Coronavirus (COVID-19): Press Conference with Howard Koh, 01/08/21

You’re listening to a press conference from the Harvard School of Public Health with Howard Koh, the Harvey Fineberg professor of the practice of public health leadership. This call was recorded at 11:00 a.m. Eastern Time on Friday, January 8th.


MODERATOR: All right, Dr. Koh, do you have any opening remarks?

HOWARD KOH: Sure, Nicole. thank you so much for hosting this. And welcome, everybody. It’s nice to see you again. We continue to be in an astonishing time in our public health history as we enter a new year. You know that yesterday we had a record number of deaths from COVID with the figures exceeding 4,000 nationwide for the first time ever. And you may know that we ended 2020 with COVID being the leading cause of death in the United States for the month of December. I actually wrote a little article in the Journal of the American Medical Association commenting on that and reviewing the trajectory of where this previously unknown condition has now caused so many deaths that it’s the leading cause of death as 2020 ended. So the trends, unfortunately, are continuing now into January 2021. But the good news, of course, is that two vaccines have been authorized by FDA and a vaccine rollout started in mid-December. In our country, that rollout has been slower than expected, leading to much initial frustration that we can discuss more through this call and beyond. If I can say I have lived through many of these public health and prevention efforts as the former commissioner of public health here in Massachusetts and then as assistant secretary for health. When you stop and think about a new vaccine effort are part of what we do in public health and they are never easy. Prevention sounds easy, but it’s not. And so this is a time where public health, usually an invisible system, is now very visible to all of us because its success will determine whether our country gets back to any sense of normalcy by this summer or early fall. Right now, about twenty-one million doses of vaccines have been shipped and distributed, but only about six million doses have been administered, and so there are a lot of debates about how we can make those numbers go up. Only about 30 percent of doses that have been received at the state and local level have been administered so far. And you know that we’re still in most states in the first priority group of recipients, that is front line health care workers and people in long term care facilities. So going through this process in the future will depend on a state and local public health system that is supported by the public and policymakers. About a week ago. Dr. Mike Fraser and I of ASTHO wrote an opinion piece in CNN talking about how the success of our vaccination efforts for COVID will depend on a successful state public health infrastructure. That infrastructure has been cut back for far too long. It’s been under resourced and overlooked. Fortunately, just in the last number of days, you know, Congress approved a new coronavirus relief package of some 900 billion dollars. Some eight billion of that is targeted for vaccine distribution and infrastructure. But that money is coming after a all this rollout has begun, as you well know. So that infusion of funds will be important, but it is only considered a down payment, and we have to make sure that we have the system work well to make prevention and come alive and bring this country back to health in 2021. And then in the middle of all this, of course, we have a transition in administrations with a new administration taking place in about 12 days. And the president elect has made a number of commitments about how he will conduct the pandemic response after he’s inaugurated. So we can talk about that more, too. So at this point, maybe I should just pause and take any questions. And thank you so much for being part of this press conference.

MODERATOR: Thank you, Dr. Koh. All right, let’s take our first question.

Q: Hello, thank you, professor. So I have two questions. My first one is because, you know, right now both the U.K. and Denmark have extended the time for the second dose. But the FDA just stated again that people should not consider the extension right now. So what do you think of this? Do you agree to that? To get the first shot as quickly as we can in a larger population is more important right now or the other opinions?

HOWARD KOH: OK, so if I understand, can you say one more time, I think I got it all, but I just want to make sure sorry.

Q: OK, yeah, sure. So because both the U.K. and Denmark have extended the time for the second dose and the FDA just stated again that people should not consider the extension right now. And what’s your opinion on this? Do you think we should take on the second dose later? And because the first dose is enough. Do you agree that right now because of the variant of the COVID-19, so we should get the first shot as quickly as we can in a larger population?

HOWARD KOH: Got it. OK. All right. So we’ve already delved into the most dynamic debate since the vaccine rollout began. So for those of you who have not followed this daily, let me just summarize the status of events here. You know that the FDA in the United States authorized the Pfizer and Moderna vaccines based on the phase three trials that had two doses that were three weeks apart in the Pfizer trial and four weeks apart for the Moderna trial. And as you know, the good news from both of them that was exten sively studied by outside experts was that the efficacy was excellent, about 95 percent in both trials. The safety profile was very strong. And so that was also very encouraging. And so based on that, the FDA under this administration has encouraged that dosing schedule based on that concrete data that was analyzed and then recommended by outside groups as well as the U.S. government. There are places, as our colleague here has referred, particularly in England, where the strategy has been to not hold back on any initial doses and adhere to that strict timeline, but rather a release as many doses as possible initially, because even if you have one dose in those two trials, the efficacy is still substantial, maybe 50 to 60 percent instead of 95 percent. And the argument would be that if you gave a single dose, you would still have substantial protection, even though it’s lower, and reach more people. So that debate is now very much alive and well here in the United States, and it’s a very dynamic, fast moving area. You could argue on one hand that we should follow very conservatively the results of the Phase three trials and stick to that two-dose schedule, three weeks or four weeks apart. Or alternatively, you could argue that a single dose offers lower but still substantial protection, and why hold half of those doses back? So I believe actually I need confirmation on this, but I’ve read one report that the incoming administration has just announced literally half an hour ago that they are leaning toward the strategy that promotes the single dose and that we will be hearing more details about that shortly. So what that means also is that they looked at several trials that were just published in the Annals of Internal Medicine a couple of days ago based on modeling. And those trials suggested that the single dose strategy could be more effective from a population point of view in reducing numbers of symptomatic cases. So we just have to follow this very, very carefully. I think from the broad point of view that the challenge, of course, is that the dose administration tempo has been much lower than the targets that we wanted to reach. We need as a country to have about a million doses administered a day to come anywhere close to opening up the country to some sense of normalcy in the late summer or early fall. Right now, the numbers of doses being administered is far below that ideal number. So that’s a broad summary of a very complex and dynamic area. So I think we just have to watch this carefully, wait for more science. Also, we need to make sure that the from a broad point of view that every aspect of this vaccine system is working at the highest level, from production to distribution to administration. I am very concerned that state and local public health officials are pretty exhausted right now. And now they’re expected to ramp up and embark on the most ambitious vaccination campaign this country has ever seen and make it a success. They will do so if I can say, because that’s what public health does, the field always rises to the challenge. My plea, though, is that we support these public health officials at the state and local level and give them the recognition and resources that they need and deserve. Right now, we need to help them help us.

Q: Thank you. And my second question is, because many experts criticize the British governments, they fail to detect the mutant virus into the spread over the Britain and all over the world and can now be controlled. So what lessons should we learn from it in America for the policymaker point of view or like for the established the whole public health system, should we establish a monitoring mechanism to detect any mutations of the virus so that we can response in time in the future?

HOWARD KOH: You’re asking excellent questions. And yes, that first variant was described from the UK, not because it’s just in the UK because we’ve now documented that it’s in dozens of countries around the world, including and especially the United States, but it was first described by the U.K. because genomic sequencing is more common in that country than it is here. So, in fact, our scientists here in this country have since over the last several months ramped up routine genomic sequencing to try to assess better the trends in this new variant that’s been described from the U.K. and also a related one from the South Africa. So, yes, it should be part of monitoring for the future. And you all know that these new variants have been described to be more transmissible, but fortunately not more fatal as of yet. So some would argue that this is another reason to get those initial doses of vaccines out to as many people as possible right now and not hold back for the second dose.

Q: Thank you so much.

MODERATOR: Next question.

Q: Thank you so much, Tropico, for taking our calls. I wanted to follow up on the on the second dose question. I believe what people are talking about is not doing away with the second dose, just delaying when people would get the second dose. And I’m wondering if you are confident, given what you know about the way the supply chain is working, that it would be safe for people to get that first dose and that it might be a delayed but not an inordinate delay in them getting the second dose. And in connection with that, in which scenario do you think the public health system would be the most strained, trying to get the first dose into more people or sticking with the current situation? And then I have another follow up.

HOWARD KOH: OK, these are excellent and difficult questions without easy answers right now. So just to start from the beginning, what makes this public vaccination effort so challenging has to do with so many factors, well, one of them is that the first two vaccines authorized require two doses, in contrast, for example, the seasonal flu, that’s usually a one-shot effort. When you ask people to come back for a second dose at a specific timetable, as we have asked the American public, at least in these initial weeks, it already complicates a very ambitious effort. And you can imagine the logistics that might be involved to remind people to come back, and what happens if people forget, those sorts of logistical issues are all part of what public health has to do right now at the state and local level in addition to many, many other dimensions of orchestrating this vaccination effort. So, again, one could argue from a logistical point of view that it might be easier just to recommend a single dose for now, which is offering, as I said, a lower but still substantial protection. And that would also ease some of the logistics stream. But the counterargument could be we have two vaccines that are excellent terms of the efficacy and why not give maximum protection to people in the way the studies have demonstrated to date? So not so much of this is going to depend on what our supply chain is going to look like over the next number of months. We know that we’ve had some twenty-one million doses or so shipped out, but we all know that for this whole effort to work, the whole vaccination system from invention to injection has got to be absolutely working well. And every pass of the baton and the federal, state to local level needs to work well. And in fact, my overall observation on the opening couple of weeks is that we need once again in this pandemic, a one government approach that unifies coordination from federal, state and local officials. Everyone is trying their best, but it’s not clear that coordination at the highest level has occurred yet. And it’s got to improve if we’re going to get to the targets of some 85 percent of the population vaccinated and achieving herd immunity.

Q: So it’s sounding like you’re referring at this point that the one dose and then deal with whether to give a second dose later to happen, let me know if that’s right?

HOWARD KOH: I think the answer is not definitive either way right now. There have been some modeling studies that are literally a couple of days old, so people are still trying to digest them. And it’s not based on clinical studies, which is what the two-dose phase three trials are all about, that were followed so carefully. We’re going to continue to have dynamic debates on this for a number of months is my guess.

Q: My other question has to do with people that have started to sign up for and register to get the vaccine, specifically some in the seventy-five plus group. We had a report that in one case as a person was signing up, they were asked whether or not they were on blood thinners. And once they checked the box, yes, they were kind of rejected from signing up for a vaccine and weren’t able to do it. I’m wondering if you’re hearing about that happening on a widespread basis and what you think of that, because what I’ve seen from FDA guidance was that you should tell the person giving you the vaccine that you’re taking a blood thinner, but not that you would not be able to get the vaccine and that you should check with your doctor. So I just wanted to see if you’ve heard about this as well.

HOWARD KOH: I have not heard about that as an issue, so I’ll have to look into that more. But I have not heard that as a reason to exclude anyone I think would be a reason to monitor them more carefully after the injection. And of course, while we are expected to monitor these for 15 minutes after the injection for side effects and anaphylaxis, which fortunately the rare so far. So that could be another reason to monitor carefully, but I don’t think that’s a reason for exclusion right now.

Q: OK, thank you so much.

MODERATOR: I will say, if you need somebody to check on that, I can see if there’s a clinician that would be available or sent you to one of the hospitals and they may have a little more information about that topic.

Q: That would be great. Thank you very much.

MODERATOR: And you’re all set right?

Q: Yes.

MODERATOR: Perfect. Next question.

Q: Hi. Thanks for taking my question. I have a question which is related to the accessibility of the vaccine. So, the reason why there is a shortage of vaccines for people, they can’t get to the first and second shot in a shorter time is that basically governments are relying on the production capacity of the pharmaceutical companies. So I you know, if you as a scientist think that a way to expand production is to accelerate the release of doses and possibly to people to get the first and the second dose is to basically adopt a compulsory licensing system where the pharmaceutical companies, which to basically issue licenses to a third party manufacturers, which could contribute to the production. And, you know, government is actually doing that there was a proposal by South Africa, at the the World Trade Organization by the Council of the Treaty on Intellectual Property and basically all Western countries, including the US and Europe were opposed. So I’m wondering whether the government is actually defending the interests of pharmaceutical companies other than the death of their citizens. As I said, the third-party production will increase all of the production and the possibility of people who get the doses. So that’s the question.

HOWARD KOH: OK, I hope I got all that. Let me just say that there are lots of ways to potentially increase supply here in our country, the current administration embarked on Operation Warp Speed, which has brought us to this point and gave our funding and support and collaboration with six pharmaceutical companies and, you know, the first two that are messenger RNA vaccines that have been authorized and that’s what we’re distributing around the US right now. And there have been negotiations by the current administration to buy more doses. And we can get into the details of all that. There has been discussion and actually the president elect has announced that he wants to leverage our Defense Production Act more fully and maximize any supply through that mechanism. In the pandemic so far, President Trump has leveraged that Defense Production act at some points or earlier on to increase ventilator production, but not throughout the whole process with respect to PPE and masks and now vaccines. So those are the efforts and suggestions that are being debated in our country right now, particularly as a new administration comes in.

Q: Follow up question; you don’t agree with the possible intellectual property exclusivity to a third-party manufacturer to produce vaccines for people?

HOWARD KOH: I have not heard about that option, so I’m sorry if I can’t answer a single word about that. I think you’ll be hearing under a Biden administration more about the Defense Production Act as a possible way to maximize as much supply, not just for vaccines, but also for masks and PPE and gloves and other items that have been intermittently in short supply.

Q: What is the range of a mutation of the virus, which basically would make the current vaccine ineffective, I mean, there is a danger of mutation which can be tolerated by the vaccine or any fractional mutation in the domain of the virus that can basically neutralize the effect of the vaccine?

HOWARD KOH: OK, I’ll have to defer the specific answer to one of my immunology colleagues. We know that mutations occur all the time with viruses and coronaviruses. We also know that as of now, there’s no evidence that the coronavirus in this country or anywhere is escaping the neutralizing antibody production that’s induced by vaccination. So that’s good news from a public health point of view. But in terms of the exact number of mutations, I’d have to defer to a basic science colleague.

Q: OK, thank you.

MODERATOR: And if you have some questions specifically about the Defense Protection Act, there is somebody over at Harvard Business School that I could try to connect you with and he would know more about that Act and how it could be used.

Q: Yeah, I would be grateful for that. Thank you.

MODERATOR: All right. Next question.

Q: Thank you. So my question may be too specific and not exactly your niche. And if that’s the case, I apologize. But according to the new model, Florida will hit a new daily death peak on the twenty sixth with about one hundred eighty-one deaths a day. And curiously, there is a steep drop after that in our daily deaths. It just goes straight on down. And that drop is also visible in IHME’s national model as well. So do you have any idea as to why that drop exists? Could it be the end of this holiday rush?

HOWARD KOH: I’m not sure I can answer that one. I think your speculation is potentially accurate. You know, we’ve had a spike, unfortunately, several weeks after Thanksgiving and now several weeks in the opening, weeks after the Christmas and New Year’s holidays. So that could be one factor. I know Dr. Murray well, the head of IHME and the global burden of disease efforts. He’s an outstanding scientist. I’ve watched his models carefully, you know, in those models that he also factors in mask usage, whether that’s going up or down, the social distancing, whether that’s going up or down. And then most recently, of course, increasing numbers of vaccine doses administered. So my guess is I haven’t seen that exact drop, so I’ll have to go back and look. But my guess is the model is factoring all those timing after the holidays have receded and perhaps the initial impact of the vaccine. But let me let me check on that one to.

Q: And since I’m here, let me ask you a public health question, since that’s your thing. Here in Florida, we have a more unique system in how we’re rolling this out through the public health. I just want to know your take on that. We’ve got a very governor centered approach where he’s making all the decisions and it’s trickling down to the Department of Health. And I know that’s not standard. Department of Health usually take care of their own counties in that kind of thing. And in my area, in particular, southwest Florida, we have a lot higher percentage of older people. So the governor’s executive order that sixty five and plus can get the vaccine is actually limiting in a way, the 80 plus people that can get it because they can’t sit in their cars all night and they’re not as technologically advanced to sign up for these online. So I just want to get your thoughts on some of those things.

HOWARD KOH: OK, you’re asking a couple of questions. And one is, when the charge comes to the states to implement vaccination, does that occur in a uniform way across the state or county by county or city by city? That varies across the country. And historically, that’s been the case because our public health system is generally fairly decentralized that way. So if in Florida it’s more centralized, that’s something that I would defer to your state leaders. I think the other question that you’re raising, though, is as an interesting one, which is when you open up to people over 65 as has been done in Florida, will you have supply meet the demand? And will the end result be an experience that’s viewed as convenient and accessible and respectful to everyone? That’s the challenge for all local public health officials, because the goal is to have a limited supply any time achieve the greatest good for the greatest number. So as one who is watching what’s happening in Florida with the rest of the country, there may need to be some adjustments in how the various priority groups are coming forward by the public health officials, because there’s been a lot of attention to the people waiting in lines for hours and hours. You’ll have to tell me more about whether it’s changed in recent days, but that is one of the challenges of trying to take limited supply and meet demand in times like this.

Q: OK, thank you.

MODERATOR: Next question.

Q: Hi, thank you, Dr. Koh. Here in Dallas, as I’m sure in most cities, there’s quite a disparity of where the COVID cases are occurring geographically. And of course, they are occurring and affecting mostly black and brown citizens and people who work in essential jobs, et cetera, everything we all know. So my question is, now that the vaccines are rolling out, what would be the ideal way for public health officials to monitor who is actually getting the vaccine, you know, their age, their gender, their comorbidities, their home zip code? And what do you know about how this is taking place anywhere in the country? So in other words, to me, it would seem like we would want to know as a city or county or a state where people are getting vaccinated and if we need to be checking whether the hot spots are getting vaccinated. And I would just like your thoughts on that. What is the ideal? And then what do you know about what is actually happening and how that’s being monitored? Thank you.

HOWARD KOH: OK, that’s a great question. And it also has many parts.

Q: Yes, I know. Thank you.

HOWARD KOH: And actually, my CNN op ed that that I’ve co-written with Dr. Fraser addresses some of that. So ideally, one of the many parts of orchestrating the ideal response by state and local public health officials is to have an information system that’s real time and accurate and collects all the information you just mentioned so that on a daily basis, we have accurate updated information about where doses have been administered and who has received it by age and by zip code and by community. This is especially important because communities of color have been really hard hit by this pandemic as have noted, and I’m very concerned about that not only as a public health official, but as a person of color myself and a son of immigrants.

Q: Yes.

HOWARD KOH: Now so many public health departments have archaic infrastructure and there are many local health departments that are still tracking these outcomes by a pencil and paper. So this is why we need to support our public health departments. I’m hoping some of that federal money coming in will address that as soon as possible, because we all need updated information to make sure that these vaccinations are occurring at the right place at the right time for the right population. And there are some challenges to that right now.

Q: Do you know of any places that it is occurring correctly, for example, in Massachusetts, it’s a smaller state than Texas. I know I’ve seen some of their data. It’s better than what we have available here in Texas. Are they tracking by zip code or precinct or is anyone doing this correctly, so we really know where the vaccine needs to go and how to deliver messages to those people or which churches to set them up in, you know, the clinics and et cetera? Like, how do you know if any place that is doing this correctly?

HOWARD KOH: I’m going to say that there is no state that has an ideal information system right now in terms of the real time public health information that we need. And unfortunately, saw this already with the testing, slow rollout of testing and all the confusion about testing and the number of months, I mean, getting race, ethnicity, information from public health laboratories weren’t required by the CDC until June or July of last year, you know, months after the pandemic started. And we have a country where we spent a lot of money on information systems in hospitals. That’s very valuable. But we need similar attention to building most robust information systems for communities and for public health departments.

Q: Well, then how are we ever going to know that enough people have been vaccinated? Like, are we just going to have to watch the course of the disease and see cases go down? Or how do we know?

HOWARD KOH: We will get the information, but there may be a lag. In fact, some federal officials are saying that the doses administered numbers are actually higher. If you listen to them, they’ll say the numbers are actually higher than reported because there’s a lag in the reporting systems. And I think that’s probably true to some degree. But I think your overall point is excellent. And, you know, most people don’t think about this until times like this. We need the best information possible from a population-based point of view by community, by neighborhood, by race, ethnicity. And we need that in real time. And it’s got to be reliable. And we just don’t have those robust systems right now and we need more time.

Q: And I’m sorry if I keep repeating, but so how will we know whether the vaccination effort is going well?

HOWARD KOH: I think we will get the information over time is just there will be reporting delays. Unfortunately, part of trying to do the best we can with what we have and so this is why, again, in the op ed, Dr. Fraser and I make a plea for finally, you know, giving the resources to public health officials who have faced so much resistance in the last 11 months or so to help them do their job and then get people like you with the information that you and we all need.

Q: OK, thank you, sir.

HOWARD KOH: Thank you.

MODERATOR: Next question.

Q: Thank you very much, Dr. Koh. Also, my question, I mean, in terms of the pay rollout, some of the broader structural issues like coordination at the federal level or the lack thereof, like the underfunding of public health departments, I’d like to ask what you think might be the one or two key drags in terms of what’s happening on the ground. You mentioned the 30 percent vaccination versus allocation. What do you think are the key factors once the vaccine is there on the ground, at the sites, at the nursing homes, at the hospitals, that’s keeping that allocation number low? You mentioned the reporting lags, CDC has mentioned people have talked about issues like hesitancy. So what do you think of the one or two key things at that level that’s keeping the pace from accelerating like it should be? And what are you seeing being done or could be done to solve those problems? I may have a follow up depending on your response to that.

HOWARD KOH: Thank you for that question. So, you know, that could be answered in so many ways. But the highest level we need, federal, state and local public health officials working one government proactive approach with as much advanced planning as possible, because at the state and local level, as we’re all seeing now, they are responsible for identifying clinics and facilities and sites and then making sure that those sites have the staff, supplies, space and storage considerations required to make this all go forward. We’ve already mentioned the complexities of having two doses instead of one. The special storage needs ultracold, the storage considerations for the Pfizer vaccine that requires purchase of expensive freezers. That may not be an option except for major hospitals in big cities, for example. And then and a huge issue that concerns me is that the broader communication nationally about how we work together as these various priority groups get introduced then and whose turn it is and what the strategy is going forward so that we can all support each other and get through this as a nation, that communication effort is just barely started. There’s an effort by the ad council and the COVID collaborative that’s in the works. And we are hearing that there will be a communication campaign coming out of HHS now. Now in the next administration, because it hasn’t really come out in the current one. But that communication effort should have come out months ago. And in fact, I have advocated in a previous op ed that we should have built on the flu vaccination efforts because, you know, that infrastructure does exist, but it requires broadening it and expanding it and then really having federal government support the state and local officials who are absolutely overwhelmed.

So that’s my longer answer to a simple question at this point. There’s more discussion that the president elect, for example, has mentioned about having more federal sponsorship of establishing and implementing sites. Some discussions about having more mobile units, more so-called mega sites like stadiums. I think all those options are worth discussing. But if I can say that planning should have happened months ago and it’s becoming unfortunately clear that it wasn’t at the level that we all needed.

Q: If I can follow up briefly when you talk about the communications issues, are you talking primarily about communicating to people where, when and how they can get the vaccine? Or are you talking about the kind of communication effort that goes into convincing people to take it in the first place? And I’d like to get your thoughts on some of the reports about very low take up, especially among the frontline health care workers and nursing home staff. Has that been an issue in the numbers and what can be done and is being done, do you think, to address that?

HOWARD KOH: So the answer to all your questions is yes, you know, we haven’t had enough communication. Well, there’s obviously broad concern that’s been public for months about hesitancy in general, about vaccines. That’s been rising over years, driven a lot by social media. And then that concern swirled around the FDA authorization process. I think the FDA actually led that process very well and really rallied the scientific community to support the authorization moving forward. But the hesitancy is still a challenge and it even affects health professionals. And, as you pointed out, it’s been a major factor for the low rates of immunization and long-term care facilities, particularly among staff. So that theme is going to come up more strongly as this whole rollout continues and we’ve got to watch that carefully. This is why, Andy, I have often suggested that we need as many societal leaders coming forward to support the vaccination effort the way that the president elect, the vice president, Pence, Dr. Fauci, got their vaccinations on camera. We need the support of business leaders and school leaders and faith-based leaders are coming forward, have been very helpful in past vaccination efforts like measles in 2019. So this is an all hands on deck effort. It’s going to involve of all parts of society.

Q: Thank you, Dr. Koh.

MODERATOR: Next question.

Q: Hi, thank you so much for taking time with us. Just a quick question. The CDC’s vaccine tracker shows the vaccine distribution per one hundred thousand people. And I notice that the states don’t have this even distribution. So I was wondering if you know why and if it’s like the earlier that we saw with PPE, are states having to compete for the vaccines coming from the manufacturers?

HOWARD KOH: OK, that’s an excellent question. So, again, I’ve now written six op-eds through the COVID response, and my very first one, last May or April was in Stat. And the title was something like, we need one, not a 50-state strategy for a pandemic response. And so for the vaccine rollout, as we’ve seen for so many other parts of the pandemic response, it’s been very much left to the states to take up the responsibility for making public health come alive on the ground, and as you pointed out, we did have very unfortunate examples of states competing against one another. So we need the federal coordination and leadership now for the vaccine rollout, because the last thing we want to do is have states competing against each other. In fact, it would be better, of course, if one state was doing well, another neighboring state was struggling, the states helped one another. And it’s not clear that such a mechanism exists right now. Some regions have had their governors try to create coalitions. And that got some attention a number of months ago, but we haven’t heard much about that lately. So I think that’s something very important that the new administration will have to take on. And so they make sure that we’re having a united response for the United States.

Q: Do you know, just to follow up, do you know if the states are having to have contracts with the distributors, or do they have the contracts with CDC?

HOWARD KOH: I cannot answer that definitively. Let me just say, though, that, you know, the process that goes on occurs every fall with flu vaccine, and it’s usually through private distributors. But again, another reason why this year is more complex is we’ve had with Operation Warp Speed, the Department of Defense involved, and they’ve also worked with private distributors. So for this particular pandemic, I’m not exactly sure of that same infrastructure is being followed or altered or changed. It’s also added to the complexity. And if I can say some of the confusion that you heard from General Perna.

Q: Well, thank you so much again for your time.

MODERATOR: And while waiting for to see if anybody else has questions, I have a couple for you. So one of the things that I have heard about some people being concerned about is a black market, just very elemental economic short supply, a lot of demand. People do what they can to get a hold of whatever is in short supply. Do you know any protections or anything like that to prevent something like a black market or people jumping the line to get a vaccine before they should be there?

HOWARD KOH: So again, in a time of scarcity and limited supplies, this is the risk. And so I’m not surprised to hear that theme, Nicole, and I’ve heard some sporadic reports. So we will have to track that going forward. And so this is where public health and law enforcement and all of government at the local, state and federal level have got to work together again. This just can’t be left to the local public health officials to be enforcing this. I think good public health officials are best at communicating the priority groups in the process and where to get their vaccines and then have to have the support of other parts of government, especially law and law enforcement and then state and federal leaders.

MODERATOR: Next question.

Q: All right, I came up with another one, so you’re calling for a renewed investment in public health, but what do you think the chances of that actually happening are?

HOWARD KOH: I’ll tell you what, when you stop and think from a big picture about how we got into this terrible public health crisis that’s engulfed our country for now, almost a year, actually, it’s because we’ve had this fast, preventable infectious disease pandemic being fueled by a slower preventable chronic disease pandemic that with so many people at risk and all the above could have been. Prevented with a stronger public health system as one who’s been in public health for many years now, when I’ve made the plea to budget officials for more investment, the reply was often we don’t have enough money for public health and prevention. And now if you look at the devastation we’ve had, the tragedy is not just that so many have suffered and died, but it’s amplified by the fact that so much of this suffering and death could have been prevented. So I’m hoping with a new Congress and a new administration, there will be a strong reinvestment in public health at the federal, state and local levels, because otherwise we just risk going through this again. And, you know, I am, as Nicole mentioned, one who’s been at this for several decades now is the city health commissioner through 9/11 and anthrax. And after that, there were public health emergency preparedness programs and funds established, also hospital preparedness and program funds. There were promises that we would always be prepared going forward on behalf of our country. But if you track the funding over the last number of decades in public health and in those specific programs in particular, they’ve been cut back and not supported because people were focused on other areas. So we just can’t allow that to happen again, given the devastation that we’ve witnessed so far.

Q: Thank you.

MODERATOR: Next question.

Q: Hello, I had a question about the vaccine phases or tiers for each of the groups that are supposed to get the vaccine and whether or not, how will states be able to sort of determine the population sizes of how many, say, first responders or how many health care workers? Because right now we’re seeing a bottleneck just in the first tier. And how will states know when to pull the trigger on sort of escalating their vaccine distribution to the next tier of people?

HOWARD KOH: So that’s a great question. That’s precisely what state and local public health have got to do state by state. So this is where if the general priority groups are put forward by federal groups like the CDC and their advisory committee on Immunization Practices, it’s up to state and local leaders to tailor that according to their own state and by the dimensions that you just mentioned. So I’ll give you one example. You know, it’s relatively easy to identify who’s over a certain age, but then to even. Identify which groups qualify as front-line essential workers is a matter of debate. I mean, there’s general consensus that first responders and teachers, particularly since we want schools reopening soon, could be and should be part of those front-line essential workers. But other groups would also perhaps want to be considered as part of that umbrella. So this is where the federal, state and local coordination has to be really at a high level because the broad principles come down, but the implementation happens at the local level, as you’re implying.

Q: Thank you.

MODERATOR: Next question.

Q: Thank you. Just to follow up quickly on the question, Doctor, how do you think that tiering is in any way contributing to a vaccine sitting on the shelf, so to speak, in that states or jurisdictions are, for example, setting aside large amounts for the nurse for the long-term care community, or trying to make sure they have enough to get those numbers of frontline workers vaccinated and therefore, a vaccine is sitting there and getting unused. And is that a problem? Is that a bottleneck that you see as a as a problem?

HOWARD KOH: That’s a good question. And yes, that issue has come up. So we obviously want some rational order of priority groups, but we also do not want available vaccine being disposed of because the people who appear are not in that precise group, so there’s got to be some flexibility and we were all concerned about some initial reports that certain clinics would and there were available doses that were discarded that we cannot allow that to happen. So that’s when each clinic and its facilities got to use their best judgment and make sure that every dose available is administered.

Q: Is there a lot of concern, you think, among the state health departments in the facilities about or too much concern perhaps about finding themselves, this gets back to the to those questions, if they switch from that kind of prioritization or holding on to it when it gets time to administer the second doses to those front line and nursing home populations, they’re going to not have it. Is that a worry that you’re seeing? And is it a fair worry?

HOWARD KOH: Yeah. I mean, so, we’ve all heard on this call and every day how complex this is, how formidable the logistics are, and especially given that we want to reach perhaps eighty five percent of the population. So this is why public health, which is usually invisible, is now really highly visible and needs to be supported. It’s also a dynamic process, as we’ve already discussed today, because it’s one thing to put out advisory guidelines on the federal level, but when the rubber meets the road in the local community, we get to see what works and what doesn’t. So this is where we need strong public health leadership at all levels to keep adjusting the system, make sure the limited supply at any time can achieve the greatest good for the greatest number and then communicate this as clearly as possible with the backing of federal leaders so we can get to the other side of this.

Q: Thank you.

MODERATOR: All right, I think that may be our last question, Dr. Koh, do you have any final thoughts for us before we go?

HOWARD KOH: Well, thank you. All of you all asked some very, very extensive questions. I think this is going to be a process that’s going to last. Well, we all know it’s going to be a process, that it’s going to last for quite a while. I hope everybody appreciates how complex this is and the reason why we’re talking about it is this pandemic has made visible a public health system that’s usually invisible, and if I can say underappreciated. To repeat a theme from earlier, prevention sounds easy, but it’s not. We wish we had a cure for COVID, but we don’t, even though we’ve had some advances in treatment. So the only way to put this pandemic behind us is maximizing the power of prevention, whether it’s vaccination or mask usage or limiting crowds. All those themes, vaccines are not a silver bullet, by the way. So those other prevention guidelines have to continue until we get to the other side of this. And that’s going to require a lot of effort for a pretty exhausted country right now. So if we can use this as an opportunity to show the power of prevention and the importance of public health, I think that would be a positive outcome in an otherwise very, very difficult time for our country. So thank you for your support and interest.

This concludes the January 8th press conference.

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