Q&A w/ Virginia state vaccine liaison Dr. Danny Avula


Nicole Pasia


Dr. Danny TK Avula is the Virginia state vaccine liaison for the Virginia Department of Health and the director of the Richmond city and Henrico County Health Departments.

In this Q&A, Dr. Avula shares an outlook on how the winter season will impact COVID rates in the state, protecting kids that are back in school, and battling vaccine misinformation. 


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Nicole Pasia: How is the state currently coping with COVID and the Delta variant? What concerns are top-of-mind for you as the state vaccine coordinator? 

Dr. Danny TK Avula: “We’re seeing very well established decreasing trends in both cases and hospitalizations, and that is encouraging. It’s a pretty rapid decrease, just like we saw a pretty rapid rise of the Delta variants in August and September. That, to some degree, was to be expected. 

It’s the same pattern that we saw in the United Kingdom, in Israel, as we followed the epidemiologic curves around the Delta variants. Obviously there’s news from yesterday or the day before about the identification of this Delta variant subtype. We don’t know a lot about that,  but it’s not that it’s creating an upturn of disease. They identified a subtype of the Delta variant that potentially was about 10% more contagious. [It’s] something to keep an eye on, not anything that is really impacting our case rate yet, but it does represent a category of concern that we have throughout this [pandemic], which is that we know that the virus will continue to mutate … That’s the ongoing concern, globally, about how this pandemic is being controlled, and not very well controlled in some areas of the world. And does that continue to allow ongoing mutation to cause a new variant. 

I think we have had the benefit of having — really throughout the last 18 months —  kind of head’s up [on COVID-19 trends]. Israel and the UK are two entities that actually have really great data collection capacity and can monitor disease trends really well. They’ve been able to foretell what has happened in the United States. [There’s] nothing emergently concerning, and all things point to a continued decrease of trends. Now, we’re about to head into winter months, and we know that there’s seasonality to respiratory viruses. As people spend more time indoors and in close quarters, it gives virus a greater opportunity to spread. 

I don’t anticipate we will see anything like we saw last winter, because we’ve done a really great job in getting vaccinated here in Virginia … The combination of immunity from vaccines, plus the immunity from natural infection, and the advancement of effective treatments I think will mean a very different set of outcomes for this winter.”

NP: How have vaccine mandates impacted whether or not people initiate vaccination?

DA: “There’s no doubt that the vaccine requirements increased vaccine uptake. For people who had not been motivated to get vaccinated, or maybe weren’t sure, or wanted to wait longer,  there was a clear impact of when many of those vaccine requirements [occurred,] you could see an uptick in the vaccination data … Right now we’re just under 73% of the eligible population that’s fully vaccinated, and about 81% with at least one dose. When you compare those numbers to a lot of our neighboring states, we have done really well. I think vaccine requirements played some part in that, but even prior to requirements, we have really good success here in the state.”

NP: For those who have not yet been vaccinated, what might be their concerns? For example, parents deciding to have their young children vaccinated, or pregnant people?

DA: “To be clear, we do not yet have an approved vaccine for younger children. We’ve had an approved vaccine for 12 and up. We’ve had a relatively consistent uptake with the 12 and up population somewhere between 50 to 55% there. We anticipate that five to 11 [year old] approval will come in the first week of November. So, we’ve done a lot in preparation for that, making sure that messaging is clear, figuring out how to ensure that the vaccine is accessible across a lot of different channels for families and their children. And then to ensure that we are having the right kind of communication with those families that helps them understand why younger kids should get vaccinated … 

While the vast majority of younger kids who get COVID do fine, we’ve had almost 1,000 hospitalizations in the pediatric population and 10 deaths in the state of Virginia to COVID. So, it is not a completely harmless disease for young kids. If you have the option to protect them, and the benefit of vaccination and protection against severe disease outweighs the risk, then we should absolutely encourage vaccination. Now, we suspect that will be the case based on some of the initial data that we’ve seen from Pfizer, but that data has not yet been formally reviewed by our scientific agencies. That’s what we’re waiting on at this point is for the FDA and CDC to do their review of the data, and based on that review, to determine, ‘Does benefit outweigh risk, and therefore should we move forward with vaccinating children from [ages] five to 11?’”

NP: How are you working to address vaccine misinformation?

DA: “I have a feeling that the fight against misinformation will persist as long as COVID is hanging around, but will also emerge with new and different health threats. In public health, we are very good at exercising, practicing, [and] having a good handle on the operations of mass vaccination and countermeasure delivery. We get federal money every year to purchase flu vaccine. … The point of it for us as public health agencies is to ensure that we can deliver vaccine very efficiently to as many people as possible. So much of our preparation as a public health entity is around the operations of pandemic response. What none of us anticipated was the way that public opinion, the traditional media, and social media would impact people’s behaviors and distrust in science and in the vaccine. 

Those efforts to really unravel what social media has done to communities — that’s going to be central to this public health issue, but all future public health issues. It means we’ve got to get savvier about engaging social media … We recognized that you can only accomplish so much with good messaging. At the end of the day, there’s such personal decisions for some people that they need to hear it from close, trusted individuals whether those are family members, or healthcare providers, or peers. So, that’s where the work has shifted over the last six months. Early on in the vaccination effort, it was just about the operations. That was distributing vaccine effectively, getting into as many channels as possible, and trying to prioritize based on risk,  but once we got to April, and got plenty of vaccine supply …  the effort changed to ‘How do we identify the communities where we’re seeing lower uptake? How do we engage them effectively through the right trusted messengers and use those relationships and that credibility to get people to get vaccinated?’

For example, we really focused on healthcare providers, because we know that for a lot of adults, if they are asked by their doctor or nurse, or they have the opportunity to engage in asking questions with their healthcare provider, that’s going to increase the chance that they’re going to they’re going to get vaccinated.” 

NP: How do you see the pandemic evolving in the coming months, and how might the state prepare for it?

DA: “Our hope is that this downward trend continues … We will see some outbreak activity this winter. But as we come into the spring, if there’s not another variant that’s really dominating the scene, we can expect that [COVID-19] will become a regular part of the mix of viruses that we deal with year in and year out. You’ve probably heard the terminology ‘going from pandemic to endemic.’ So this idea that instead of this new emerging threat, this just becomes a part of the milieu of viruses that exists in our community. 

There are more things every week coming around that will allow us to deal with [COVID-19] effectively, which are first and foremost, vaccination. We know that is the best way to protect against severe disease. But then there also have been advances in treatment, and so not only in hospitalized patients, where we’ve seen steroids and some other antiviral medications be really effective. Just recently, Merck submitted an application for the first oral medication … Early studies showed a 50% decrease in hospitalization for people who take this oral medication when they’re first symptomatic. If we have an effective oral agent, that’s a game changer for avoiding hospitalization and death. 

I think access to rapid testing — we’re seeing some more access. Right now it’s still somewhat cost-prohibitive, particularly for lower income families, but we will get to the point where we have wide availability and access to low-cost, rapid testing. For kids who are in school, and when they have the inevitable exposure to COVID, instead of having to quarantine for 14 days and deal with that loss-of-learning issue, they’ll be able to test themselves daily. If they’re negative, then they can go to school. There are technological and medical advancements that will equip all of us to be able to learn how to live with [COVID-19]. Hopefully, ultimately, we have enough of a baseline level of connection between vaccination and natural immunity that the rate of severe disease drops to what we see with the flu or lower.”

This interview was edited for clarity and length.