Coronavirus (COVID-19): Press Conference with Barry Bloom and William Hanage, 06/25/20


You’re listening to a press conference from the Harvard T.H. Chan School of Public Health with Barry Bloom, the Joan L. and Julius H. Jacobson, research professor of public health and William Hanage, associate professor of epidemiology and a faculty member in the Center for Communicable Disease Dynamics. This call was recorded at 11:30 a.m. Eastern Time on Thursday, June 25th.

Transcript

MODERATOR: Dr. Bloom, do you have any opening remarks?

BARRY BLOOM: Just to say that as each of these calls, the situation in the United States with COVID is getting quite out of hand. In 27 states, the numbers are going up. If you look at your Australia, many other countries, the epidemic has been brought to relatively low levels. And I guess in the first of these calls, what I found most interesting is that people don’t just understand what exponential means. And it means if you have 7,000 cases today in Texas, you may have 14,000 cases in four days. So we’re way behind the curve and it’s going to be very challenging.

MODERATOR: Thank you, Dr. Bloom. Dr. Hanage, do you have any comments you’d like to make?

BILL HANAGE: Good morning to all of you, especially those I’ve not spoken to before. Barry, always a pleasure to be with you. As Barry said, we’re seeing increases in case numbers in many states outside the initial beachhead of the virus in the Northeast. Hospitals are approaching their capacity to be able to cope in Houston and Arizona, and shortly, almost certainly elsewhere. And we can see that the states in the northeast are urging visitors from other parts of the country, especially those badly affected by the virus, to self-quarantine. Meanwhile, the total numbers are increasing in the U.S. and globally. And I would like to draw the comparison between now and a few months ago, because a few months ago, numbers were going up, mostly concentrated in a few states, whereas now they are much, much more widespread. And while that means that we are seeing the increases that we are seeing right now have the capacity to produce far more disease in the future.

MODERATOR: All right. Thank you very much, Dr. Hanage, first question.

Q: Yes. Thank you so much for doing this, as always. Can one of the experts talk about what can be done at this point to get control of these outbreaks, particularly in Texas, Florida and Arizona? Are we thinking about stay at home orders again, mask mandates, closing some businesses like restaurants and bars? Or is it. Are we past the point where these kinds of actions would be helpful?

BILL HANAGE: All right. Well, thanks for the question. The situation in these states has been allowed to build such that we now have significant community transmission, which is increasing. And the only way that we have of stopping that at the moment on the sort of non-pharmaceutical interventions which we have outlined. Now over the last few weeks as cases have been increasing. There has been a continued push to reopen or to continue providing, continue reopening for the sake of economy. However, doing that also provides opportunities for the virus to transmit. The only thing that we can do in order to put a lid on this is to prevent the virus transmitting. Now, the only way we can do that is through some of the interventions we’re talking about. At minimum, I think that mask use is sensible in places, especially in places which have not yet seen a large quantity of disease. Now, in those places which are seeing a large quantity of disease, in places where there is risk of the health care system being overwhelmed, then we need to take more intense interventions of the sorts which were eventually forced upon us in the Northeast. So I would, it depends a little bit on exactly what is happening, where you are – what I would recommend. But I would just urge people to remember if you put in milder interventions earlier on so that you do not build up this big powder keg of infections underneath you, which are eventually going to start flowing into the ICUs, that’s a better outcome than allowing a large outbreak which wants to shut down.

MODERATOR: Dr. Bloom, to have any comments you’d like to make?

BARRY BLOOM: No, I think there will be lots of questions. So I think Bill answered well.

MODERATOR: OK, great. Next question.

Q: Hi, yes. Thank you very much. I’m wondering what you think about the, what the research is saying so far in terms of crowd gatherings outside versus crowd gathering inside, you know? Is there any evidence that say, you know, large gatherings outside, the protests have been causing any of these spikes? Or is it been mostly emanating from indoor transmission? And then I have the follow up question too.

BARRY BLOOM: I’ll start. It’s probably too early. Or is just getting to be too early to ask the question, to what extent the protests, the Black Lives Matter protests in any 3,315 cities and towns in the States have had an impact on transmission. The good news is that they were outdoors and hopefully aerosols were dispersed. Most of the people in those, by and large, have been young, healthy people. And the expectation is that the impact of all of that might be less than you might expect. The problem there is whether they catch it in those circumstances and remain asymptomatic and don’t get ill. The question is, when they bring it home to their parents or their grandparents, whether they serve as sources of spread, and we won’t know that for some time. We’ll know that best actually, when we look at whether hospitalization numbers go up. Bill, comment?

BILL HANAGE: I think you’re right. I agree with Barry that while there is currently not any evidence of spikes in infection which can be linked to the protests, that does not mean that asymptomatic transmission could not have happened, which we will only be able to detect once it starts showing itself as hospitalizations. I will note, however, that the some of the thinking about the protests could ignore other things that might happen as a consequence of them. While you have people gathering outdoors, it’s true the transmission rate is much lower outdoors than it is indoors. It’s not nil, but it is much lower. There could be subsequent tendencies of people in those in those people who are not involved in the protests to stay at home. And so you might actually see a total net decrease in contacts. We also need to think very carefully about the proportion of contacts which are made at a protest outside in comparison with the total number of contacts which are made in indoor settings across places which are reopening because we know the transmission is much more likely indoors. So the sort of science which happens behind closing down large gatherings and we’ll think of the protests as a large gathering, is such that there’s no point in stopping large gatherings if you’re still having everything else open, because the fact is that, you know, if you shut down the baseball game, people will go to a bar and watch it and make the same number of contacts there. However, if you do both of them, if you shut down both the bar and the baseball game in the sense of a shutdown, then it can have an important effect. So in the same way as states are reopening the total opportunities for transmission, which are being offered by that, are larger probably than the total number of opportunities which are given for transmission by the protests. And so we need to think about the net impact in those two if those two different processes.

MODERATOR: Did you have any follow up questions?

Q: Yes, I just had one follow up. Thank you. I’m wondering what you think of the recent French research about there may be less likelihood of transmission among schoolchildren to parents or other children. Are you optimistic about that or pessimistic about that research?

BILL HANAGE: I’ll grant this and then see if Barry has something to say. Yeah, that’s interesting because the there is conflicting. There has been conflicting evidence on the role of children in transmission. It seems almost certainly that young children and I want to emphasize here, I’m talking about like elementary, maybe some of the younger junior high years, younger children are less likely to become infected and then figure, which I keep, costs about 50 percent of the risk of adults, although that is biased probably by these sort of designs we’ve been able to do so far. That’s why this French study is interesting. And they’re also less likely to transmit, although to it’s not as impressive a degree. You can compare it with a preprint which came out of Israel, which showed, again, children are roughly 50 percent as likely to acquire the infection and maybe a little less. They did not find a significant difference to transmit it. Now, taken altogether, what that means is that transmission in schools is likely lower than might be expected of children like adults. That doesn’t mean, however, that schools can necessarily reopen because contact some children might make in schools would be very different to those that might be making elsewhere. And so you don’t want the school to become a net contributor. I will then add that this is not the case for adolescents and high schoolers because adolescents in high schoolers seem to be much more likely to become infected and transmit like that much closer to the adult situation. And in fact, repeated studies from many different places have shown large rates, relatively high rates of zero positivity in this group. As a result, I think that there is some reason for cautious optimism there, but it’s not necessarily a reason to throw the schools open. And I will probably be asked more about schools like that, because I do have a little more to say on the subject. But I’ll shut up now and give Barry an opportunity to speak.

BARRY BLOOM: I agree totally. And I think that the data on young school age children is not very clear, but not a reason not to start schools, preferably in places and states and districts that have a relative control of the epidemic. But I think when it gets to high school, for example, they do behave as adults in Korea or Japan. They allowed school children back earlier than high school. And that seemed not to contribute significantly to the epidemic, which they then control very well.

BILL HANAGE: I can add one further comment to that. Israel’s recent numbers of increase in cases once again, they seem to be tied back to schools and in particular high schools. That’s another relevant there.

MODERATOR: Next question.

Q: Good morning. Thank you all for doing this again. My question is about the rolling two week average and what it means. You know, here in Florida today, it’s 10 percent. So, you know, if you have 10 people in a room, does that mean one of those people is going to have it? Is it really as simple as that?

BILL HANAGE: So the rolling two week average, when you thinking about it in particular, you think about the rolling two week average of proportion of tax? Well, OK. It’s you kind of take it as simply as that because it depends a great deal on the number of tests that are being done and where they’re being focused now. If if it were the situation that everybody was being. Everybody in the community was regularly being tested, then yes, it would mean that. But that’s not happening anyway. Instead, it has to be concentrated either on people who we believe may be infected or either because they have symptoms or because they’ve been named as a contact. And then in some places, people are sort of showing up to be tested just because they are concerned for themselves. But nowhere, nowhere are we doing the kind of population level surveillance which would make the interpretation that we’ve laid out a reasonable one. So the way to think about those tests, that statistic is particularly useful as a way of measuring how much the testing that’s being done is capturing the state of the underlying pandemic.

Q: Thank you. To follow up on testing, the Miami Herald reported this morning and I see that the two journalists are actually in on this call, too. So thank you for that. They said that Florida is 29 out of the 50 states in testing. Does that mean that we need more testing to bring the percentage down? You know would more testing become more accurate representation? If the last few days have showed us anything, it’s that on the days when we have more testing, the percentage is lower.

BARRY BLOOM: Testing is not the intervention that will interrupt transmission. And I think that’s the common folk. The intervention is the isolation of people who test positive to prevent transmission to other people. So focusing on testing without linking that to isolation and contact tracing would be simply scorekeeping in the middle of an epidemic. Bill?

BILL HANAGE: Absolutely, I couldn’t agree more. That’s testing links to testing is relevant when it is linked to an action, because if you don’t do that, you are really just you know, you’re just being like a stenographer, counting numbers. So it’s not only about getting testing. It’s about using that information.

Q: And then one more question. This morning, The Washington Post had an article that said Florida will bury more people in July because of the lag. Is that something that you agree with?

BILL HANAGE: Well, it depends more people than what or more people than in more people it would have expected to bury in July? I absolutely agree with that. It will bury more people in July than it would in an ordinary year if there was not a pandemic and a failure to take interventions capable of stemming the pandemic would’ve led to.

BARRY BLOOM: I would I think that’s an important question. And I think Bill’s answer is correct. A number of governors have commented that while the testing numbers go up, hospitalizations have not gone up in parallel. And the reason is probably that it takes time to get sick enough to end up in an ICU. We haven’t seen all the new testing positivity percentages that are going to need to be hospitalized. So the lag will come, after the tests go out to hospitals. And many of the hospitals in those states are at 89 to 93 percent capacity. It’s going to be very bad.

MODERATOR: Next question.

Q: She would like me to read it out, given the risks, the risk associated with certain conditions, including obesity, hypertension and diabetes, what value is there for the goal of possibly reducing severe symptoms of COVID-19, of getting hypertension and diabetes under control and having people lose even a small amount of weight?

BARRY BLOOM: A medical point of view is if you already have hypertension and diabetes. Independent of COVID, you should try to control those. And as you do, you will almost certainly to some extent reduce the risks associated with superinfection with COVID-19. On the issue of losing weight, I think it’s hard for people to lose weight. And I’m not sure if COVID is the reason to try to do that. And the impact of that is not going to be immediate. In any case, whereas reducing hypertension, controlling diabetes are things that can get rather quick and safe results.

MODERATOR: OK, thank you. Next question.

Q: Great. Thank you for taking my question. So my questions related to something that was mentioned a little bit earlier, and it’s the idea of, you know, why is the mortality rate nationally still declining while we have these surges? The president has pointed to this. And do you think that’s just a lag or is there something to the idea that we may be testing more younger people or more healthy people and that we may not see as many deaths in the future because of that? Just your thoughts on how to interpret the trends as we see them now?

BILL HANAGE: So one of the things which is interesting, which is true and incidentally, I think it reflects the situation, which does offer a crumb of comfort, is that the testing across the Sunbelt has generally been finding infections in younger people. This suggests good testing, better testing. It suggests that people are being tested who are not displaying very severe symptoms, which are such that they might require hospitalization already. That’s that’s good. However. When we’re looking at the total numbers of deaths, you would expect that to only be limited if you have relatively small outbreaks which are confined to sectors of the population, which are not likely to become severely ill. Now, nowhere has been able to thoroughly insulate the part of the population which is at risk. And the higher the rates of community transmission you see in any age group, the higher the risk for those who are actually vulnerable to the most severe consequences of the infection. So what this likely means is that the outbreak across the south is being recognized at a somewhat earlier stage than the outbreak in the northeast was. And that’s a good thing because it means that if there’s any window of opportunity for action, it’s like right now and things you do now will have great consequences. However, if you do not take action now, then the community transmission is going to continue to build and then sooner or later it is going to get into those at risk and they are going to be starting to have and in time, as we have been saying, those deaths and hospitalizations are a lagging indicator. In time, those people will start to go to the hospital and they will start to die. May not be immediate. Maybe a couple of weeks, maybe a little bit longer, but it will happen. And remember, it’s happening in a far larger total population than the outbreaks in the Spring were.

MODERATOR: Next question.

Q: Hi. Thanks for doing this. I just want to ask about kind of the White House’s role in this and the federal government, I mean, what-  it seems like there’s pretty broad consensus they’re not doing enough. I mean, do you agree with that? And, you know, if you were suddenly, you know, made like the federal government’s czar for this, I mean, what would what would your actions be that you think the federal government should be doing or the president should be saying or doing?

BILL HANAGE: I think Barry should start on this one.

BARRY BLOOM: I’m happy to take that. I’ve given a lot of thought to that and I’m really quite appalled at the way the United States has responded. At the best, the way journalists put this in the press is that there have been conflicting signals from Washington. I don’t think they’ve been often conflicting. I think the president doesn’t believe that you need to wear a mask. And I think as the leader and the symbol of governance in this country, if he doesn’t need to wear a mask, why should I wear a mask and be inconvenienced? That’s a very clear signal that I think is very difficult for people down in the public health system to persuade people, ignore your president and do what I tell you. So I think that’s a problem. The second problem is the government has basically, with rare exceptions, accented themselves from taking control of what should be done and turfing it back to states. So we do have a CDC. There are competent people at CDC and probably they could link a set of recommendations which they have now finally put out with some censorship I have to say, of how it could best be done in the States. But to have public health officers in all 50 states come up on their own to develop the kind of knowledge that’s been accumulated in past epidemics and pandemics and figure out how to do this supply chains, the distribution of PPEs, what do we have a government for if not to be able to pull the country together with a common set of precautions and policies that every state could implement that were reasonable, so that I think the government is not home in this epidemic and that has made things worse.

BILL HANAGE: Yeah, I agree with all of that, I would add to it that following a period a few months ago when attention was paid to the pandemic. The government now appears to be taking a somewhat ostrich like attitude to the pandemic, sticking its head in the sand and hoping it’ll go away. Pushing the responsibilities onto the states. This is not necessarily what had to happen. A couple of months ago there was reporting from Politico on the existence of the 2016 Obama administration pandemic playbook. And if you look through that, it includes very specific things, such as is the amount of PPE that is available sufficient to cope with a surge? If yes, do this. If no, do that. And, you know, it is for the most part, good guidance. These things are there and that’s what a government do, because otherwise you just end up in a situation where you’ve got all the states on their own and, you know, we’re only going to be as strong as the weakest link.

MODERATOR: Do you have a follow up question?

Q: Do you, no, thanks, that makes sense. Do you feel like I mean, has the testing and PPE and, you know, this this stuff that the federal government should be doing, seems like maybe that’s gotten a little better. I mean, is that right? Or I mean or is there still just a long way to go on that? And they need to be doing more to ramp up supplies and that kind of thing?

BILL HANAGE: Well, as you know, the government has been cutting funding to COVID testing centers. So, I mean, I don’t think that can cover itself in glory. And I think that we can be one thing that we can be sure of is that there is going to be more infection happening elsewhere. And we are seeing what I said at the start about an exponential. And so even if there is PPE availability now, then we have to be prepared for them to be requiring a lot more of it. You know, I sent this on my Twitter bio. You know, don’t panic. Do prepare. And that’s something which I think we can still learn from.

Q: Thanks. That’s good with me.

MODERATOR: Next question.

Q: Thank you. I was hoping to follow up on an earlier question and just ask a little bit. Sorry, there’s an ambulance going by my house. I was hoping you could be a little bit more specific in terms of what measures you think could be implemented now. You said sort of at a minimum is to stop with phases of reopening and sort of assuming there is not the political or public will feel for like a complete return to what happened in March and April. Like what? What could be done? For example, Greg Abbott, today, the governor of Texas stopped elective procedures again in hospitals and in the counties experiencing spread. So, like, what are other sort of tangible steps that governors in those states could do to sort of slow the snowballing that’s happening?

BARRY BLOOM: I mean, it varies from place to place and state to state, depending on the state of the epidemic. But, for example, when bars are open. It sounds silly and I have not frequented bars often, but there is no distancing available in most bars that I’ve ever seen. And if you again look at outbreaks in Korea, a single person when came into the country and went in one night to five bars and started an outbreak that got infecting hundreds of people one night, one person in multiple bars. So I would say if they want to keep some things open, look at places as we have now in Massachusetts, where stores are open, food markets are open, but they mark two meter or six feet spots on the floor. They allow only certain numbers of people in in Texas when they have opened up it’s my understanding that they have restaurants that are allowed to be 75 percent of normal capacity. Seventy five percent is woefully close to 100 percent. From my point of view, unless they’ve organized the geometry so that the tables are really that far apart, it’s unclear if that 25 percent is actually going to do what you want it to do, which is to restrict transmission. So my fear is they will let things get really bad, which is what the bending of the curve was supposed to prevent, which is rendering the hospitals overrun so that people can’t get serious medical attention. And at that point, they’re going to have to shut down as we were back in April. And that’s going to be politically extremely difficult and economically extremely difficult to take.

BILL HANAGE: I fully agree. I. Just to add that said, I don’t think it’s a I think it’s basically what Barry was saying, but you want to avoid shutdowns, shutdowns are what become necessary when you have a large body of infection in the community, because when you actually stop new infections, if you stop all new infections right now, the worst cases will be rolling into your ICUs in two or three weeks. So you’re not going to be actually, even if you manage to be perfect for handling all your transmission train starting up, you would still be looking at an increasing number of problems. And so that’s if we’ve got a very severe crisis upon you. You have to take much stronger steps than if you are at an early stage of an epidemic curve or if you’re in an early stage in the epidemic curve, then what you should be doing is, you know, I would say a minimum of masks, a minimum of preventing transmission within the high density establishments like Barry was just talking about. I would encourage business owners to be moving towards that side, pick up if possible. Everybody should be starting to practice social distancing. And we should be prepared to take those things up if you put those things into iplace and you still see increases in disease.

Q: And thanks very much.

MODERATOR: Next question.

Q: Thanks so much. Thanks for making the time. So here in Miami-Dade, we’ve been taking this approach recently, given our surge in cases. The mayor here, Carlos Mendez, is calling a tough love enforcement approach so similar to this discussion of non-pharmaceutical interventions. We’re talking here about more enforcement of these non-pharmaceutical inventions, such as face masks, but not actually shutting down establishments. I’m just curious to get your thoughts on these kind of middle ground measures where you’re not shutting down restaurants, altogether, but you are shutting them down if you see reports of people not social distancing or wearing masks inside. Can someone walk that tightrope or do you think that that’s kind of fighting a losing battle?

BARRY BLOOM: I’ll turn that to Bill. I just think it’s very hard to know what a middle ground means in the middle of an epidemic that is doubling every couple of days. Masks do help, but what does enforcement mean? For example, New York is now restricting people who come in from eight states that have increasing incidences of COVID to stay at home for two weeks. And they’re putting financial fines on those who don’t abide that. And the question is, is that really enforceable? And I guess my sense that goes back to the earlier question of leadership. It is not the public health system and it’s not the government that is going to control this epidemic. It’s the behavior of the people in the cities and towns of this country that will either be sensible and stay at home to the extent possible, avoid circumstances where they can get infected, wear masks, avoid crowds. If they don’t do that, cutting a middle ground where people don’t change their behavior is probably not tenable. And it means that the only thing that would possibly work is to cut back. If people don’t do it voluntarily, then I think you have to start closing things so they don’t have the option of transmitting and being transmitted to.

BILL HANAGE: I would add to that, you ask, is it possible to find a middle ground? Well, we’re going to find out aren’t we. I, as I said previously. If you’re going to be looking for a middle ground, you want to be doing it at a point when you don’t already have a large amount of disease in your community. So, you know, I would I would be urging people to be starting to practice physical distancing even when there is no community transmission right now. A lot of small things you can be doing for masks, not shaking hands, are very little and then just preparing the fact that as disease activity ramps up, you’re going to have to be doing more. I think one thing which is often missed is that when we’re speaking about reopening and so on, there is a, we are tending to think about the importance of reopening everything when actually I personally think it would be a better thing to do to prioritize the things that we think are really important. And then, you know, if keeping, say, a school open is not possible without making some contribution to community transmission, well, maybe somewhere else is going to have to be placed under greater restrictions. In order to accommodate that, you need to think more intelligently about these things. And a middle ground is, I think, only really possible in places which don’t have a lot of disease.

Q: One quick follow up question. Thank you. I’m just catching up to your last comment here. I’m still but just one thing. Another development that was announced yesterday here in Miami-Dade is doing something that the state discussed for a while never ended up doing, which is to provide housing for people who test positive are identified. Either self reported or via a contact tracing and have nowhere to go where that. Because, you know, what we’re hearing from our local officials is that a lot of this surge, at least in Miami Dade, is coming from lower income areas where people don’t have the option to stop working. They catch the disease while they’re out doing their job and they bring it home and they, in fact, everyone in the household. So they’re trying to figure out a way to to isolate people who don’t have anywhere else to go. And this is something that the state wants to discuss, but is no longer doing. Is that an intervention that you would like to see more of this providing housing to people?

BARRY BLOOM: Bill would have, I’m sure, lots to say. That was a key part of what brought the epidemic under control in China, Korea and Japan, is they provided temporary housing for people who tested positive to isolate them, which is the key intervention from transmitting to their households. And if you look at the building construction in Korea and Japan and China, they’re giant buildings. So once you have transmission on the floor of a building and in elevators, it’s harder to control. But having those people in separate facilities for two weeks seemed to have a very positive effect.

BILL HANAGE: Well, I completely and utterly agree. I think your examples are the examples she brought good ones. I don’t know. And with that, Singapore, which had such a great pandemic experience of a large outbreak, again among migrant workers who were living in dormitories, in which it was very difficult to enact social distancing. So, yes, I think this is a good thing. What Miami is doing.

Q: Just one last thing. Thank you. I’ll make a quick. As you know, we’ve had a lot of news here last few days. One other thing that I’ve asked DLH here in Florida, why they’re not tracking current hospitalizations. I’ve seen a lot of public health experts and epidemiologists on Twitter saying that they’re puzzled by why Florida has never tracked this in real time. Miami-Dade County, we have tracked it in real time. But Florida as a state only reports cumulative hospitalization and bed capacity. I’m just wondering, you know, we’ve seen a lot of alarm over what we’re seeing in hospitalizations in places like Arizona, Texas. And, you know, all we hear about here in Florida is bed capacity. So I’m just wondering if you all have thoughts on how valuable that metric is and, you know, whether it is a best practice to track current hospitalizations?

BILL HANAGE:  Well, I would say that part of that migration is the more manageable. And I would urge I would love to merge consistency in data gathering and reporting across states. But I realize that’s likely a losing battle.

BARRY BLOOM: I would just say my big worry for Florida is to be prepared for hurricanes. We’re in hurricane season. We’re in very short order. Vast numbers of people have to be evacuated. And it is not clear to me that Florida has taken care to plan for facilities, gymnasiums, are often used in hurricanes to house people temporarily. That’s not a great idea in terms of transmission of COVID, auditoriums and churches. I think Florida has to worry about a double hit if there are hurricanes during this season.

BILL HANAGE: Super smart point.

MODERATOR: OK. Next question.

Q: Hi. Thanks so much. I wonder if you could expand on the evidence on whether the outbreak is actually hitting younger people than in the spring. And separately during the call, the Texas governor actually announced a pause in the reopening. And I wonder if you could react to that.

BILL HANAGE: I’ll start on this quick way. I don’t think it’s hitting younger children, younger children. I don’t think it’s hitting younger people than it did in the spring. I think we’re just noticing it more. If you look at the age distributions of people who were in places badly affected in the spring, we find that the, you know, the peak age, which is likely to show evidence of infection on the younger age groups around the sort of 20 to 30 and maybe a little bit older than that. And that’s consistent across many different settings. So I think what’s happening now is that we’re seeing that in real time rather than picking it up later. And I don’t think it’s a big change in the pandemic. I think it just means that we might be catching it or getting a better idea of what’s going on with it at an earlier stage. I’m not up to date with everything the Governor Abbott has been doing. However, I would say that if there’s a pause in the reopening, then that’s an extremely good thing. Take that pause, look carefully, take tough decisions if you need to take tough decisions and then regroup.

MODERATOR: Barry, did you have a comment?

BARRY BLOOM: No pauses, middle ground. They have already opened a lot of things that where transmission is now occurring. It may be they’re going to have to close some of the things that they’ve always opened. And you can tell from the political point of view. That’s an unpleasant choice for any government.

MODERATOR: Do you have a follow up?

Q: That was all. Thank you.

MODERATOR: Next question.

Q: In Arizona and Florida, I think some of what’s been noteworthy is not just the case increase, but the share of tests coming back positive. I wondered if I’ve got that right?  I wondered if there’s a way to talk about the nation in terms of positivity rates and what the nation is looking like now vs. in April.

BILL HANAGE: I’ll start with that. I don’t think we can talk about it nationally because there’s too much variation, because different places test in different ways. And as I said, nowhere is doing sort of surveillance studies to just try and capture the true fraction of the population that is actually infected at any one time and making it worse. There are some states, and I believe Arizona is among them, where it is not clear whether or not a test is from a person or a specimen. So if a person turns up and tests positive, then that’s a test positive test. If you test them again a few days later. Well, that’s another positive test potentially. But it’s not new infection, it’s you know, so you have to actually be counting the number of infections as well as a number of tests. Because if you were using your tests for those kind of purposes, muddy with the data and we’ve seen as you know, we have seen so many, numerous unclear less than transparent testing practices across the nation. And I can only urge points to make them more transparent.

Q: Thanks. A quick follow up. I think one of you mentioned at the outset that there’s better control in Europe right now. If I if I heard that right. What’s happening in Europe? That’s different than the U.S.?

BARRY BLOOM: One of the things that’s happened is that countries have had national policies where every citizen have to reinvent the principles that were going to happen there. And so once they recommended things to be locked down, they were locked down. And once they were open, they were stages that were country wide. But countries in Europe are, as some of them are, a lot smaller than a single state here. I think it has not been helpful that there hasn’t been a general policy of, for example, opening social events, depending on what the number of contact tracing capacity is. If the intervention is to identify positives and isolate them, when you have 7,000 cases a day, you’re not able to be able to trace people who become positive that day and isolate them. So that’s the criterion that really is required to get the numbers really down. And that’s what the lockdowns have done. They kept people from mixing. And when you stop mixing, you stop transmission after a couple of weeks. So the genie is out of the out of the bottle here. And in Europe, for the most part, England was behind. They kept the caution’s in place and social distancing in place until they got to the point where they can now identify most cases and isolate them. And all of them still have the capacity, as do China and Korea and Japan have introduced cases from outside that slip in and start transmission again. And China has just had, as you know, a significant outbreak. That’s going to be the ideal case coming forward for the next year. Small outbreaks, identifying cases, isolating them, stopping transmission chains of transmission locally. But we’ve got to get the numbers down where you can do that. And when there’s 7,000 a day, that’s not possible.

BILL HANAGE: Indeed. And when you have 7,000 a day, just think about it, you both track same contacts of those 7,000 and then once you find the positives and then you’ve got to frankly, on contacts of those, it’s exponentially increasing. I think the issue the only thing I’d add to that is that the European Centers for Disease Control, the ECDC, seemed to phrase the reopening and content in the context of refining shutdowns as opposed to just sort of reopening. So the idea is you refine it in order to try to figure out things which are less effective, which actually speaks to some of the other questions on this call. That’s, in my view, a better way of doing things with good contact tracing and stuff to keep a lid on the on the pandemic than to simply have a kind of rapid on the kind of rapid openings that we have seen, especially across the south of the country, without good without testing which is capable to keep track and project right or or do good contact tracing.

BARRY BLOOM: I had just one point that I find of concern that hasn’t been much made of. There have been recent reports, for example, in New York, that in the contact tracing that is calling people to tell them they have been in contact with a CORONA positive individual. Two things are happening. One is people are not taking the phone calls, so they’re not being notified that they were in contact. And some that have been have decided not to spend two weeks in isolation. And they’ve ignored the phone call that they might be infected and able to transmit. I don’t think that happens as much in other countries, certainly not in Asia, when they’re called and told to isolate and they’re checked on, often they isolate. Here, if everything is voluntary, there will be a fair amount of noncompliance, in which case contact tracing and isolation is not going to work. That’s why I think the outcome is dependent on the behavior of the people more than it does on the public health system or the state government. If people are ignoring the epidemic, it’s going to be very hard to control. And leadership should inspire people to be more cautious.

Q: Gotcha thank you.

MODERATOR: Next question.

Q: Hi. Thanks so much for doing this. It seemed like a couple of weeks ago when everybody was starting to reopen their economy. There was this idea that as people moved about, there would be some sickness, an increase in infections and an increase in deaths. And that’s the price you pay for, you know, the economy getting back, going. I’m curious what you think may have changed. All of a sudden, we are seeing more people worried, governors pausing their reopening’s, et cetera. What did we overestimate our own capacity to tolerate infection and death?

BARRY BLOOM: I’ll let Bill answer the question, but I would say that what I find striking it goes back to what the idea of people understanding of exponential expansion of an epidemic. If you only look at what you see today, you’re three weeks behind the curve. So what you see today is not really what’s out there and happening in the community. And it’s only when if people don’t understand that what you see today is going to get much worse tomorrow. People when the political leaders wait till it gets really bad. That’s where we are now. That’s not what happened in Hong Kong, Singapore and other countries that have controlled things. On the other hand, Italy has shown. Things can get really bad. But if you clamp down and lock down and really control movement, they were able to get back down to a remarkably low level comparable to other countries in Europe. But it’s trying to imagine what will be three weeks from now rather than what you see today. It should be determining policy. And we’re not good at that.

BILL HANAGE: I agree. I would say that, however, rather than overestimating our abilities, we underestimate the virus. Well, we didn’t underestimate an epidemiologist could see the situation. But I think that we as a people have underestimated the virus’s capabilities. We, the reopening reflects some things which I think are entirely reasonable. And I want to point out very, again, as loudly as I can. I do not like shutdowns. I mean, I think shutdowns are a bad thing, but it’s not the only thing that you have at your disposal to prevent an even worse catastrophe than there is something which you may have to use. Now people, for reasons that I do not fully understand, because I can’t sit in the minds of my fellow human beings, seems to think that the amounts of reopening that we were seeing would be compatible with the kind of background rate of disease that would be tolerable, as you say. However, if you offered the virus sufficient opportunities to transmit and that is what reopening does, duh, then it will take them. And we will start to see things increasing and we will see an exponential climb that Barry just described. The question then becomes that this is absolutely true, that the quantity of that we can have a level of background transmission which will lead to a background, background, drumbeat of hospitalizations and deaths which could be considered tolerable. And I think that that is actual policy in some places. However, that is only possible if you are continuing to keep the reproductive number somewhere around one. And even if it gets anywhere above one, then you’re gonna have to put something in place in order to stop it going up and producing an exponential, like Barry says. I think a way to think about it that might be useful is that if the reproductive number’s two, that means on average, one person infects two others. Now, think about the number of contacts that you make in a day. A number of the numbers of close contacts on which you might be able to transmit if you just get rid of one of them. If you just get rid of half of your contacts, then you are bringing your personal reproductive number to one, rather than to two. And that’s the kind of intervention that we need to be thinking about. But sadly, I think, I wish more people listened to epidemiologist.

Q: With that said that, the president, I think, just tweeted while we were on the call that we have the lowest death rate in the country and it’s something we’ve talked about before about not seeing three weeks ahead. Are you worried? Because I’ve heard governors talk about this, too. In Tennessee, the governor said the most important date is the death rate. Are you worried that the death rate is now being used as justification to continue reopening the economy?

BILL HANAGE: I think that if you’re going to do that with the death rate, you should be prepared to look at the death rate in a month or so and the following. Hold on to that statistic. If we’re going to follow it, because you might not find it so attractive in a couple of weeks.

MODERATOR: You all set?

Q: Yes, thank you.

MODERATOR: OK, next question.

Q: Dr. Hanage, at the outset, you said you had plenty to say about schools. So here’s your chance. There’s a little bit of a debate brewing over whether we should be asking how to open schools safely versus asking how do we control community transmission so that schools can reopen?

BILL HANAGE: Yes.

Q: Does that make sense to you? And I’d love to make on that. And anything you want to say about schools, that makes absolute sense.

BILL HANAGE: I don’t know if you were referring to some comments that were made on Twitter yesterday.

Q: Yes, of course.

BILL HANAGE: If you were, I’m slightly biased about the person who authored that because that’s my wife who’s just over there. But I think that her thoughts are extremely [inaudible]. I think the points to take on what she would say and to emphasize with a framework which I’m finding useful. I think you need to separate, but you need to think about this in terms of three sort of risks. The first risk is the children themselves. What’s the risk of transmission among them? Then you have to think about the risk of children in schools and transmitting to caregivers, whether it be teachers or family members. You know, some kids will live in multi-generational households, for instance. And then finally, there is the risk to the community. What happens when a school becomes a net contributor to the community as a result of so many things come into it that it’s just actually acting as a sort of, to amplify the virus and send it back out? Now, as regards to the risk to children, no age group has zero risk of infection, but children are much less likely to have really severe outcomes. For the small fraction who do have a severe outcome, well, again, you might not want them to be exposed when community transmission is high. So this means we want to stop community transmission for the group in the middle. Again, that risk is going to be highest in terms of getting disease from the school and getting disease from the community if community transmission is high and then in terms of the school becoming a net contributor, well, that’s more likely to happen if you have more introductions. And also, if you have like, you know, Barry said very wisely earlier, these testing criteria, which are going to be like, you know, you test and then you do something. You need to figure out what you’re going to do with a positive test result before you run the test. If we do that and just sort of saying, well, if we have more than a certain number of tests come back positive, we are going to shut the school down or we’re going to close that. Well, again, that’s going to happen from the community transmission. So I think instead of looking at instead of asking the question of whether or not you want to open schools, I think the way to notice that, like Barry said at the start, in places where community transmission is low, opening elementary schools for younger children would not add a huge amount to it. I mean, I still think that you should monitor very carefully community transmission. But that’s and that’s the situation when you should be most able to open schools. However, if we allow community transmission to get higher, then that could impede our ability to open schools, which is and schools are surely one of the most important things that we should be looking at within our society. I mean, they can not only educate children, they feed them. They for some children, they are safer place than home. And as a result, we ought to look at school and say, what is the contribution of school is making? We should be wanting to be able to open schools and schools should have a higher priority, arguably, than some other parts of the economy. Now what those are. I think that needs to be debated. But I would note that, you know, if you’re having an argument about whether or not you should be opening casinos, then, you know, I’d far rather see a school open than necessarily a casino. I know that there are going to be economic impacts, opportunities as well. But I think that what we should be thinking about in reopening is not reopening everything in a safe way, but which things we want to reopen and being able to do that without enhancing community transmission. Sorry, that went on a bit long.

Q: No, no, no, no. Keep going if you want. But thank you. That answers my question.

MODERATOR: Are you all set? I’m sorry, Dr. Bloom has something he’d like to say.

BARRY BLOOM: I would just say I think that Zeke Emanuel has made a really important case for what Bill just said. Schools are absolutely critical for the development, socialization and education of children. Schools also free up parents to go back to work. So they’re enormously important. And in terms of the priorities, I would put an enormous amount of reducing things like bars, casinos, church worship services and stuff by limiting transmission in the communities to enable, as a priority, schools to get high priority for opening. And we’re not doing.

Q: Thank you for the additional perspective.

MODERATOR: OK. Are you all set?

Q: Yes.

MODERATOR: Next question.

Q: Bill. Hi. Thank you for taking my question. So, yeah, I’d like to change topic. Going to the issue of vaccine. So I guess the moral, the administration U.S. is going off with a new wave of contagion and the economic breakdown, then the higher will be the price of vaccine that is going to be developed. So actually, the more I talk to a to research, large independent research centers, the more I find out that, I think five or six years ago, many of them, they already tested on animal SARs vaccine, and those vaccine, actually, they managed to target the common parts of COVID virus in general, and they didn’t get enough funding from BARDA to scale up their project and to go to phase one and phase two of the vaccine, ahead of the pandemic and now in the middle of all these exercises is the actually they tested the SARS vaccine on the new SARS-CoV-2. And actually, it worked, but they’re not right now and there’s not a lot of media coverage about this stuff. And I also learned, there’s more research that was taken over by Sonofi in 2016 and they also developed this SARS vaccine and Sanofi shut down the platform for that and now Sonofi is again, that puts the platform in place after getting money from BARDA, from the U.S. government. So I’m really wondering, what’s your opinion on this industry driven? I mean, preventative health system now which. I mean, could have saved money. Maybe lives. If there’s vaccine. Well, I mean, there would be at least the phase two and they could have opportunities on that now. Again, it’s nice to meet. It sounds a bit the kind of [inaudible].

BARRY BLOOM: So the vaccine situation, which I know a bit about, is a complex one. So to start with platforms. The quickest vaccines that are now becoming available for testing did not exist three years ago, four years ago. So we have no experience with A) how effective they will be and how safe they will be. The second thing is vaccines are made not by academics and research labs and even bio techs. They’re created. But this is high scale industrial company stuff. And one of the limiting factors is who can make a billion doses? There’s 7.6 billion people on the planet. In principle, you’d have to vaccinate about six billion to assure the herd immunity for the whole world. Nobody expects that to happen. But if you want to make a difference in stopping the epidemic, we’re talking about the production of billions of doses of any candidate vaccine. Third, many of the new platforms, as you say, have been developed in the past for things like Ebola or SARS. And but they have not been tested with the spike in attention or other antigens of Coronavirus. So we really don’t know anything about the safety and efficacy in large numbers of people of any of the new vaccines that are moving quickly here. They are moving quickly because they were available and tested to some extent against the other infectious diseases over the past H1N1, for example, for some. The problem is that once those epidemics went away, there was no incentive for the companies to do further testing. So most of the safety tests that we could have learned a great deal about by testing the Ebola vaccine in large numbers of people or the flu vaccine or the SARS vaccines. That research stopped dead certainly in pretty close to dead in the federal government. So we really have no real knowledge of the safety and effectiveness of any of these new vaccines. And that is why there has to be a large scale phase 2 testing. I would remind you. That in contrast to drugs that go to sick people, vaccines go into healthy people, so safety is the absolutely highest criteria. And if you’re asking the question, how many people do you have to test? Why is it taking so long? If the prevalence in a country is one percent. One person in 100 has to be protected. Then you have to do 30,000 people to be able to get statistical power to know if it’s protected, if the target is only 100 people being protected. So there is no shortcut to getting very large numbers of people vaccinated and tested with each of these, because we really don’t know how safe and effective they are. The only other thing I would say is it looks like, in contrast to many other virus infections, people who recover from COVID infections do have antibodies. They do have neutralizing antibodies, but they dissipate very quickly so that at 24 weeks they’re down to about 10 percent of what they were shortly after infection. And that raises the possibility that the new vaccines not only have to work, they have to work better than natural infection, which is very hard to do. So the only way we’re going to know whether these vaccines are any good is, and safe, is to go through large scale testing. And that will take time. And finally, the question is, when will we have vaccines? The question is, who is we? There may be a phase 3 trial finished in early January. That doesn’t mean a billion doses or three billion doses is going to be available instantly all around the world. And so the actual implementation of vaccines is going to take one to two years. If there is a successful safe vaccine, and that is people are going to have to be prepared for that, which when they read the newspapers and say we’ll have a vaccine by January is very misleading.

Q: The thing is that, in the past, those sorts of vaccines went through a safety test. And in the phase 2, I mean, we need to see but, they could develop at least the antibodies and those safety tests. And the phase 2 tests were conducted on many people then, I mean, maybe research now would be much faster. We shouldn’t go through phase 1, phase 2, at such a low pace.

BARRY BLOOM: No, I don’t agree, because even if they were safe for Ebola with the Ebola antigen and if they were safe for H1N1 or they were safe for SARS, and it’s the same platform, every time you manipulate a biological agent, you run the risk of introducing errors and mistakes. One has only to look at the testing at CDC that introduced a contaminant, probably something of DNA floating in the air that was unmeasurable, that got into the test kits, and that slowed us down by three weeks. So, no, you can’t take safety from a prior vaccine that looked very good, manipulated genetically in the lab and assume you can skip phase one and two. I don’t think that’s possible. I think the chances are very low that a mistake or a contaminant could have happened, but they can always happen. And you have to test for that.

Q: OK. Thank you.

MODERATOR: All right. It looks like that’s our last question. Dr. Bloom, did you have any final comments?

BARRY BLOOM: No. But I thank you all for awfully good and challenging questions.

MODERATOR: And Dr. Hanage, to do any final thoughts?

BILL HANAGE: Well, I just point out it feels like I have this awful feeling of déjà vu like it’s March all over again.

This concludes the June 25th press conference.