Coronavirus (COVID-19): Press Conference with Howard Koh, 11/10/20

You’re listening to a press conference from the Harvard School of Public Health with Howard Koh, the Harvey V. Fineberg professor of the Practice of Public Health Leadership. This call was recorded at 11:00 a.m. Eastern Time on Tuesday, November 10th.


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

HOWARD KOH: Sure, Nicole. And welcome, everybody. First of all, Nicole, thanks so much for organizing this very important call. And what a time for our country. What a day in particular. So much going on. And as many of you may know, I’ve had the incredible privilege of not only being a practicing physician for several decades, but also a commissioner of public health for Massachusetts and then also the assistant secretary for health in the Obama administration. So from that perspective, I can comment very quickly on seven key areas, just, you know, 30 seconds each maybe.

First of all, moving into the most dangerous time in our pandemic response. As we all know, over 10 million cases, nearly a quarter million deaths. We are shattering records in new cases every day. Hospitals are getting overwhelmed, test positivity is rising, and importantly, deaths are rising. And it’s very troubling to be at this point in the pandemic response in our 10th month and counting. There’s so much we need to do to advance prevention, public health treatment and then vaccines. We are very excited to have a president elect who on his first day yesterday made it clear that addressing this pandemic was going to be his highest priority. All through the campaign you heard him say that he wanted to empower the scientists and empower the top public health agencies. That meant a lot to me. If I can say, as a former state health commissioner and a former assistant secretary, and I know the vice president or the president elect now actually is experienced in this because I had the pleasure of working in his administration with President Obama through H1N1, the last pandemic. The only way to get through tremendous health challenges like that is through a science based, evidence-based approach, and through a one government approach that coordinates federal, state and local leaders. And sadly, we have not had that level of coordination until now. So that was a major theme of his comments yesterday and his appointment of this task force. Many of the members I have worked with and respect very much. So I thought that was a step forward. You also noted that he has been a firm supporter of universal mask usage and leads by example in wearing a mask whenever he’s is in public and sponsoring events where people are socially distanced, so we’re going to watch that example carefully as we go forward in many aspects of his strategic plan that he is putting together now and leveraging in the next number of days will be critical to watch. But one theme I just want to point out is that he has already announced that he wants to reengage in the WHO. You know that President Trump had announced that he wants to withdraw from WHO a number of months ago. So President elect Biden has announced that he wants to reverse that. The importance of a timely transition is absolutely critical right now because so many lives are at stake. And you know that the news is filled with some challenges about a timely transition. That has to start immediately because the future health of our country depends on that. So we can talk more about that if you want. Third, you all know that about an hour ago, oral arguments for the Affordable Care Act started before the Supreme Court. I had the incredible honor of being in federal government when the ACA became law on March 23, 2010. So over a decade later, the ACA, while far from perfect, has made so much impact on health insurance coverage and on public health in our country. I personally cannot fathom how the ACA could be withdrawn at a time like this when we have our worst pandemic in over a century, because if it is dismantled, well over 20 million people will lose their health insurance coverage. 135 million people will lose their protections that they have when they have preexisting conditions and need affordable health insurance. And 160 million Americans may lose protections regarding caps on their medical expenses because of limits on their expenses for their health insurance. That has to do with annual limits and lifetime limits. So we’ve got to watch those things very carefully through these arguments today and beyond.

The fourth area that I want to comment on is this is just a critical time for public health at the state and local level, I can say that as a former commissioner, we have the flu season vaccination going on right now and we have to support these public health officials who have been overwhelmed for the last number of months. We need this flu vaccination effort to be very successful this fall and serve as an on ramp for a future COVID vaccination, that’s now looking like it’s going to come sooner rather than later. The American people need to see that the system is working on their behalf. Fifth, we heard just this morning that Eli Lilly has gotten emergency use authorization from FDA for a new monoclonal antibody product. So critically important in that announcement is that it’s authorized for non-hospitalized COVID patients who have mild or moderate disease. It’s not for severely ill COVID patients. So that’s an advance in therapeutics. But one challenge is that the supply will not come anywhere close to meeting demand. So there’s going to be a lot of discussion about who should be getting that treatment, first and foremost. And those themes also apply to the announcement yesterday, item number six on our list, that Pfizer has preliminarily shown that their COVID vaccine is 90 percent effective, which, of course, is preliminary, but very exciting news. So we have to wait until this trial is completed, they have to wait a full two months after the second COVID vaccination dose for the 44 thousand people enrolled. And we also need an independent expert advisory committee to look at these results objectively. But based on that assessment and then an FDA decision, we could be starting a vaccination by the end of this calendar year. Again, the themes of who gets the vaccine first is critically important. There’s a pretty broad consensus that health care workers and first responders should be in that first group. But we can have discussions about who else should be vaccinated and in what order. And then last comment before I open it up is so much of this public health effort right now depends on making sure that trust and confidence in our public health system is at the highest level. That means, again, focusing on the science, empowering the top public health agencies, having excellent communication from the federal government and also state and local leaders, and making sure that’s all coordinated, making sure that our flu vaccination efforts, now, and our COVID vaccinations in the future, are well coordinated. I’ve mentioned that already. And then keeping a global view on all this so that we can move forward as a worldwide community to get beyond this pandemic. So those are some opening thoughts for everybody. And we’ll stop here and be happy to take any questions.

MODERATOR: Thank you, Dr. Koh. All right. Looks like first question.

Q: Hi, thanks for doing the call. So the question about the Eli Lilly drug, you mentioned it a little bit, but I want to get your thoughts on how impactful it will be in terms of the trajectory of the pandemic, and also what that debate about who gets the limited supply will look like. Are we talking about vulnerable people who maybe have symptoms but not a severe illness yet? Thanks.

HOWARD KOH: Yeah, that’s a very important question. So we’re going to have to do some work to decide how to take a relatively small number of doses and maximize its public health impact. Again, the company stresses that the goal is to treat non hospitalized patients with mild and moderate COVID. The studies that have been performed so far, preliminarily show that it can reduce chances of hospitalizations for those with relatively early disease. So when you stop and think about the numbers, I mean, right now we’re having over 100,000 people a day diagnosed and the projections of how many doses will be available from the outset are well under a million from what I’ve seen. Maybe you’ve seen other numbers. So you can just see that if we’re not careful, those doses could be used in a matter of days. So it’s going to be used with the best public health impact. But my guess is there’s going to be a discussion now with FDA and the professional groups about how to direct this to the first priority groups. Almost undoubtedly, health care workers and first responders should be in line first.

Q: Thank you.

MODERATOR: Next question.

Q: Hello, I hope you can hear me. I have a question in regard to this new vaccine that you mentioned, Pfizer. I read a study that antibodies are good about five months. So what would be the system? So if this vaccine is 90 percent successful if it’s distributed, so do we need to take this vaccine like every five months or every, I don’t know, like three months? What would be the system?

HOWARD KOH: That’s a great question and I can answer that in so many ways. So what we know so far is very encouraging, but very preliminary. We need the study to be completed and then fully analyzed and then authorized by FDA before we can start talking about other dimensions. We also need to know more about the safety profile that has not been well defined because we need to follow all persons who have received this vaccine for at least two months after the second dose. And then getting to your point, we don’t know for those who are immune from vaccination how long the immunity lasts. We don’t have any information on that yet. Here we have flu vaccine efforts. Everybody needs a vaccine every year. But then there are other vaccines where you may need a vaccine much less frequently. So the length and duration of immunity is unknown yet. And while I’m at it, we don’t really even know who can benefit from the effective vaccine results that have been demonstrated so far. Is it just as effective in older people as it is younger people? Is it just as effective in people of color as it is for other populations? All those dimensions have to be explored more carefully right now.

Q: And how is it going to be distributed in a perfect world? What is the population percentage that needs to be vaccinated in order to be able to get over this pandemic worldwide?

HOWARD KOH: OK, again, many parts of that question to be answered. If you take a step back. I mean, there’s a general consensus that to achieve what’s been called herd immunity, we need about 70 percent of the population to achieve that level, either through vaccination or through exposure to the virus and having recovered from it. We know that there are still relatively few people from a broad perspective, that have gotten COVID so far. So to get the majority of Americans to receive this vaccine will be a major lift. Let me just put this in perspective. Last year for flu vaccine, American adults had an uptake rate of about 45 percent. So we’d have to go much higher than that for a COVID vaccine, complicating this research further, this is a two dose vaccine that’s being produced by Pfizer, messenger RNA based. And it also has some of the challenges of ultra-cold storage that you’ve been hearing about. So that complicates some of the issues with distribution and dissemination for all these reasons. This is why we need the strongest public health infrastructure possible at the federal, state and local level, all working together. And regarding COVID vaccine distribution, this is where the involvement of the Department of Defense in Operation Warp Speed will be very important because we’re relying on them to make the distribution and dissemination process even more efficient than it is in a usual flu season. So we’ve got to watch all those dimensions very carefully.

Q: And my last question is, is it going to be free? Like how you see it? Or is Pfizer going to make a lot of money selling this vaccine?

HOWARD KOH: So if you watch the news as part of Operation Warp Speed, the United States government invested in a number of pharmaceutical companies to make their vaccine so that they wouldn’t have to take the financial risk. For Pfizer, that money was not invested in them up front. But there was an agreement that if a promising vaccine candidate was put forward, that the United States would invest almost 2 billion dollars to buy 100 million doses at least. So all that’s going to transpire. I know the American public expects this to be low or no cost and we need to maximize distribution. Otherwise we’ll never get this pandemic behind us. So this is again where coordination from our federal leaders, another stimulus package from Congress to make sure that these efforts are funded and the infrastructure is strong now, making sure that the vaccine is free to everybody and reaches the right people. And we also address the terrible disparities of this pandemic that we’ve documented and seen so far. So those are some of the many things we’ve got to look at closely as a potential vaccine moves forward.

Q: Thank you so much.

HOWARD KOH: Thank you.

MODERATOR: Next question.

Q: Hi, Dr. Koh. And thank you for the time today. I want to ask, what should families be doing and planning for Thanksgiving right now, especially in cold weather states or areas where eating outside is just unrealistic? We’re talking about an extended meal of eating and drinking, which makes masking an unrealistic solution. Should families have and plan for Thanksgiving? Should they try to seek preemptive testing for going home? What’s the protocol?

HOWARD KOH: OK, so in terms of public health, this is an opportunity, despite the major challenge, it’s an opportunity for every family to have an explicit conversation about risk and benefit, starting with who is at risk for a family gathering, particularly relatives of older age and people with preexisting conditions. Then, keeping the number of people who are together on Thanksgiving Day at the absolute lowest number of possible. I mean, this cannot be Thanksgiving, as usual. We want people to enjoy Thanksgiving, but it’s got to be a completely different and safe way if there’s going to be very important conversations about having friends and relatives come from outside the community. And if they do, are they willing to quarantine and get tested before their arrival and after they leave and rejoined their community? As you noted, if this could be held outdoors in places with warm weather, that’d be great. Can we ventilate the setting as much as possible and then keep people distanced as much as possible? So if you add it all up, it’s trying to keep the numbers as low as possible, keep the risk as low as possible, and just accept the fact that this is just not going to be a normal Thanksgiving. But something that if we plan explicitly now, we can enjoy and get through and look for a healthy holiday going forward.

Q: Thank you for that. And to follow up on that, what should governments be doing as far as Thanksgiving, should they be guaranteeing testing? Is it realistic for governments to guarantee testing for people before they come home? And what should the messaging be? Should they be saying don’t do Thanksgiving or should they be saying, here’s how to reduce risk?

HOWARD KOH: I think this is, again, an opportunity where every family can say, OK, this is what public health is all about. It’s about protecting our loved ones. It’s about enjoying a holiday and enjoying the gift of health and life but doing it in the most responsible way. In terms of what government should do, I know that in my state of Massachusetts, the governor has announced that the recommendation is no more than 10 people together in any indoor setting for any reason, whether it’s Thanksgiving or otherwise. I know that every governor is putting out similar guidelines and the numbers may change somewhat, but the theme is trying to keep those numbers as low as possible. And then your other point is trying to make sure that testing is available to anybody who needs it. And making that a timely effort is hugely important. We now have over a million tested in the United States and a total of about 150 million. But even from the beginning, we have just not been able to keep up with demand. And so I’m hoping that the new task force that the president elect has convened can look at the systems issue for testing and make sure that both the PCR testing and the rapid testing capability can work better together, so the end result is that people can get a test quickly and reliably and in a timely manner.

MODERATOR: Are you all set?

Q: Yes, thank you, Dr. Koh.

MODERATOR: Next question.

Q: Hi, thanks so much for taking my questions. I was wondering if you could talk a little bit about nursing homes, do you think that we’ve learned anything or that this wave that we’re heading into now is going to be any better for people in nursing homes?

HOWARD KOH: Hi, can you say that again? I couldn’t hear you too well.

Q: I’m sorry, I’m having Internet issues. I’m wondering about nursing homes, and whether we’ve learned anything since the spring. Are things going to be better at nursing homes over the next couple of months as the pandemic spreads or are older people still going to be the victims of this, and the most vulnerable to this virus?

HOWARD KOH: Well, we’ve learned some very tragic lessons about the risks for older, vulnerable people and the particular risk in nursing homes, that the something like 40 percent of all COVID deaths nationwide are linked to nursing homes and long term care. Here in New England, that number is well over 50 percent. Last time I looked, New Hampshire had 75 percent of their deaths due to nursing homes. So we have recognized from the very beginning that this is the highest of high risk sites. So there have been efforts to maximize infection control to make sure that people in nursing homes and long-term care are cared for and in a way that minimizes risk. There have been efforts by the federal government to increase testing in nursing homes for staff and residents. There are some challenges with the rapid testing that have been documented over recent months, but those efforts have got to continue. What we’re facing for nursing homes is trying to build a system for testing and tracing and infection control that had really not been evident before COVID hit. And so it’s going to take even more efforts. I’m hoping we can accelerate the initial efforts that have been done under the current administration going forward, because these are some of our most vulnerable, beloved members of our society. And this is where a disproportionate impact has been extraordinary, as we’ve all unfortunately witnessed.

MODERATOR: Did you have a follow up?

Q: Only if you know anything about the PPE situation, are we going to be in any better shape if the government policies improve the situation at all? Or particularly for nursing homes?

HOWARD KOH: OK, that’s a great, very important question. And it’s so timely because, again, flu season is here. Our hospital frontline workers are already overwhelmed in so many parts of the country. And once flu starts to really make an impact, it could compound the stress on health care workers. So we need to make sure that PPE shortages are not the issue that they were a number of months ago. This is where the transition will be really important to make sure that the outgoing and incoming administrations have an understanding of where we are with the PPE supplies and whether they can meet demand and also be ramped up as part of what we call surge capacity. The other theme that the president elect has talked about through his campaign was that he says that he is more willing to leverage the Defense Production Act for PPE production if needed. So I’m sure that issue is before the new task force front and center. So we have to follow that very important theme very, very carefully. We cannot allow these heroic frontline workers to be putting themselves at even more risk because the PPE supply is not there for them.

Q: Thank you very much.

MODERATOR: Great. Next question.

Q: Hi there. Can you hear me?

MODERATOR: Yes, we can.

Q: OK, sorry. There may be an echo here. I wanted to ask about the hospital staffing situation because I’m hearing that it doesn’t really matter if you increase the beds, if you don’t have the staffing to manage those patients. And that’s the situation facing many hospitals right now. So some of them are contracting out with the Public Health Service or HHS, but it’s very short term. So I wonder if you can address that and what a Biden transition team might be able to do to help the staffing situation.

HOWARD KOH: Yeah, so that’s an, unfortunately, a very important and very timely question, so let’s make this really concrete. We’re seeing parts of the country, particularly Wisconsin and Texas and Utah, where surge capacity needs are paramount in those states. Field hospitals have been erected and efforts to increase bed capacity, but exactly as he pointed out, just because you have more beds in a field hospital doesn’t mean you’re going to have more staff and health care professionals to take care of patients in those beds. So this is where the surge capacity and planning statewide and nationwide is very important. I would like to think that communication is better now than it was in the earlier parts of the pandemic. But again, if you look back, we have not had the national coordination about bed shortages and personnel shortages that we need to get us through this pandemic as one nation. We’ve had each state left to figure this out by themselves. And it’s led to some very tough situations where states were sometimes competing against each other for personnel and supplies and resources. So this is, again, where I’m hoping the president elect’s efforts with his new task force can help maximize national coordination, make sure that data on shortages are available so that if there are more personnel needed in one part of the country versus another, that could be addressed as a nation. Certainly, making sure that every state is doing this in a timely way, particularly during this flu season. This is where this coordination and communication team is hugely important. By the way, maybe I can say a little bit more on the communication theme. I am envisioning that, well, we’ve already seen the president elect make a couple statements about a need for planning on COVID and speaking directly to the American people on themes like the need for masks, the more direct communication the president elect does to the American public, sending a consistent message that the better off we’re going to be as a country getting through this pandemic. But the response so far has been marred by mixed messages that sowed so much confusion. And I think the new administration has a chance to right the ship, by sending out clear, consistent messages from the White House, from our top scientists and public health officials, and so that the American people feel like that we’re doing this together as one nation.

Q: If I can ask just a quick follow up, do you think he’s already started on that?

HOWARD KOH: Absolutely. The fact that he was declared the winner on Saturday and on Monday already announced this task force has made several announcements about the importance of tackling the pandemic in a scientific way, with top notch scientists appointed and the commitment to a plan based on science. Those are all themes that we’ve all needed to hear for a long time. So having said that, we are, again, in a very difficult part of the pandemic response. If you look at all the curves and numbers and figures, this is going to be an enormous lift going forward. But if we coordinate our efforts to maximize prevention and public health now, have the vaccine coming sooner rather than later, and distribute that in a timely and informed way, that it’s the highest priority groups first and the highest need populations first, this is my hope that we can get this pandemic behind us and move back to some hint of normalcy sometime next year.

Q: Thank you.

MODERATOR: Next question.

Q: Hi, Dr. Koh, thank you so much for your time and for visiting with us today. I’m just following up. You were talking about the mixed messaging and the hospital crisis, and that’s certainly something we have seen here in Oklahoma as well. We’ve got record hospitalizations. We doubled our case numbers over the weekend. We had more new cases on Saturday than the state of Florida had, which is extremely alarming. We still don’t have a statewide mask mandate. Yesterday, the state epidemiologist told me that it’s a political decision about a statewide mandate. He’s leading our state’s pandemic response, so in terms of this mixed messaging, how harmful is that as we continue to see cases to skyrocket and our deaths are continuing to go up at alarming rates?

HOWARD KOH: So thanks for the question and I’m sorry to hear about those trends in your state. I had the pleasure of visiting Oklahoma a number of times when I was assistant secretary and was always impressed by the passion of the public health leaders there, so I have very fond memories of those visits. This is a time where we absolutely have to maximize the power of prevention while we wait for a vaccine and cure and we know how to prevent and contain this virus as much as possible. Other countries around the world have done this. Look at places in Asia, in Australia and New Zealand and South Korea and Taiwan, where they’ve been able to contain the virus and keep the numbers low. In Europe, many of those countries were able to do that, too, although unfortunately now they’re in the second wave. So back to your question front and center through this is the universal use of masks. Again, countries in Asia have made this long ago the new social norm, the new public health norm, because they have found it to be effective to save lives. So I am hoping your state can follow as well as another 15 or so states that do not have a mandate yet and say this is just part of a new public health norm that allows you to actually regain your freedom, to interact with your loved ones, to enjoy the gift of health, to make your business and school get back on track and help you to engage in society. I know some people object to this as an impingement on their freedom, but I think it boosts their freedom. And we in public health often point out that, when you get in your car, you put on your seatbelt. That’s what everybody does to improve and contribute to public safety and public health. And then when you drive, you know, stopping at stop signs or red lights is just part of the new normal in the normal terms, again, contrary to public safety and public health. So I’m hoping consistent messages like that can help in places like your state and others.

MODERATOR: Do you have a follow up?

Q: Yeah, Doctor, thank you. That is extremely helpful. And to Christine’s point as well, we are seeing the hospital crisis here as well, and our health care workers have told us really just heroic but also exhausting stories. As you mentioned, they are weary right now. We have no ICU beds left in Tulsa. As of last night, there have not been ICU beds in Oklahoma City. But seemingly, we still have a different message that there isn’t a crisis because of exactly what Karen mentioned, that we are being told by some, not by any hospital leaders, however, state leadership saying that we don’t have a hospital bed crisis because there are still beds. However, city and county leaders and every hospital CEO will tell you that none of those beds are staffed. So what do you make of that? Just a message that it truly seems like the Twilight Zone. I mean, why would we be saying one thing that’s not factual?

HOWARD KOH: You know, as a physician who has cared for patients for decades, one lesson I learned was when a loved one dies, that’s a tragedy. But when a loved one dies and you know, that death could have been prevented, that’s a tragedy that haunts you forever. And we unfortunately don’t think much about our health until it is forfeited or lost. I, as a physician, know so well that our good health is a gift and we got to protect that gift every day in places like Oklahoma. I don’t know if this helps you, but I’m sure people there, like everywhere in the country, just assume that if they get sick, they can go to a hospital in a timely way and get care and treatment they need and deserve. But our concern right now with the health care system so overwhelmed, is that we can’t make that assumption any more in too many parts of the country. But on the other hand, we know how to turn the faucet off, which is just maximize the power of prevention where we are and make that the new social norm until a vaccine or a cure comes along. So that’s what we’re trying to do as one country, and we need that consistent messaging to get that strategy going forward.

MODERATOR: Are you all set?

Q: Yes, thank you so much, Doctor, I greatly appreciate. I’m sorry to have to be so specific about Oklahoma, but unfortunately, we’re not getting any clear message. So I appreciate your willingness to speak about it specifically.

HOWARD KOH: I’m glad you asked. Maybe one more thing I can say is, you know, I’ve had the privilege of serving as a state health commissioner and as assistant secretary on the federal level, as I mentioned. So through my years of service in government, I have served as a public health official for multiple Republican governors and a Democratic president. So I have never viewed public health as a partisan issue, especially in a time like this, the worst health crisis that we’ve had in a century. This is a time where we have to rally around and say we are one country, but we have to follow the science, follow the evidence, maximize prevention, don’t take our health for granted, and do that in a way that includes everybody and not make this a partisan effort. So I think those themes apply to what you’ve been commenting on, Tiffany, and will certainly apply to any COVID vaccine that’s going to be coming down in the future.

Q: Again, thank you so much. I greatly appreciate it, Dr. Koh.

HOWARD KOH: Thank you.

MODERATOR: Next question.

Q: Hi. Thank you very much for coming. I’ve got a couple of questions. First, on the vaccine, is there anything that older Americans should be doing to prepare? I mean, should we be starting to scout out places where that would have a vaccine? Do we call our health departments? Are lists out there?

HOWARD KOH: So thank you for that good question. One thing I mentioned, but I will repeat, is when you stop and think about it, getting lifesaving vaccines is something that we do day in and day out in our country, and it’s become part of the public health norm with seasonal flu vaccination being the prime example. So if we just think about what it takes to get flu vaccine and try to build on that for a COVID vaccination effort, that would be a really strong and coordinated outcome for our country going forward. For any senior who is getting their flu vaccine at their doctor’s office or at their pharmacy or at their workplace, they should start asking, OK, are you now prepared to build on the flu vaccination efforts to help me and my family get access to a vaccine once it’s authorized or approved? That conversation should start now. And this is also where the involvement of medical professionals is absolutely critical because in a time of trust and confidence being jeopardized, people still have the highest trust and confidence in their doctors and health care providers, so that conversation should probably start with your health care providers and also with wherever you’re getting your flu vaccine right now. And hopefully, if we build upon that, we can make all of our public health efforts very successful.

Q: And Dr. Koh, you mentioned earlier about the safety concerns and about the safety of the drugs, especially in older people, do we know how many of the participants in the trials have been older? I thought it was really not like the larger subset.

HOWARD KOH: That’s a great question. So let me just stress here. This is an unfortunate part of scientific communication during COVID. The Pfizer announcement came through a news release, a press release. I don’t think any of us have seen any studies or raw data. And so your question is an excellent one, we don’t know the age distribution of those who have been vaccinated yet. We don’t know its relative efficacy in various age groups, particularly those who are older. We need to see those results as soon as possible in a transparent way. We need independent expert advisory groups to look at that data and weigh in. And that’s the process by which FDA will make their decision, hopefully sooner rather than later. So your question is a good one about safety, efficacy in certain populations, particularly older ones, and making sure that this is based on science and not on communications where we have not seen the raw data to date is the time to ask something else.

Q: Just a quick question. As you know, the hospital beds are getting filled up with COVID patients. There was a problem early on in the pandemic where people with heart attacks and who need cancer surgery, et cetera, didn’t get treated. Do we have any solutions for that now? I mean, can we send those patients to an ambulatory care place? What are hospitals doing? Even in Oklahoma, if the ICU beds are filled, you know, what about patients and cardiac arrest and stroke?

HOWARD KOH: I am so glad you asked that. That is a hugely important question. So there are now a number of studies from the CDC and also from Virginia Commonwealth University that’s been published in JAMA showing that of the excess mortality we are seeing this year, two thirds are directly due to COVID. That’s not surprising. But a third appears to be indirectly related because of exactly what you said. People with heart attacks and strokes are presenting late to their doctors or not at all.

Q: I’m sorry. Excuse me. The numbers that you just cited is that coming from a CDC study?

HOWARD KOH: There was a CDC study on excess mortality and also there was a study by Dr. Steve Wolf from Virginia Commonwealth University that came out in JAMA about a month ago saying exactly what you pointed out, that people are delaying other care or avoiding hospitals where they’re having illnesses like heart attacks and strokes, and that’s also contributing to excess mortality. And as one who has spent his life committed to prevention, I’m really concerned that the lifesaving screening, like colorectal cancer screening and colonoscopy, are being overlooked at a time like this. So this is why, again, we need a system wide approach. We need support for our doctors and hospitals and health care systems. We need more funding from Congress to address this. We need to build up the public health system, and while I’m at it, I know Vice President elect Biden has proposed that a US public health job core be created, starting with the contact tracers there, but then about 50,000 of those hired across the country. But we need much more. This is all part of rebuilding and revitalizing our public health system.

Q: Thank you very much for your patience with my question.

HOWARD KOH: Thank you for your question.

MODERATOR: Next question.

Q: Doctor, I ask this on the topic of rising hospital rated. In Ohio, it’s been more of a slow burn than elsewhere in the Midwest, but there’s a clear and marked increase in hospitalization rates. The state government here is kind of sounding the alarm on this and raising concern about some of the staffing issues you mentioned. But the messaging isn’t changing. We’re still saying wear masks and distance. I think it’s time to change up or retarget or refocus its messaging or change policy in some way because it seems like the messaging isn’t changing and also isn’t working. It hasn’t been working. I don’t know how you square those.

HOWARD KOH: That’s a great question. This is so tough. I feel, for example, that the more we humanize the messaging, the more effective the message can become, the more we have. People who have been affected, who have lost their loved ones, come forward and share their stories, that the more effective the messaging can be, the more we have beloved national figure like Tom Hanks. Remember when he came forward, when he was diagnosed this summer? The more we have leaders like Governor Christie of New Jersey who, you know, after he was hospitalized and came out of the ICU, he said, I made a mistake. I didn’t wear my mask. I didn’t pay enough attention to this. Don’t do what I did. So I think the more we humanize them, the message and the messenger, the more effective it might be. We just have to keep being creative at reaching people, because you’re right, people can get fatigued by this, but we can’t give up because there’s no group more fatigued than our front-line health care workers who are trying to save lives. The more we do, the more we can help them and then help our whole society get through this.

MODERATOR: Do you have a follow up?

Q: Nope, that does it. Thank you.

MODERATOR: Next question.

Q: Hi, doctor, thank you so much for being here. I apologize if you answered this question earlier on the call. I was a bit late with my Eastern Time occasionally, but I apologize. So I have a couple of questions about the vaccine. How effective does the vaccine have to be to be approved? I know Pfizer put out the PR thing yesterday that’s 90 percent. But from your end, how effective does it need to be?

HOWARD KOH: So the FDA put out a set of criteria saying that it had to be at least 50 percent effective, so that was the bar that was put forward to these companies as these trials began. So to have preliminary results that the number for the Pfizer vaccine candidate is 90 percent is a very, very good news. And it also encourages all of us because this is a so-called mRNA virus or this MRN strategy has not been used before. And at least another company, Moderna, that has the same strategy. So we’re waiting for their results. So the preliminary results so far exceed the criteria put forward by the FDA, but the important caveat is we need all the data to come in. We have to look at all the data ourselves and through the eyes of independent expert advisory committees and then make sure the FDA makes their decision based on the best science and also the best safety profile that we still haven’t heard much about yet, either.

Q: To follow up, what is the safety profile? And when we talk about vaccine efficacy and I would say 50 percent to 90 percent, what does that actually mean? Like, if I were to get a vaccine and it’s 50 percent effective, what does that look like?

HOWARD KOH: That’s a great question. So we want people to be much less likely to be sick and suffer complications and die from COVID if they’re vaccinated, as opposed to those who are not. But again, until we break down the data, we don’t know if the 90 percent or 90 percent fewer people who are hospitalized, 90 percent with less severe disease. I’d be surprised if they had death data yet, so that 90 percent could be interpreted in many ways until we have more information. Ideally, what we want, of course, is a highly effective vaccine that helps prevent severe complications and death. That would be the best outcome. So we need more data and more exploration there.

Q: So what will the vaccine be able to do, the COVID vaccine. Are we hoping for obviously death prevention or kind of do we want it to go further than that?

HOWARD KOH: We will hopefully get a vaccine or vaccines, by the way, we could have multiple when this is all over, which would be the best outcome possible that prevent transmission, that prevent hospitalization and prevent death. But we’re not going to know until we have the final results and get them from all the candidates that are going through Phase three trials right now because there are five total and Pfizer is the first one that’s come forward with any sort of preliminary information.

Q: Well, so what do we want the vaccines to do or to be able to do? What’s the hope?

HOWARD KOH: The hope would be that in the best-case scenario, it prevents death, it prevents serious complications, it prevents hospitalizations, it prevents illness. That’s the whole point. But as you are pointing out, we don’t know which of those outcomes have been prevented with the 90 percent figure that’s been communicated so far.

Q: Is the vaccine the panacea? Is it the silver bullet that’s going to make all of this go away?

HOWARD KOH: No, and I was ready for that question. So here’s one thing we do not want. We don’t want FDA to authorize or approve of vaccine, and everyone says, OK, we can just go back to normal and drop all the use of masks and social distancing and the hand hygiene, avoiding large crowds. And we have to do this all together as a unified strategy until we can say that we have gotten this pandemic behind us. I think making sure that everybody understands that we got that broad strategy of prevention, of vaccination and then looking for better treatments and cures, doing that all together as one nation in coordinating our efforts coast to coast, that’s the strategy we have to pursue going forward.

Q: Does it also mean we have to include the rest of the world? Because we’re not on an island?

HOWARD KOH: Absolutely. And I think I pointed out in my opening minutes the fact that President elect Biden said that he did not want to withdraw from WHO, that he wanted to reengage with WHO, there was a global vaccine effort called COVAX that involves now over 150 countries. The current administration announced that they would not participate in any of those global efforts. President elect Biden has announced that he wants to reengage. If we focus only on the US and do not consider the rest of the world, all we’re going to do is reassure the disease keeps recurring here over and over again. So that’s not the way to do it from an informed public health point of view, we need to do this as a global community, and that’s where our last COVAX effort, which is trying to get some two billion doses available to the world by the end of next year is a hugely critical effort for all of us to participate in and follow closely.

Q: One last question, sir. You’ve been very generous, thank you. If the vaccine is not available for children and that’s what we’ve been hearing so far and they are carriers, we also know. What does that mean for the spread and the severity of COVID in the United States?

HOWARD KOH: OK, so ideally, we want children and adults covered. Again, Pfizer has some children in their mix of subjects, but we don’t know exactly how many and we don’t know how many are involved in this first analysis from the priority groups that have been put forward by the National Academy of Medicine and others that children have been put in the second or third tier. And I think that’s appropriate because we really need to focus on health care workers and first responders as the highest priority. But ideally, we will have enough vaccine sooner rather than later to cover kids as well as adults. We know that children can be influenza carriers. They unfortunately can have complications and die from this. We also know that their risks are somewhat lower than for adults, particularly older adults. So weighing all those dimensions together and having a unified approach, going through priority groups once the vaccine is available is the strategy we need to pursue for.

Q: You said tiers, what does that mean, like multiple tiers?

HOWARD KOH: OK, so there have been a couple groups that have proposed priority. Priorities with respect to vaccination. They call them tiers or phases, depending on which group you’re looking at. There have been three or four phases proposed. Phase one, everybody says health care workers and first responders should be in that group. Also, older adults, phase two could potentially involve essential workers. Phase three could be kids and other adults and schoolteachers in phase four or tier four could be everybody else. Those are very rough categories and they differ according to the groups who are weighing in on this. And also, by the way, every state, I believe, now has their own party groups in tiers. So this is all where the coordination with CDC and FDA and HHS going forward is really important. So that from a national point of view, people can get the vaccine they need and deserve, and we can keep suffering at the lowest level.

Q: I deeply appreciate your time, sir, thank you.

HOWARD KOH: Thank you.

MODERATOR: Thank you, Dr. Koh. I think that’s the last question we have for today. Do you have any closing comments?

HOWARD KOH: First of all, thank you all for your interest, unbelievably important question. This is an incredible time for our country. You know, we need a unified effort to get through this. But when we can say that we are through it and that we have put this pandemic behind us, we have to commit to never allowing this to happen again, and the only way to honor that commitment is to invest in public health substantially in the resources and the personnel and the infrastructure. This is why I’m very proud to be at a university in a school where we are trying to promote the importance in honor of this profession, because it’s been traditionally under-resourced and overlooked and that, unfortunately, has contributed to so much of the suffering that we’re seeing right now. We just cannot allow this to happen again. So I’m hoping that commitment to revitalize and rebuild public health going forward will come from all of us here and millions of others in this country and around the world.

This concludes the November 10th press conference.

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