Radha and Lexi host University of Iowa Health Care pediatrician Dr. Rami Boutros for a discussion about vaccine hesitancy among parents, how to address it, and COVID-19’s effect on children.

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Radha Velamuri:

Hello, everyone. Welcome back to From the Front Row, brought to you by the University of Iowa College of Public Health. My name is Radha Velamuri, and I’m joined today by Lexi Fahrion. And if this is your first time with us, welcome. We’re a student-run podcast that talks about major issues in public health and how they’re relevant to anyone, both in and out of the field of public health. Today, we’ll be chatting with Dr. Rami Boutros, executive medical director and pediatrician with UI Health Care. Dr. Boutros is specifically focused on how immunizations can protect children. Welcome to the show, Dr. Boutros.

Rami Boutros:

Thank you so much for having me and I appreciate this opportunity to chat with your audience.

Radha Velamuri:

And we’re so excited to have you. Can you talk a bit about your career and journey to pediatric medicine?

Rami Boutros:

Absolutely. So I knew that after, during my medical school, that this my passion is really taking care of kids and making the difference for them. And it’s always enjoyable to see a child that you put a smile on their face and when they leave your office. My journey in pediatrics has been for the last 30 years in different settings. So from being in a community-based practice with the small group to join at the Cleveland Clinic, and then joining the University of Iowa in my current role. But over the years, I also serve not only in an administrative role at the university, but I still see kids and see patients in my practice and always it’s enjoyable. But what’s relevant to our discussion is really the journey through pediatrics have showed me the difference that we have made in the development of vaccines and the improvement over the last 30 years in our vaccination and even the side effects how it decreased dramatically. So I think I’m very proud of that journey because it’s really gave me a lot about what we are talking about today about COVID and COVID vaccination from that experience.

Lexi Fahrion:

Thank you, Dr. Boutros. You certainly are an expert on this topic and have such a wide spanning career. So you kind of led into COVID, which is what we’re really here to talk about today. Can you specifically speak a little bit about how the COVID-19 vaccine protects children? Just like how you would explain it to a patient and their parents?

Rami Boutros:

Absolutely. As pediatricians we are very familiar with vaccines. We educate parents about vaccination every day. That’s not only related to COVID, but only related to other illnesses from measles, mumps, rubella, polio, all these. What all vaccines do in principle is help teach your immune system how to fight an illness, how to protect you against illness. And COVID-19 vaccine is no different than others is trying to help your immune system learn about the disease, help protect you, build immunity. So when you exposed to it, at least is minimize the risk from that disease, make it less severe, decrease your risk of hospitalization and hopefully protect you, not even having as many symptoms is minimal symptoms. And that’s what the journey is. Really the vaccine is about teaching your immune system how to fight it. I think COVID vaccine has been studied in children, has been used in the adults and serve that purpose to help that. And in the long run by vaccinating children, we minimize variants and we minimize the risk from COVID. Did that answer your question?

Lexi Fahrion:

Absolutely. If I could just follow up on that really quick, there’s a lot of rhetoric around people saying that COVID doesn’t affect children as greatly. And I think that might be some of the reasons that people are a little more hesitant to get their children vaccinated. Can you talk a bit about how COVID specifically would affect unvaccinated children?

Rami Boutros:

Absolutely. I think earlier in the pandemic, what we see in the majority of the disease happened in adults and we seen that effect and everybody at the time for that the children are more immune. The disease is very minor. They don’t have any risks. However, as we started to see the pandemic progressing, we started to see the impact on children. And actually in the recent month after the vaccine about getting vaccinated, we seen the major positivity was among the children under 18 years of age. So children are not immune to the disease. They carry the disease, they circulate the disease in the community, and yes they are not probably as adults exposed to the severe disease, but some of the children experience very severe disease, even death from COVID-19.

Rami Boutros:

And I think sometimes we can’t predict who’s the child that might have a multisystem failure and inflammation, and those. And we have many children who has been affected through this pandemic and our goal to try to protect them. So to your point, yes in the beginning we thought it is mainly adults. However, I think right now we are seeing the majority of infection is happening in younger children. As they got back into school, circulating that. A younger adolescence as they are in school and socializing, definitely they are circulating that virus.

Radha Velamuri:

Thank you. Yeah. That is a very important thing to consider all the students going back to school, especially as you know, we are student podcast here at the university, like student education is on the forefront of our minds. So let’s talk real life scenarios. So how would you as a healthcare professional respond to a parent who’s hesitant about getting their child vaccinated against COVID-19.

Rami Boutros:

Very good question. I will tell you is no difference than any other vaccine is the very important part into getting parents to immunize their children is having the facts sitting down and discussing with them or what they should expect from side effects, from the risks and benefits of the vaccine. How it’s function, decrease their worries about the vaccine and really have a dialogue with them about the risks, benefits. As any patient I sit down and say, this is the vaccine. This is the reason to do it. This is how you prevent your kid from this disease. Why to do it, what’s the potential side effects from that vaccine.

Rami Boutros:

And once they should expect immunity from that vaccine. And then I… Parents start to say, well I’m worried about this, or I read this. I try to go into the science, try to also to direct them to appropriate websites or education material by reliable resources or reliable sources to say, this is where you get the best information is really can help the parents understand why the vaccine is important for their children. But also arm them with the appropriate science and the appropriate information so they are well educated about the risks and benefits.

Lexi Fahrion:

Absolutely. I think this issue of education and where people are getting their information right now is super important.

Radha Velamuri:

I just had a quick question about how not everyone can get a vaccine. You know what I mean? There’s individuals who have certain healthcare concerns or certain religious concerns. How would you address that in a clinic when it comes to child vaccinations?

Rami Boutros:

Very important for us as a healthcare provider is to understand our families and understand their needs. And that’s I think, and everybody, every pediatrician’s mind. And so it’s very important to come with a discussion and understand where they are coming from and then help them understand because a lot of times is they might have read a someplace that this is a vaccine that it is really, it’s a virus that we are injecting their body with the virus. My goal is to tell them that this is truly is not the virus. We are not injecting you with the virus. You are not having a live virus in this vaccine.

Rami Boutros:

So it’s all about helping them understand how the vaccine manufacture, how’s the side effects, how many kids have received the vaccine, what we have seen. So I think it’s all come back to your comment is it’s about the communication, how we address, listen to them, listen to their worries and basically educate them where this will help. And if there is religious concerns, understand what these religious concerns. Is it because concern that the vaccine is built into something that they don’t like to have in their bodies. We need to understand that. And I think I, a lot of it is really encourage. I encourage all my families is let me know what your concerns, that’s my job. That’s what I do to help you through this journey and make them at ease that what they are receiving is something that is going to help them protect their children from a severe illness.

Lexi Fahrion:

I think that’s a great opportunity to take the time to not only just get to know your patients, but really communicate directly and get to the root of their hesitancy and to kind of go back and think about maybe these sources of poor information or misinformation. Can you talk a little bit about some of the most common reasons that you’ve seen for vaccine hesitancy among children or parents of children? And if you know of any sources where people are getting this information from?

Rami Boutros:

Absolutely. I think many of our families, the major source of hesitancy, I think it’s one is knowing that the vaccine is safe, knowing what’s the side effects of the vaccine. They are worried about their children. Are they going to experience major side effects? How long the vaccine been on the market and how fast the vaccine came into the market and the worries that we have potentially cut corners. We got the vaccine very quickly onto the market. Do we really know what’s happening? And my goal is to ease their fear. It’s really, this is not just a new development. It has been in the work for many years that we are working on how we expedite bringing vaccines into preventing illnesses, because an anticipation of pandemic.

Rami Boutros:

These are where the studies if has been long studied. Their hesitancy has there been enough children who are vaccinated or been included in the trials and my goal to assure them that there is bodies who are reviewing these vaccines to make sure that they are very safe for children. Many of their information come either from the web, from different sources on the web, chat, some other close people that discussing these information with.

Rami Boutros:

And some of it is knowing where it comes from not looking for the right websites or the reliable resources. Probably as a rephrasing is I think many of it is trying to find the accurate source of information for them. So I think from my perspective, as a pediatrician is really taking all those and help the directing them to a reliable website, reliable organizations. So that way they get the most accurate piece of information. Did that answer your questions about the reasons for hesitancy? Yeah, I will give you another example. And I think some of it is really is about the fear on our children. We are more protective of our children than we are more protective of ourselves. And as I practice, I have many of my families, the parents are vaccinated and their concerns is the vaccine has been enough or studied enough in children.

Rami Boutros:

And we want to wait a little bit longer to see that other children has received the vaccine and are they experiencing side effects. And my goal in that situation to assure them that there have been other children who received the vaccine, this is what type of side effects they have received. For example, right now I will tell you in my setting in our own organization, we have administered over 3,500 doses for younger children. Probably few millions administered through the United States for younger children. And that has been shown that it is very safe, minimal side effects that we seen. So this is kind of the data that I use with my families to say, you are not alone. You are here with a group and you can be assured that the vaccine is safe for your children.

Radha Velamuri:

Yeah, absolutely. I want to backtrack just a little bit. You mentioned the media and finding information on the web. We’ve been seeing concerning news about the Delta variant for a couple months now and have even seen recent news about the new Omicron variant. How do you suggest we approach protecting children and ourselves even against new emerging variants?

Rami Boutros:

Very good question. And I think to step back and say, what’s the importance of the vaccine. And the vaccine, the most important benefit from a vaccine, the more vaccinated people, the less opportunity for the virus to circulate in the community and to create variants. The more the virus is able to go from one person to the other. And in fact, others, the more likely that we see variants like Delta, like Omicron, all those. So I think it is very important for your audience and others to understand that the more we vaccinate people, the less opportunity for those. If we take a look on those, even the vaccine is very helpful in protecting patients from getting a severe illness, getting hospitalized and really experience severe side effects from those variants in depth. So what we seen, yes it might not be complete protection against these variants, meaning eliminate them from causing a disease, but what they prevent is having serious illness, severe injuries and death from those and decreased hospitalization, even with these variants.

Lexi Fahrion:

Absolutely. I think that’s something that’s on the forefront of everyone’s minds right now, as Radha mentioned, as we’re finding out about these new variants. So I’m curious Radha and I are public health folks and you are integrated into medicine. And these two practices I think, should be more combined than they are, but I just kind of want to get your take on, from like a population or even a policy perspective. What can we do to kind of eliminate this issue of vaccine hesitancy among the US population? Because we’ve seen this in issue even before COVID with parents being hesitant about regular immunizations for their children. And I hope that we don’t see this issue after COVID, but I know we’re going to have to make some big changes to address that.

Rami Boutros:

Thank you for the question. I think I will tell you as a physician, my area of expertise is treating patients and not a policy making. So I want to be clear about that, but I can tell you that on a personal experience with patients and parents who are hesitant to get the vaccine, I suggest that listening to people and understanding their concerns and talking with them about the vaccine, the risks and benefits is probably the most important step that we take to decrease hesitancy. I think many of these is related to misperception, information that they have received and as a care provider, I think it’s the most important piece that I can do is to give them the most accurate information. I think from a policy making, I will leave it up to the people who are more expert with that, but I think it is a collaboration. We really need to come in a way that we have the most accurate information for our patients to help them with adopting these preventive measures, making sure that they are getting the vaccines that they need to keep them healthy.

Lexi Fahrion:

Absolutely. I think we definitely need to get a collaborative effort going to kind of get rid of this little epidemic of hesitancy that we’re having here. I want to follow up on that because I’ve seen some discourse on social media and just from people talking that these new variants and the fact that they are infecting vaccinated people might be fueling some of the anti-vax rhetoric around, oh the vaccine doesn’t even work anyway. Can you speak? That’s not my belief. That’s just what I’ve seen around and on social media. But can you speak a little bit to what the goal of the vaccine really is and how these vaccines still are effective despite emerging variants?

Rami Boutros:

Absolutely. The goal of the vaccine is to help your immune system recognize any of these viruses. The intention, as I said a little bit earlier, the more we get people vaccinated, the less likely for these variants to exist. And I will give you an example from previous one, let’s look on polio. We did not get to eradication of polio within US, just because we have only limited number of people vaccinated because we vaccinated a lot. You look on other situations. When we look on small pox and others, you have to mass vaccinate, a lot of people to be able to get rid of the potential for that virus to circulate in the community. So I think the Delta variant and the Omicron is a results of we still not yet at the level that we have to reach from a vaccinated people to prevent those from circulating in the community.

Rami Boutros:

And so I think from a public health measure, I will say the more we vaccinate, the more likely to get rid of these variants. And if you look another example, as we look on our influenza, which is right now is one of the diseases. We have variants, but we learn from it every year. And we vaccinate because we are trying to prevent similar situation. We are trying to keep people very protected and help decrease a severe illness. So I think the primary reason for the vaccination one is to decrease a severe illness, decrease the risk of being hospitalized, decrease the risk of death. And in the long term, the more people vaccinated is really try to neutralize that virus said they are not able to create a lot of different variants that impact us in the long run. Did that answer your question?

Radha Velamuri:

Absolutely. I like how you compared current vaccination efforts to the successful campaigns for polio and smallpox and even the new malaria vaccine that was developed a couple months ago. Those were medical successes that I’m sure the public health sphere and the medical sphere can both really appreciate. Staying on topic of COVID-19, but venturing away from pediatrics specifically, I’d like to learn a little bit more about monoclonal antibody treatments, monoclonal antibody treatments are known to decrease hospitalization rates and curb progression to severe diseases and death. And we would really appreciate if you could talk more about what a monoclonal antibody treatment even is and how it’s used.

Rami Boutros:

Yep. Thank you for that question. I had the opportunity to be involved into starting this treatment, implementing the start of the treatment over here within our team. We provide that treatment for patients, and I’m very familiar with it. Monoclonal antibodies, if you look at it from a different mechanism from the vaccine. The vaccine is to try to prevent while the monoclonal antibody is to help support your body during an infection to help decrease the progression. So I will say one is on the prevention side. One is to help your body fight the illness and give you a little bit of chance, not to progress to severe illness. There is certain recommendation when we can use monoclonal antibodies definitely cannot mainly in the mild disease, mild to moderate disease patient with certain risk criteria that they are able to use monoclonal antibodies and it needs to be implemented within the first 10 days from being tested positive or having symptoms.

Rami Boutros:

And so that way it will provide the most benefit. And the goal with the monoclonal antibodies is to help decrease hospitalization, decrease progression to a severe illness and hopefully sooner recovery for the patients. Monoclonal antibodies has… We started very small and now we have multiple medication. Still I think for us, as we look at it, it is available. It is not as widely expanded as we seen, but that’s part of the manufacturing we are seeing more of the monoclonal antibodies is available. Definitely some of them are now used also for prophylaxis, meaning getting to if the patient is exposed. Hopefully we can get it immediately to them to help prevent them from developing the disease. So it is a little bit or… Decrease, sorry, decrease the severity of the disease if they develop it. So monoclonal antibodies is an infusion that we give in the setting. So you get an IV, you are getting the monoclonal antibodies in and that to help boost your immune system. And then hopefully that will help you not to progress.

Radha Velamuri:

Yeah, so if I have this right, it’s like a little booster to the immune system. I was wondering if you could delve further into the recommendations you mentioned.

Rami Boutros:

Mm-hmm (affirmative).

Radha Velamuri:

Is this a specific treatment option available for pediatric patients?

Rami Boutros:

Yep. Actually, yes, this is available for pediatrics and we have been doing age 12 and over. However, even recently this has been recommended for younger children as often you need, that was last couple of weeks, that that recommendation has been approved. So we are right now, we are working on how we get to that level, implementing that into the younger children, less than 12 years of age, the criteria include. And I can send you many of those information. One is, for example, with adults, we are looking for anybody who have a body mass index that over 25, if they have any risk factors like heart disease, asthma, diabetes, other complicating factors that we can help them to decrease the risk of severe illness. In pediatrics the same thing. We are looking for children who are at risk from developing severe disease, asthmatics, diabetics, congenital heart disease, immune system, patient who have immune disease that we need to give them some of that help. So those are some of the criterias that we are using.

Radha Velamuri:

One more question, I’m sorry to keep staying on this subject, but I just have one more question. What about immunocompromised individuals? How would this treatment with immunocompromised individuals? Would they fall under this criteria or specifically immunocompromised pediatric patients if we’re staying on the subject of children.

Rami Boutros:

Yep. Yes. All immunocompromised patients are eligible for this treatment, pediatrics and adults. And that’s one of the things we look for when we are looking from the emergency youth authorization. That’s one of the top criteria immunocompromised. So patients who have cancer receiving chemotherapy, those are patient that we will target to make sure that they are received the treatment. So they do not progress into a bad disease.

Radha Velamuri:

Absolutely. Thank you so much.

Lexi Fahrion:

Yeah. Thank you. So like you’ve mentioned monoclonal antibody treatments, you just said recently got approval for pediatrics and things like that. I was wondering if you could just explain really quick to our audience, what a monoclonal antibody is. It’s been a few years since I’ve taken my biochemistry class. Now I would guess it’s the same for some of our audience. So if you could just give like a layman’s overview of what that is and how it works in the body.

Rami Boutros:

Yeah. So the body’s immune system build what we call them antibodies when you experience a virus and that’s really to help you fight that disease. And basically what we are doing is supplementing that from outside with things that we know that it goes and fight COVID-19 and that’s why it is targeted towards COVID-19. So it’s antibodies built in addition to what we have in the system to help us fight that disease. So hopefully that’s make it in a lay term is what it is. It is a boost for your immune system to help you really get to kill the virus and not cause any more damage.

Radha Velamuri:

For sure. So tying back to variants, as far as I know with my biology background, antibodies are very specific for certain viruses or certain targets or certain variants of viruses. How could this monoclonal antibody treatment work with the different variants we see, or am I just looking at that completely incorrect? Is it like an antibody works for just COVID in general? Or is it, are there different antibodies for different variants of COVID?

Rami Boutros:

Right now, there is no different antibodies for different variants. Or what we do we look on the antibodies and the research will companies… The manufacturing companies look with the different variants to make sure that it is effective against it. So if the virus learned how to manipulate itself to that way, we cannot fight it. They look on, is there the, if their antibodies or monoclonal antibodies is effective against that variant?

Rami Boutros:

So for example, right now the current monoclonal antibodies works with the Delta variant and we give it with that. Definitely the researchers and all that will look for patient who have the Omicron and is one drug is better than the other, no difference than any other disease. We look for different antibodies and monoclonal antibodies to say, are they effective against the new variant? Because the virus is smart and learn something else that it’ll make this ineffective. So we look for those. We are only on the Omicron and I don’t know the answer completely for that, the effectiveness against the Omicron, but I will tell you with the Delta variant, it’s working and I can get you the information as we see it developed from the CDC and other sources about the effectiveness.

Lexi Fahrion:

Thank you. That’ll be really interesting to watch that research play out. So just to tie together everything we’ve talked about so far and Dr. Boutros, please interrupt me if I get anything wrong. But so we talked a lot about COVID vaccines and in my mind, the overall goal of the COVID vaccine is to build up those antibodies in your immune system so that it’s ready to fight off COVID if you are, if you become exposed to it.

Rami Boutros:

You are absolutely correct is really building that immunity. So you are ready. And so if the virus reach you, you are prepared, no difference than what we do with influenza. What we do with other viruses, polio, small pox, others that have been over the years is really prepare your body in case you get exposed.

Lexi Fahrion:

Absolutely. And then when we shifted to talking about monoclonal antibody treatments, we’re now talking about an individual who has COVID injecting them with some of those antibodies to help fight off the virus as it progresses through their body. So in the vaccine sense, we’re looking to prevent COVID by giving you antibodies before you’re even exposed to it. And the best treatment that we found so far is once you’re exposed, just pumping you kind of up with those antibodies to give your immune system the best fighting chance.

Rami Boutros:

You are correct. So I think it’s two different mechanisms. One is prevention to start with and build that immunity before the start the disease. The other one is really when you get the disease, how we help you to have the best of chance to not progress to a severe illness. And that’s what our goal is really. We want to prevent people from getting the worse, getting hospitalized and the unfortunate outcome of death. And that’s the whole goal in this treatment. Definitely if we can prevent that’s the ideal, because that’s prevent putting a lot of load on our health system and that’s what we’ve seen over the last year. And so is the burden that the health system has experienced from hospitalization, from the unfortunate outcome.

Radha Velamuri:

We know science isn’t easy and research isn’t easy, but we’re so thankful that you’ve taken the time to talk to us today and that you have this pool of knowledge to share. We were wondering if there it was any takeaway or any lessons you’ve learned throughout the last year, the last few months, while working on this process, while learning about all these vaccines and sharing your knowledge and spreading joy to the children who come and helping them recover and in your path for monoclonal antibody treatment development. Is there any lesson or takeaway that you think would be beneficial to share with our audience?

Rami Boutros:

Yeah, I think it is very important for us, I think to learn from the last year. And I think last December, all of us when seeing the vaccine develop and out in the arms of people we, but the end of the pandemic is at site and that’s I think probably did not come to pass and that did not come to pass because of multiple things. The emerging variants, probably the number of vaccinated people was not as high as expected. The COVID-19 transmission rate continued to be high and the impact on hospitalization, which has continued to put our health system into under stress. However, I think we need to really celebrate some of the successes during this and keep focus on the progress that we have made. If you look at it in one year, we have over 200 million Americans that have been vaccinated.

Rami Boutros:

We have probably over 4 billion people has been vaccinated worldwide. This is a step forward to really help ease the pandemic or put this virus to control this virus. So I think for me, I think the more joy is seeing at that develop for children over the last year and available for them. And hopefully soon, or at some point we’ll see it for younger children. We want to keep them protected. So I think for me, I will say my encouragement to people one is, especially with the holiday season, one is get vaccinated, maintain your current protection, wear your mask. We are not yet out of this, but really there is a way out. And our way out is really by vaccination making sure that we continue public health efforts to wear our mask, wash our hands, be cautious when there is a big gathering, all these, because we want to decrease the transmission of the virus.

Lexi Fahrion:

I’d like to end just right there on that kind of positive outlook that despite everything over the last two years, we have made miraculous advancements in science and controlling this virus. And I want to thank you again for sitting down to talk with us today, Dr. Boutros, because as you mentioned, the biggest success stories in your practice have been from sitting down and being the expert and really figuring out what parents fear and assuring them that we’ve alleviated those fears and we’ve fully tested this vaccine. So I think that our conversation today is a way to do that and reach a little bit larger of an audience all at once. So thank you again, we really appreciate your time.

Rami Boutros:

I appreciate you having the time with me and really sharing with your audience, the successes we have over the year and carrying the messages about how we can keep everybody healthy and help us get to the end of this pandemic. So thank you for doing this.

Lexi Fahrion:

Absolutely. Thanks again, Dr. Boutros.

Rami Boutros:

Thanks a million.

Alexis Clark:

That’s it for our episode this week. Big thanks to Dr. Boutros for coming on with us today. This episode was hosted and written by Lexi Fahrion and Radha Velamuri and produced by Alexis Clark. You can learn more about the University of Iowa College of Public Health on Facebook. Our podcast is available on Spotify, Apple Podcasts and SoundCloud. Our team can be reached at CPH-GradAmbassador@uiowa.edu. This episode was brought to you by the University of Iowa college of Public Health. Stay happy, stay healthy, and keep learning.