People experiencing homelessness • Shelter staff and residents • High-risk, incarcerated individuals • Individuals in group home settings • Education sector (K-12 Teachers and support staff in schools) • Child-care workers • Continuity of government Age

Decedents < 65 yo • 35% among Hispanics • 30% among NH Black • 13.2% among white

FIGURE. Decedent race/ethnicity,* by age group, reported to supplemental COVID-19 surveillance (N = 10,647) — 16 U.S. public health jurisdictions,† February 12–April 24, 2020

MMWR Morb Mortal Wkly Rep. 2020 Jul 17;69(28):923‐929. February 2, 2021

Housing

NYT Jan. 23, 2021 Phase 1c (updated 1/25/21 by MDH)

• All Marylanders over 65. • All other public safety (not in Phase 1A) • All other healthcare (not in Phase 1A), • Including, but not limited to Lab Services, Public Health, Vaccine Manufacturing, other healthcare professions). • Food and Agriculture Production • Critical Manufacturing • U.S. Postal Service • Public Mass Transit • Grocery Stores • Veterinarians and Support Staff 2 • Clergy and other essential support for houses of worship Workplace Outbreak Investigation, Utah, March 6–June 5, 2020

• 58% associated with manufacturing, construction, wholesale trade • Latinos and non-whites accounted for 73% (970 of 1,335) of workplace outbreak associated infections although they make up 24% of that workforce

MMWR Morb Mortal Wkly Rep. 2020 August 21, 2020 / 69(33);1133–1138 Why is this happening?

US Census Bureau. https://www.americanprogress.org/issues/race/reports/2012/08/08/11984/the‐state‐of‐ latinos‐in‐the‐united‐states/ Even if you meet criteria, what next? The devil is in the details • Mistrust • Proof of Eligibility (IDs) • Digital Divide • Language • Literacy • Work hours • Transportation • Fear of deportation (police/national guards) • No doctor Communication

Figure 4. Tu Doctor y Tu Municipalidad has a live “ask your doctor” format and provides direct feedback about community concerns ACCESS IS THE FIRST STEP

Social networks to overcome vaccine hesitancy

Relationships- word of mouth Hotlines and Community Health Workers

• Esperanza hotline • 6000 calls Go to where people are

Vaccine Equity 2.0: MAKE IT EASY

VACCINE ROLL OUT PROVIDERS

• Access is key to overcome hesitancy • Trusted source of information

• COVID vaccine ambassadors • Reach out

• Hotlines • Make no assumptions, ask questions

• Go to where people are • Acknowledge fear/mistrust • Hotspots • Leverage existing and trusted infrastructure • Flexible hours • Be specific Excess Mortality in 2020

Whites: 11.9% Native American: 28.9% Blacks: 32.9% Asian: 36.6% Hispanic: 53.6%

MMWR Oct. 20, 2020 56 COVID-19 Health Equity: Our Response at Johns Hopkins Medicine Proposed Reasons for Health Disparities Related to COVID-19: African American Community

• Differential risk (work from home, essential workers, etc.) • Differential access to healthcare • Structural racism – Higher density neighborhoods (redlining), fewer hospitals • Social determinants of health – Housing, poverty, comorbidities Impact of COVID-19 Health Disparities on the African American Community

• One-third of African Americans reported that someone close to them has died of COVID-19 (de Beaumont Foundation) – Grief, depression, fear, anxiety – “Every time you look up, there is another RIP post, or a friend seeking prayers for their loved one who is battling this cruel virus,” said Desha Hargrove of Detroit, who lost her husband to Covid-19 in March. “I am simply devastated at how this virus has mainly impacted our communities.” (Vox) COVID-19 Vaccine Hesitancy: Medical and Scientific Distrust  Immunity Inequality HISTORICAL DISCRIMINATION AND RACISM DURING SLAVERY AND POST-CIVIL WAR

Medical and Scientific Contributors Social Conditions and Policies • Eugenics Theory defining certain races and • Redlining and predatory lending leading to racial ethnicities as biologically inferior residential segregation and housing insecurity • Closure of medical schools training black • Inadequate investment to maintain public works and physicians in 1910s school systems in minority neighborhoods • Experimentation on vulnerable groups without • Discrimination in access to high quality jobs with their consent adequate health insurance

↓ Trust in Healthcare provider medical bias toward Structural and institutional racism establishment minority patients

Language and Physical Context Environmental Context ↑ communication barriers ↓ neighborhood stability, poverty cleanliness, sidewalks, Crowded multigenerational open space, parks living conditions Healthcare Context ↓ access to healthy food Mass incarceration Poor access to care, ↓ quality of ↓ affordable housing ↑ service sector employment care, ↓ participatory decision-making in ↑ public transportation use patient-provider relationships, ↓ health literacy Inadequate PPE

↑ Stress, Blood Pressure, Obesity, Cholesterol, Blood Glucose, Lung Disease ↑ COVID-19 Exposure

DISPARATE HEALTH OUTCOMES DISPARATE HEALTH Diabetes, Heart Disease, Hypertension, OUTCOMES Asthma COVID-19 Health Equity

• Healthy People 2020 defines health equity as the “attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.” Executive Assistant Administrative Tamala Knox Coordinator

63 JHHS Diversity and Inclusion

• JHM/JHHS Director of Diversity and Inclusion: Karen Jones

• Diversity and Inclusion Training and Education Program Manager: Cheri Wilson

• Program Specialist, Diversity, Inclusion and Health Equity: April Lugo

• LGBTQ Programs and Clinical Director, Center for Transgender Health: Paula Neira

64 School of Medicine Office of Diversity and Inclusion

JHM Vice President, Chief Diversity Officer Dr. Sherita Golden

SOM Director of Diversity Senior Associate Dean for and Inclusion Diversity and Inclusion Shellon Johnson Dr. Robert Higgins - Oversee SOM diversity awareness training (coordinated with - Focus on URM faculty, housestaff, and post-doctoral fellow JHM ODI) diversity and inclusion - Programmatic and strategic oversight for SOM Diversity Council - Chair SOM Diversity Council - Program development for URM faculty, housestaff, post-doctoral fellows, and students (liaison to SOM Office of Faculty Development) - Oversee report preparation and assess program outcomes Assistant Dean for Graduate Student Diversity, SOM Dr. Damani Piggott

SOM D&I Program Assistant Dean for Coordinator Medical Student Diversity, SOM (Deysheena Brown 2/1/2021) Dr. Shari Lawson - Administrative support for SOM Diversity Council - Oversees coordination of URM Residency Program Recruitment Weekend - Oversees CARES Symposium - Assists in coordination of medical and graduate student second look activities - Coordinates sending students, residents, and faculty to URM scientific meetings for recruitment purposes JHM Health Equity Advisory Committee Co-Chairs Felicia Hill-Briggs and Sherita Golden Health Equity Leaders and Stakeholders across JHM representing Office of Johns Hopkins Health Equity Physicians; Schools of Medicine, Nursing, and Public Health; Language Access Services; Center for Health Equity; Center for Health Disparities Solutions; Urban Health Institute; Armstrong Institute; Center for Transgender Health; Nurse Case Management; JHHS Operations Quality, Integration and Operations; Disability Services

JHM Social Determinants of Health Work COVID-19 Health Equity Work Group Group Chair Sherita Golden Chair Kai Shea JHM Sexual Orientation/Gender Identity JHM Language Services Advisory Council Work Group Chair Tina Tolson Chair Paula Neira

JHHS Health Equity Steering Committee Co-Chair, Panagis Galiatsatos (data) Co-Chair, Felicia Hill-Brigg (implementation strategies) April Lugo (program coordination) , Cheri Wilson (education) Entity Health Equity Champions

Felicia Hill-Briggs, PhD, Panagis Galiatsatos, MD, ABPP MHS Professor of Medicine; Assistant Professor, Health, Behavior and Pulmonary & Critical Care Society Medicine Health Equity Senior Lead Health Equity Co-Lead Johns Hopkins Center for Health Equity Director, Lisa Cooper (Academic health equity and policy expertise)

Maryland Hospital Association JHM Health Equity Advisory Committee Health Equity Task Force Co-Chairs Felicia Hill-Briggs and Sherita Golden JHM Representatives: Felicia Hill- Health Equity Leaders and Stakeholders across JHM representing Office of Johns Hopkins Briggs, Renee Blanding, Elizabeth Physicians; Schools of Medicine, Nursing, and Public Health; Language Access Services; Kromm Center for Health Equity; Center for Health Disparities Solutions; Urban Health Institute; Armstrong Institute; Center for Transgender Health; Nurse Case Management; JHHS Quality, Integration and Operations; Disability Services

JHM Social Determinants of Health Work COVID-19 Health Equity Work Group Group Chair Sherita Golden Chair Kai Shea

JHM Sexual Orientation/Gender Identity JHM Language Services Advisory Council Work Group Chair Tina Tolson Chair Paula Neira

JHHS Health Equity Steering Committee Co-Chair, Panagis Galiatsatos (data) Co-Chair, Felicia Hill-Brigg (implementation strategies) April Lugo (program coordination) , Cheri Wilson (education) Entity Health Equity Champions Health Equity Faculty Operational Team

• Risha Irvin, MD, MPH—Health Equity Community Affairs

• Thomas Cudjoe, MD, MPH—Social Determinants of Health Workgroup

• Kathleen Page, MD—Latinx Health Equity Champion

• Bonnielin Swenor, MPH, PhD—Disability Inclusion Champion

• Dr. Rachel Johnson Thornton, MD, PhD—Office of Population Health

68 Health Equity Response in Marginalized Communities

• Focus on COVID-19 vaccine community education – Internal JHM messaging and external messaging • Listening sessions to understand community concerns • Inventory of COVID-19 efforts across JHM to foster collaboration • Partnership with other health systems to focus on COVID-19, Faith, and Race • Establishment of COVID-19 Health Equity Group – Messaging, Community Messengers, Marketing COMMUNITY FORUM WITH DR. : EVERYTHING YOU SHOULD KNOW ABOUT THE COVID- 19 VACCINES

GOALS

Recording can be found at: Johns Hopkins Coronavirus Resource Center SLIDES & RECORDINGS ARCHIVED ONLINE https://bit.ly/2Y2DIDj