You’re listening to a press conference from the Harvard T.H. Chan School of Public Health with Yonatan Grad, the Melvin J. and Geraldine L. Glimcher Assistant Professor of Immunology and Infectious Diseases and a faculty member in the Center for Communicable Disease Dynamics. This call was recorded at 11:30 a.m. Eastern Time on Friday, September 25th.
Transcript
MODERATOR: Dr. Grad, do you have any opening remarks?
YONATAN GRAD: I can just jump right into questions.
MODERATOR: All right. Thank you, Dr. Grad. First question.
Q: Hi, Yonatan. Thanks for doing this. Well, my question has to do with pandemic trajectory. When I’ve spoken to some epidemiologists, I guess a month ago, who felt that a second wave would be hitting the state of Massachusetts, New England and generally maybe the country later this fall. So I was wondering if now that we have a bit more data on how the fall is going. Does the second wave still look like it’s coming? And how will we know if we’re in the second wave?
YONATAN GRAD: So first comment is that while we use the metaphor of waves, it’s important to remember that our experience with the pandemic is very much dependent on our choices. So to the extent that there are individuals who are susceptible to infection and opportunity for the virus to transmit among them, we will see transmission. So a lot of this really has to do with, you know, when we will see a rise or when we see a rise in cases. That’s really a reflection of our providing an opportunity for the virus to transmit. So, you know, it’s not like weather patterns or waves in the ocean where they come in some predictable pattern. It really is dependent on the choices that we make as individuals and as communities. And I think some of that anticipation of a rise in cases had to do with changes in restrictions where we’re starting to see places open up, meaning fewer social distancing interventions are now starting to see bars and restaurants open opportunities, in other words, for the virus to transmit among susceptible individuals.
I think that may have been why some people were anticipating that we would see arising cases, at least in this area. In addition, the rising cases in other places in the country would provide opportunities for introductions into this area as people traveled. Right, so people started to take planes or drive in different places, get exposed and bring it back into Massachusetts or the Northeast. More broadly, there would be more opportunities for the virus to transmit, and that could lead to an increase in cases which I think we just call that increase in cases a second wave. But really, we’re just seeing opportunities for the virus to transmit. I think that’s what we’re seeing both in Boston and in many other places is that the increase in cases right now may well be attributable to a couple of things that are most prominent, at least. And it seems to me in the media right now, at the start of in-person classes at colleges and universities, I think there have been a number of high-profile outbreaks at some of these institutions of higher education. And again, that is a reflection of the factors that I was describing before. Having people come from around the country, I think I had seen a figure that at least for Boston, 20 percent of the undergraduate students come from California, Texas and Florida, places that at least until recently had had fairly high positive test rates. And then, you know, these are college students who do what college students do and there are fraternity parties and other social events where in the absence of masking and distancing, again, there’s opportunity for the virus to spread. So my sense is that may be one of the factors in why we’re seeing increases in cases in a number of places where it had been fairly well suppressed recently. And then again, movement towards more opening of different parts of the economy. Again, seeing restaurants open, bars open and so on. That also will help accelerate spread.
MODERATOR: Do you have another question?
Q: Yeah. So basically, the answer is it depends on what we do.
YONATAN GRAD: Yes.
Q: Yeah.
YONATAN GRAD: As has always been the case. Right? I mean, this is in some ways, it’s been the refrain from the beginning. We’re talking about social distancing interventions back in the late winter, early spring as a way to flatten the curve. And it’s still this way.
Q: OK, so I guess my follow up question is, if we see kind of cases really start to rise in this region again, maybe not exactly like it did in the spring, but it’s a bit similar kind of trajectory. Would you expect that our lives would go back to the way they were in April and March when everything was really shut down, businesses were closed, and everyone was staying home?
YONATAN GRAD: Not necessarily. I think it really depends on how widespread the cases are and how quickly they’re detected and how well we can identify where the cases are taking place. If our testing, which is much better than it was back in the spring, can help us identify exactly where the cases are taking place, the communities that are at risk, we may be able to proceed with much more localized interventions and increased monitoring. And I think that the implementation of more focused interventions rather than the blunt instrument of community quarantine could help suppress continued transmission, so long as we have sufficient testing, monitoring and opportunities for contact tracing, case identification, isolation and quarantine.
Q: Sorry, if you don’t mind me asking, do you feel like in this state we do have that infrastructure in place to be able to use more localized interventions?
YONATAN GRAD: I think we do. I think that there is room for improvement, but I think it’s certainly better than it was back in the spring. And also, the number of cases that we’re seeing now is far lower than what we’re seeing in the spring. And that actually makes monitoring and the various interventions that I mentioned much easier to enact. So I think while the numbers remain low, even as we’re starting to see an increase, the opportunities for more directed interventions are far better than if we had large numbers that if we got to the point of widespread disease in transmission, I think would be much harder to have focused interventions. It would be an indication that those really had failed and then we would need more kind of blunt instrument community quarantine. But I think we’re in a much better position to be able to avoid having to do that.
Q: Great. Thanks so much.
MODERATOR: Next question.
Q: Hi. Thanks, so much for doing this. My question is also about the trajectory of disease. I obviously cover universities and have been talking with public health officials in counties and states around the country this week where there are big universities that saw big jumps and numbers of cases in August, mostly types of people in the county where the University of Iowa is and where Chapel Hill is and a few others. And I was asking them if they’ve seen that, can that spread go beyond the campus communities into the surrounding areas? For the most part, they told me that it’s kind of hard to measure. But when they were had been looking at age, the ages of the people that are testing positive, and while they did see in their counties big jumps in the 18 to 24 year old age range, most of them I mean, all of them actually were able to answer the question, said that they didn’t see this. They weren’t detecting spread beyond the campus community. So beyond that age group. So, this seems like it could be good news about university openings. But I want to be cautious about that and ask if you think it sounds it sounds good to you. Why that might be that the spread is not going beyond that group yet. And if maybe it’s just too soon to tell or if we should see this, then as a real sign of universities sort of success in containing it?
YONATAN GRAD: It’s hard for me to speak to those specific instances because I don’t know those numbers exactly. But in general, I would expect that there will be spread in communities as a function of how much the college campuses are actually, and those populations are integrated together with the surrounding or neighboring communities. So, you know, if the college students are in dormitories and those are all separated from the communities in which they reside, and there really aren’t that many opportunities for those individuals to interact with their neighbors, then I think that lowers the likelihood of spread or slows the appearance of those cases in the communities. And then it also has to do with what types of interventions the communities themselves have in place in terms of masking, distancing and so on, how whether any introductions into the community will continue to spread and cause community-based outbreaks. So, a lot of it depends on the details, both of the structure of the college campuses with regard to their neighboring communities and what types of interventions the communities have in place.
So a kind of inverse problem or situation to what you’re describing could be seen with like that, the NBA bubble. So even as cases were going up and actually reaching for the high levels in Orlando and Orange County in Florida, the bubble, which had fairly extensive testing and other types of interventions in place to help prevent transmission, really hasn’t seen it. So, you know, it is really about how these different entities interact with one another to the point of, you know, the age groups and what to learn there or what to expect in Florida over the summer as another example. There was a claim by the governor and others, as I recall, that, oh, no, don’t worry, we’re just seeing cases in their communities and young people. And there we did see spread into – sorry, it looks like the connection was with some spluttering – but so, we did see spread into older individuals. I mean, it’s just that’s also the nature of how communities are structured. Young people interact with other people and eventually we could see spreading to older individuals.
I would say that we still have a bit to wait to see if there is community spread, and if there is, I would anticipate that we would start to see cases in older age groups as well.
MODERATOR: Did you have a follow up?
Q: Oh, no. That’s really helpful. And it sounds like it seems to you like this is a possibility that the universities have, depending on their mitigation efforts in their communities, it’s possible that they could have contained it, but it kind of remains to be seen. You’d want to look more carefully at the specific data.
YONATAN GRAD: I think that that’s right. It really it depends on each of the different scenarios and how and what the efforts are on each campus and the interaction with between the campus and the local community and as well, the community’s mitigation efforts.
Q: OK. Thanks a lot.
YONATAN GRAD: You’re welcome.
MODERATOR: Next question.
Q: Hi. Thanks, so much for doing this. I wanted to ask a question about the vaccines. We know that HHS and CDC are building all kinds of new data technology systems. There’s the vams, the VAMS that they call it. There’s another data lake that they are building to sort of house all this information about who has gotten which dose and how many doses they’ve received. There’s something they’re calling Operation Tiberius. And I’m just wondering if this is in your wheelhouse, are you at all concerned or should we be concerned that there’s a whole bunch of very big I.T. systems coming online at once that are going to be super important in the opening days of getting a vaccine? When the supply doesn’t equal the demand?
YONATAN GRAD: I think the question about the I.T. infrastructure to monitor who has received what dose or which vaccine and how many doses is a critical one to be able to monitor that the effectiveness of vaccines of each of the candidate vaccines, particularly as I think as you mentioned, we have a number of different vaccines that are expected to make an appearance around the same time. So, yeah, that I.T. infrastructure is going to be critical. And I think as we’ve seen in many circumstances, bringing online new I.T. systems are often fraught with challenges. It seems like they’re expecting that one should expect to see challenges with any new I.T. system. So, it’s you know, I think it will be another challenge. We’ll have to figure out how to overcome.
Q: One related point to that, on privacy issues, HHS has said that they are going to want to identify the data that states would send them identifiable data, and then the CDC and HHS would identify it at their end. Do you see any privacy concerns when at war or potential political issues with states turning over whole boatloads of patient data to the Trump administration?
YONATAN GRAD: I don’t know the details of what you’re referring to, so it’s hard for me to, again, speak to specifics if it’s just about who’s received the vaccine and or whether it includes other health information. And of course, that will depend on whatever our vaccine prioritization strategy is so if there is, as we start with limited numbers of doses, if we want to prioritize essential workers, for example, then there are questions about who those essential workers are, and especially in this environment when we’re worried about the questions around immigration. I think you’re right. And we’ve seen that the first most heavily impacted communities tend to be those vulnerable communities, often ones, including people who have concerns about immigration. It could absolutely be problematic. I don’t know. And even though it’s not about even health records, that’s just about who the people are and their interactions with the rest of their community society and their profession and the risk. So, I think that there absolutely could be concerns around vulnerable communities if that kind of information is being directed in identifiable way to the federal government.
Q: Thank you very much.
MODERATOR: Before we go to the next question. Dr. Grad had an op-ed come out in The Washington Post today and was including a link to that in the in the chat room. If anybody would like to take a look at that and ask him some questions about that as well.
YONATAN GRAD: In fact, in there’s a section in there, just going to get to your question that is about the importance of I.T. infrastructure in vaccine distribution and how you know that. The underfunding, the chronic underfunding of local and state public health systems has made even monitoring COVID-19 so challenging. How are we really going to get in place something so quickly to monitor vaccine distribution? I think it’s a really important and challenging question.
MODERATOR: Next question.
Q: Good morning. Well, first of all, it’s really interesting because I am reporting a story about how public health departments have gotten approximately two percent of the funding they need to distribute a COVID vaccine. And so, I’ll definitely check that out. But I wanted to ask about vaccine prioritization. It seems like coming out of the CDC ACIP meeting earlier this week, that there was consensus that health care workers should be first by some questions about whether the next priority would be essential workers or people at high risk of severe disease. And I was curious if you had thoughts on which would be most appropriate.
YONATAN GRAD: Yeah, I think it really has to do with a few things, including what your goal is. So, in work we recently put out a preprint – it’s a manuscript, it’s currently in review and undergoing good review – we looked at what the vaccine distribution should look like if you want to minimize deaths and if you wanted to minimize cases. And if you want to minimize deaths, then under most assumptions about what the efficacy of a vaccine is, particularly in the at risk populations such as the elderly, then what you should do if you want to again try to limit mortality is vaccinate those people at highest risk of dying. So that seems fairly standard. It really seems to be that the conclusion looking across a range of different assumptions. So, you know, if the goal is to reduce deaths, that’s a high priority population. If the goal is to reduce cases, then there’s more variation depending on the demographics and the interactions among individuals. But it seems like, at least in the US, targeting younger individuals to the people who we anticipate are most important and in spread, that would be the way to go. So, yeah, so it’s then no more to the actual logistics of implementation. Defining what constitutes an essential worker becomes another challenge. And how do we decide exactly who those individuals are? But that I think is going to be another. Certainly, it’s not an unreasonable strategy. It just depends on what we want to accomplish most quickly, depending on the amount of vaccine that’s first available.
MODERATOR: And I put a link to that preprint in the chat as well.
Q: And any thoughts on whether, you know, limiting deaths or limiting cases is not appropriate?
YONATAN GRAD: I think that’s a decision we as a society need to come to. It seems to me like no one limit. I mean, my sense is move most quickly to limit deaths first. But that’s you know, I think we need to think. And I think that there are a number of different bodies, including not only the ACIP, but the National Academy of Medicine and other places that are thinking through exactly these questions to try to arrive at some kind of consensus so that you include not only epidemiologists and virologists, toxicologists, but also ethicists, so that you can come up with a reasoned argument for whatever the distribution or prioritization strategy should be. But I see Barry’s on the call. I’m curious if Barry has his thoughts on this to.
MODERATOR: I don’t know if Barry still is on the call, I pulled him off. Barry, are you still there?
MODERATOR: I may have pulled him away and distracted him.
YONATAN GRAD: I see. OK.
BARRY BLOOM: I’m here and you did distract me.
MODERATOR: Very good.
BARRY BLOOM: What’s the question?
MODERATOR: Can you ask your question again?
Q: Oh, sure, we were just talking about vaccine prioritization and how that could depend on whether our priority is minimizing cases or minimizing deaths. And I asked, you know, which do you think is should be the priority?
BARRY BLOOM: So the way you get rid of, in my view, an epidemic is the key is to interrupt transmission. And the head of the committee, the national co-chair of the committee of the National Academies coming up with these recommendations is Bill Fahey, who’s the guy who developed the strategy to interrupt transmission of smallpox, which was one of the great public health achievements. We didn’t have to vaccinate everybody. You had to wait till a village reported and then get only the people in those village to interrupt transmission. One of the things that jumped to the answer to your question, the priority of the report from the National Academy, surprising to me, focused almost entirely on preventing severe consequences of infection and death. And the focus on how you would get rid of transmission was barely touched upon. And I think you can obviously understand the priorities.
The elderly, perhaps health care workers, would get the most obvious priority in people’s minds. It is unlikely that they’re the two groups involved in major transmission, as Yonatan had said. So we are very likely to be in a circumstance where the vaccine will prevent people from getting severe illness and dying. There is no requirement in the protocols to measure infectivity, that is nasal swabs looking for virus. And so we won’t know, as far as I can tell, unless the companies additionally want to look at it, whether we are blocking the ability to transmit in the people who received the vaccine, which means we’ll have the virus around for a long time, both because it may not block transmission, although it saves people from being sick and dying, and also because it’s likely to be 100 percent effective. So, some people that get the vaccine will still get sick. Yonatan, is that OK?
YONATAN GRAD: Yeah, that’s great. I think your point about what we’ll learn about the impact of their vaccine and transmission is a key one. If we look at, for example, what was observed for the AstraZeneca University of Oxford vaccine in trials and in macaques, these are the initial animal studies, my understanding is that it helps prevent symptoms. But that was when challenged with a virus after vaccination. We’re still able to shed virus. So, we call this the distinction is the direct effect of a vaccine, which is reducing symptoms or severe manifestations of disease. And the indirect which is in helping to reduce transmission. It’s spread and very you’re totally right. I think that the trials are designed to assess just the severe manifestations and whether it prevents symptoms and not so much whether people can be infected and shed virus. So, yeah, I think that’s a really important point.
Q: Thanks.
MODERATOR: OK, great. Does anybody else have any follow up questions?
Q: Thank you. Yes. So, I was wondering if both Yonatan and Barry, you can answer this question. What are you doing now in your normal lives that you might not have done back in April or May or something like how many you’d like, but what is the riskiest things that you’re doing or what sort of precautions are you still taking?
YONATAN GRAD: Barry? I moved from one corner of the room to another corner. I think what really it seemed like the whole time to travel or to see people, of course, over the summer when both case counts were so low in this area and the weather was accommodating. Right. It was a chance to see people, you know, have meals outdoors and so on. And those were those were things that that well, I didn’t travel, but at least in terms of seeing people and having meals outdoors, that was something that I was doing and that I hadn’t been doing in the spring. But I think it is you know, it’s going to be a concern as we move into colder weather.
And it becomes harder and harder to have social time with people outdoors. You know how we’re going to get that social interaction that we need as social creatures. And I hope that we can continue to maintain through testing and monitoring and good control over the virus in this area. But I think that questions of how we’re going to interact when it becomes harder and harder to do so outdoors would be a challenging one.
MODERATOR: Dr. Bloom, are you still there?
BARRY BLOOM: I fully support Yonatan’s answer and I guess from a point of view of conditioning the public, the question is often asked, when can we get back to normal, whatever normal was before COVID? And I think what you’re hearing from both of us, it’s that’s going to be a long time until there is rapid testing and everybody can test themselves on a regular basis and has the will to lock themselves up if there’s a possibility they may be able to transmit or have been recently infected until everybody on an airplane and people traveling across states can be sure they’re not bringing with them the infection. I think we’re going to be in a different state than we were before COVID for quite a long time, with or without a vaccine.
MODERATOR: Did you have any other follow up questions?
Q: No, I think that’s it. Thank you for doing this.
YONATAN GRAD: Thank you for your questions.
This concludes the September 25th press conference.