You’re listening to a press conference from the Harvard School of Public Health with Yonatan Grad, the Melvin J. and Geraldine L. Glimcher assistant professor of immunology and infectious diseases and a faculty member in the Center for Communicable Disease Dynamics. This call was recorded at 10 a.m. Eastern Time on Thursday, December 10th.
MODERATOR: Dr. Grad, do you have any opening remarks?
YONATAN GRAD: Thank you so much, Nicole, as always, for the introduction, for moderating and for organizing this. So what I thought I would talk about today is some of the work we’ve done along two different projects, or one is work that emerged from collaborative efforts with the NBA. It’s really been a fantastic opportunity to collaborate with a number of other people who have been advisers to the NBA and with the NBA itself in using the data that they’ve generated from the 2019- 2020 season restart both leading up to the bubble and including the bubble.
So with the testing that they were doing, it was really a pretty incredible cohort of longitudinal prospective testing using PCR. So we actually had quantitative data and we were able to, from these data, put together the first description of the full viral trajectories over the course of infection. So really monitoring as people went from being negative to being positive following the PCR results. We’re using the cycle thresholds, which are basically a reflection of how much virus is present and modeling what those viral trajectories looks like. And that’s information that can be used for a variety of different purposes. And in that preprint, we not only characterize those trajectories, but look into a few of the different ways in which those data can be used, from improving diagnostics to considerations for public health. And I’m happy to talk about those in more detail too.
And then the second project that I think also pertinent in these times is thinking about vaccine prioritization. This was work that was led by Kate Bubar and Daniel Larremore, graduate student with Dan at the University of Colorado at Boulder and close collaborators. And this is a project that involved several other close collaborators, Marc Lipsitch at the School of Public Health and Stephen Kissler, who is a post-doc with me, and Sarah Cobey at the University of Chicago. And this was an effort to try to understand what is the impact of different vaccine prioritization strategies considering age as the basis for those strategies? How do we minimize mortality? How do we minimize cases? And perhaps the one liner, the general conclusion, as we considered a range of different situations to try to understand the impact of different vaccine strategies, is that under most of them targeting those at highest risk for mortality, in this case the over 60 age group with the first round of vaccination, so when vaccine availability is limited, was the most effective in reducing mortality. And I think that’s pretty consistent with what we’re seeing in the recommendations both from COVAX and the National Academy and what we’re now seeing as reported for state strategies like that from Massachusetts. So with those introductory remarks, I’m happy to open it up for questions.
MODERATOR: Thank you, Dr. Grad. All right looks like first question.
Q: Thank you for making time this morning, so I want to talk about the NBA bubble. You know, you kind of mentioned somewhat the lessons we learned from it, so if you could just be a little more explicit in that. But also, I’ve heard that there are a lot of families that want to replicate that, to see each other for the upcoming holiday. So any ideas that you have on how they can safely do that when they would need to start things to keep in mind stuff like that would be great.
YONATAN GRAD: Sure, so there’s a lot to say and a lot that can be learned from the NBA restart effort, the manuscript that I was referring to earlier, specifically was really looking at the impact of regular repeat testing. And the information that we gleaned from it, which had to do with understanding what happens with the amount of virus over the course of infection and what we can learn from those trajectories. So as you might expect, once you get infected, the amount of virus will start to increase. There’s a proliferation phase, and then as your immune system starts to control the viral infection, it will peak and then decline. And there’s a clearance phase as your body fights off the virus and you get better. So what has been unclear prior to these kinds of data was just an understanding of what it is that the tempo with which we see this increase. Almost all of the data that we had previously was really from the time of diagnosis, often from people who are asymptomatic onward. So that’s usually at or after the peak in the virus. And really what we were describing beforehand or what was available in the literature was just the clearance phase. So we really didn’t have much information on the timing or the tempo of this proliferation phase. With the data from the longitudinal perspective cohort from the NBA testing, we could start to now describe what this proliferation phase actually looks like. And those data are really important for all sorts of decision making, both clinically and from a public health perspective. For example, one of the strategies that has been advocated very strongly by a colleague of mine here at the School of Public Health, Michael Mina, is this idea of regular repeat rapid turnaround testing, using antigen tests or other tests that can be inexpensive.
And that strategy in some ways was contingent on what this trajectory looked like from the proliferation phase and the clearance phase. And in work that recently was published in science advances led by Dan Larremore and with Mike Mina and Roy Parker as senior authors, they assumed a particular trajectory, which, as it turns out, was very, very similar to what we saw empirically in this cohort. So it really helped to substantiate that approach. Another relevant to, I think, the second question, another lesson that we can learn from this is with the effective sensitivity of testing is when you are testing prior to an event. So let’s say that you want to have a game or a religious service or a collection of people come together and you want to test them two days or three days or four days before they actually arrive for that event. Well, the test you’re using may have high sensitivity for that day, meaning that when you’re tested, if you’re positive, you’re positive or negative, you can believe that you’re negative, at least for that day. But what happens when the event actually is delayed by one or more days from the time of testing? Well, in that case, a test tells you about where you are right then, but it doesn’t tell you about could you have been infected the day before and then turn positive in a couple of days? You can’t predict that just from the day of test. And so what we could do using the trajectory data is start to actually tell you what your effective sensitivity would decline to on the basis of the timing relative to the actual event. And in the chat, Nicole had put a link to a website where we basically developed an app where people can put in the numbers and determine for themselves what the relative sensitivity is and therefore what the risk would be for an event. So the strategies for the bubble itself included several. So it was not only regular testing, which was a key facet to it, but also there was testing before you arrived. There was a quarantine period before you were allowed to engage in the bubble. And then there’s masking and distancing also as key parts of the bubble.
I think there are themes that people can strive to replicate for themselves, and those include quarantining and testing as ways to try to be as confident as possible that you are not infected and to minimize risk to others. Continuing with masking, social distancing as one can when there is possibility or concern that you might be infected while waiting for your results. And then interacting with one another when possible in well ventilated spaces. So a lot of the lessons that I think are now well known and have been advocated by public health agencies at the local and national level, I think all of those are really key to being safe even within our own families as we’re starting to if people choose together and of course, I would say that right now, with the rampant spread of COVID-19 around the country, people should really think hard about travel and if possible, avoid it. I mean, just right now, we’re seeing such widespread transmission that the safest option, of course, is to stay where you are and try to figure out when in the hopefully in the near future you can safely return to gather with family and other loved ones.
Q: Thank you very much.
YONATAN GRAD: You’re welcome.
MODERATOR: Next question.
Q: Hi, thanks. I just got kind of a general question, which was, you know, in the short term before a vaccine is widely available, given that we have such high spread of the virus everywhere, if you were a governor or president or a position in the government, what would you be doing in the short term? I mean, since it’s so prevalent, I mean, people obviously testing and tracing, but is that really realistic at this point? Is it more up to just sort of blunt measures of would you be closing bars and closing indoor dining and maybe even more than that as a solution?
YONATAN GRAD: Yeah, so I think you’re totally right, in many places around the country, levels of spread need or warrant consideration of what types of mitigation efforts would be effective. Testing, I think is still a key part of that. I think tracing can contribute but is very hard to contribute much. And when you have such widespread activity, other activities or other mitigation efforts like masking, distancing, remain key. I do think that we need to consider where transmission is happening and to think about implementing more efforts to slow that spread, whether that means, as you’re saying, closing down indoor dining for the near future, especially in those places where we’re seeing not only the spread of the virus, but such rates of hospitalization and ICU bed occupancy, that it really is starting to really threaten the hospital health care infrastructure and our ability to provide optimal care. So I think in those places where it’s inescapable really to consider such measures and then people really need to balance. It’s an awful situation. You have to balance the economic challenges with the challenges to health. And these are not easy decisions for sure. But given the stress placed on the health care infrastructure and the need to try to slow down transmission, I think we have to really consider those kinds of interventions.
Q: Got it, thanks. If I can ask one unrelated question, I don’t want to take up too much time, but I don’t know if you’ve seen the Pfizer vaccine data, but I’ve seen some discussion that it appears there’s a lot of efficacy even after one dose, as opposed to getting both doses of the vaccine. I’ve seen some people saying, well, if we have a scarce supply, maybe we should just plan on giving people one dose for the time being, given that that helps to some extent. I wonder what you make of that idea.
YONATAN GRAD: Yeah, I think that the trial was done with two doses and I think that means we’re going to be stuck with two doses for now. The FDA, and we talked about this just before starting, the FDA approval meeting is going on right now. So we’ll see what they say. I don’t know that was intended to look at just what happens with one dose. It may be that one dose is having enough efficacy to warrant a single dose use, but I don’t think we can really confidently say that right now. I think it’s you know, with a two-dose vaccine, there’s always going to be a challenge in getting that second dose to everyone. And so there will be for sure a significant fraction of the population that gets vaccinated with only one dose. So we’ll have to really closely track what happens to those individuals. So, again, this is a vaccine that’s intended to have two doses and it will be approved as such. And then we’ll need more data to determine if a single dose is really going to be the way to go. But for right now, I think we’re stuck with two doses.
Q: Got it. Thanks.
MODERATOR: Next question.
Q: Thank you so much for doing this and taking the question, this is a pretty big question. So I guess can you sort of explain epidemiologically where things stand in the US right now, like what’s going on and what stands out to you? And specifically, I’m guessing a lot of what the data is capturing or is still not quite reflecting is what might have happened over Thanksgiving, like if someone contracted the virus two weeks ago, maybe those people are just now showing up in hospitals. So if you can just kind of give us the lay of the land, that’d be great. Thanks.
YONATAN GRAD: I think we are seeing the unfolding disaster. We’re seeing incredibly high rates of transmission, we’re seeing increasing hospitalization, we’re seeing increasing ICU bed occupancy and, in many places, where they are running up against the limits of the resources that they have available to care for people. So I think it’s challenging in the extreme right now and it’s going to get worse. I think that you’re right that the people who may have been infected over Thanksgiving, we will think there’s continued spike in cases. I think that part of that will be due to Thanksgiving and that will lead to more hospitalizations. And then a couple of weeks after that, more ICU bed occupancy and more deaths. So I think without interventions to try to limit spread, we’re going to see these numbers just continue to climb. People have talked about it; we’re facing a dark time coming up in the next month or so. And I think that’s totally right. It’s tragic and a really difficult situation coming across the country.
Q: Just sort of separately, I know the ultimate goal with vaccine is to get uptake of 70 percent plus or as many as you can get, basically. But I wonder if is there a point at which the percentage of immune protection in the population, whether from vaccine or natural infection, like you, might see a noticeable slowing of transmission before that point, even if you’re not getting to a full sort of herd protection?
YONATAN GRAD: Yes, so I think as more individuals become immune, rather, through natural infection, leading to recovery and immunity or immunity through vaccination, that will slow spread. And so what is one of the epidemiological terms that got a lot of play back at the beginning of the pandemic and I think has continued to other perhaps less so since is the basic reproductive number. So this is if you were to take in an infectious individual and put them into a room full of susceptible people, how many people would on average become infected? If the reproductive number is two, then an infectious individual would on average pass it on to two more people. But as the people in the room become immune, whether because of natural infection or vaccination, then the way you start calculating is not the basic reproductive number, but the effective reproductive number. So again, again, this is the average on average, the number of people infected by an infectious individual. If the infectious individual is just contacting people who are already immune, the number of infected people will go down. So the effective reproductive number will decline as the fraction of the population that’s immune increases. So, yes, we should expect to see a slowing, but that will depend on the extent of the role that the vaccine and also the extent of disease in the population. It’s a combination of those two. But, yes, we would start to see things slow.
Q: Thanks so much.
YONATAN GRAD: You’re welcome.
MODERATOR: Next question.
Q: Hey, thanks so much for taking my question. So we are following the vaccine rollout here in South Florida. We have a couple of hospitals who are anticipating getting the Pfizer vaccine any moment, really as early as tomorrow, and we’re following how that’s going to play out here in phase one among health care workers. There’s some debate about long term care residents. For instance, should a young and healthy health care worker who simply works in a hospital system not directly with COVID patients be prioritized before a long-term care resident or a high risk patient? These are the kind of questions that we’re still asking. We don’t have a lot of details on how that’s going to work. So I’m just curious if you could kind of weigh in on those decisions about prioritization and where you come down on how to grapple with that.
YONATAN GRAD: Yeah, these are questions that I know many have been working on across every state trying to come up with a vaccine prioritization policy. In Massachusetts, the policy was announced yesterday after a committee of a number of individuals representing all sorts of constituencies and expertise had to meet for some time to devise that strategy where they decided here. And I’m not familiar with the plan in Florida, so I’ll just speak to the one in Massachusetts was to include both health care workers and those in long term care facilities as the top priority. Now, there are arguments for both. First, the people who have been at high risk in terms of delivering care, those you can make an argument for vaccinating those individuals, the health care workers, both because of the risks that they have sustained for the duration of the pandemic, and also with the idea that by vaccinating those individuals, you improve their ability to continue to provide care. And that is going to be important for several reasons. So in some places in the country where we may not be limited by beds, we’re actually limited by the numbers of doctors, nurses and so on available. You want to try to maintain that population by protecting them against infection. They don’t have to stay out if infected in isolation or if contacted by individual, they don’t have to quarantine. Right. So it really helps to bolster the infrastructure of the health care system to sustain itself under the threat of the pandemic. There’s also that seeing health care workers take the vaccine, I think can be a very positive message to the rest of the public that this is a safe vaccine and help convince people who may be skeptical that this is something that they should do too. I’m sure you’ve seen numbers that a significant fraction of the country remains either unwilling or unlikely to get vaccinated.
Q: Can I stop you right there, because you raise a great point, because we had a story this morning about our public hospital system and they were surveyed last week and about half the hospital employees responded. And of those, half said they would take the vaccine in phase one. Thirty five percent said they would consider taking the vaccine at a later date and fifteen percent said they would not consider taking a vaccine. So you had about half saying they’re ready for it and the other half saying maybe later or not at all. Is that better or worse than you would expect? I mean, I spoke to another expert yesterday who said that there might be a misconception in there that health care workers are more likely to say yes than some other people. I mean, where do you come down on that question?
YONATAN GRAD: It’s hard for me to say without looking at what fraction of them are likely to take it. But I think on the whole, I would guess that people, health care workers are more likely than the general public because of familiarity with vaccines and with vaccine safety to be willing to be vaccinated. But I’m not familiar with the survey that you described, so it’s hard for me to comment on that specifically. Tony Fauci has said he’ll be first in line and that he would have his family vaccinated. And I think statements like those from public officials, from leaders, from health care, from people in the health care industry, that will be, I think, quite valuable in both showing safety and confidence in the vaccine and encouraging uptake. I mean, it goes back to people have been talking about this vaccine efforts with polio and the importance of having Elvis Presley get vaccinated on TV. So just convincing many people who may be skeptical or concerned that this is, in fact, not only important to do, but safe. The health care worker side in terms of people in long term care facilities, work that we’ve done, and many others have done, really suggest that the benefits of a vaccine for those at highest risk are huge and that having those individuals in if you really want to reduce deaths from COVID-19, they’ve targeting those at highest risk of dying from infection is the way to go. When you have a limited vaccine supply, as we will have for the next couple of months, targeting those at highest risk is critical. So by combining the two and doing both health care workers and those at highest risk, I think you can achieve you have to balance these goals. I think you can really work towards both of them.
Q: Can I just ask one quick follow up I don’t want to take up too much more time, but just on that note you just mentioned, that was kind of what I was getting at. The way I understand it, it would be the whole health care system who has access to the vaccine. So someone who might not have as high a risk of working directly with the patient and someone who might be young and healthy. Now, I understand long term care facility residents would be part of phase one as well. But what we understand is the next phase would be high risk patients within the health care system. So someone who they have in the medical records, as you know, of an older age, maybe has hypertension, maybe as other underlying conditions. I guess the question I’ve been seeing is whether those high-risk individuals should be given a shot at the vaccine before someone who is young and healthy and may work in, like the physical therapy department or something like that in the hospital. And it’s our understanding that the latter would actually get a shot of the vaccine first rather than the high-risk individual.
YONATAN GRAD: Right. So the details about COVID facing health care workers versus those who do not directly interact with COVID patients, I think that is one part of this debate. And you could easily make an argument that, of course, you want to vaccinate for the reasons that I was describing. I think the fact that many people within the hospital system continue to interact with one another. And those are really when you think about the social groups or the interactions within health care facilities, you can make an argument that by vaccinating all of the health care worker population, you will reduce the risk across the board even further. So there are ways to argue this on both sides. I don’t know that there really is an absolute right answer. Here it is again, weighing risks and benefits. But, yeah, I think it’s a legitimate question about how best to balance these risks and benefits.
Q: Thank you so much.
MODERATOR: Next question.
Q: Thank you for taking a few minutes. I cover the NBA, and just from a big picture standpoint, what is the NBA’s contribution to helping understand COVID-19? Why has their willingness to participate with medical studies been so important? And then moving forward, the NBA is trying to pull off a season coming up amid the pandemic outside of a bubble. You know, what have you learned the NBA has learned that can help them do this successfully this season?
YONATAN GRAD: So I will answer from my perspective, I certainly can’t speak for the NBA as a whole, but I will say that the lengths to which they’ve gone to try to contribute to our broader understanding of COVID-19 and to accelerate the development of new technologies has been remarkable and laudatory. I mean, it’s pretty incredible, the enthusiasm and eagerness with which they want to translate what they have learned to clinical and public health information and practice. So a couple of examples. They ran clinical trial within the NBA for saliva direct. So looking at platform for diagnostics through the testing data that we used for its paper, I think we generated data that had not otherwise been available. And that data is being used not only in the ways that I described earlier, but actually by many others actually around the world. Some of those products I’m familiar with. But I suspect there are many others. So I think that they have really been at the forefront and quite progressive in their thinking and in contributing what they’re learning to general knowledge and to improve in response to the pandemic. I think the bubble in and of itself was an example of how you can, even amidst at the time over the summer, was high levels of transmission in the Orlando area and in Florida overall, be able to engage in an activity safely. And it took a belt and suspenders kind of approach. But it was a I think, a reflection of the success of these kinds of approaches to keep people safe. So I think that in that demonstration, it was also quite useful and remarkable.
So, you know, I think as we’ve learned from other sports leagues, there will be ] quite a challenge in trying to maintain a season outside of bubble. And I think, again, trying to figure out how to put in place the mitigation efforts that will keep people safe is going to be the key challenge. So the importance of testing, the importance of a regular testing, the importance of mitigation efforts, masking, distancing and so on, cannot be overemphasized. And I think those have to be core. And I think in the one hundred and forty or so page document that the NBA put out, that is for the upcoming season, they’re really doing everything they can to try to emphasize each of those mitigation measures and that each are part of a overall combined effort.
Q: Thank you so much.
YONATAN GRAD: You’re welcome.
MODERATOR: Are you all set?
Q: I’m good, thank you.
MODERATOR: OK, so with that, next question.
Q: Thank you for taking some time out. I want to talk a little bit about public messaging and with so many state and local officials telling people to stay home. Especially with the holidays and a lot of people getting COVID fatigue and breaking the rules anyways, I’m wondering what you think about more leaders adopting a harm reduction approach and whether more people will likely follow the important guidelines. And instead of just telling people, no, no, no, from an official standpoint or a leadership standpoint, you might empower people to do low risk activities. And what do you think of adopting some sort of harm reduction messaging will help not just people follow the guidelines, but then also.
YONATAN GRAD: Sorry, I think you cut out a little bit at the end there. Could you repeat your last couple of sentences?
Q: Yeah, I just want to know if you think a harm reduction messaging and instead of just people telling people, don’t do this, don’t do that, while you think that could be effective in helping people reduce some high-risk activity and slow the spread of coronavirus.
YONATAN GRAD: Right. I think you are correct. A combination of advising people what is high risk and what is low risk, and then given the risks that they’re taking, how best to manage that risk is an important role for public officials. So really trying to, as you say, achieve a harm reduction message while at the same time advocating for those low or no risk strategies that would be the ideal ones to take. And so underscoring that if you are going to gather doing so in small groups, testing as much as possible, gathering in places with good ventilation. So trying to understand what are the risk mitigation measures that one can take to try to reduce the risk of transmission and to keep both yourself and your friends and loved ones safe. Absolutely. Those are key points. And that also gets back to one of the things we were just talking about, the importance of when vaccination becomes available to you in whatever group or category you’re in, in taking up the vaccine. And so being able to add that layer on to efforts to slow transmission and again, to keep you and your network safe.
Q: Great, thank you.
YONATAN GRAD: You’re welcome.
MODERATOR: It looks like that’s our last question for right now, but I have one just in case somebody is still contemplating and needs a moment to raise their hand. So you were talking about the NBA and how proactive and supportive they were of researching, testing. I mean, it would have been very easy for them to just kind of shut out all the researchers and not have anybody looking around be safer for them, in fact. So why do you think they were so interested in having researchers around and investigating how the testing was going with them?
YONATAN GRAD: I think it reflects two things; one is their value system. I mean, I think the NBA from the beginning was a leader in response to COVID. As soon as they had their first case, they shut down the league the same day. And I think the first really big cultural institution to do so. The decision to do so, I think, also helped the NCAA then decide to shut down March Madness. And many other leagues and I think businesses saw this as in some ways setting off the dominoes. So I think they are bold and attend to and respond to public health issues even from the beginning. So I think it’s in keeping with their values and their thinking. The other part of it is that the response that they established was one that was totally based on science and informed by science. So they wanted to keep track of what was actually happening in real time and continue to update their protocols and their activities based on what they were seeing. So, again, I think by involving infectious disease specialists, epidemiologists, public health specialists in their activities, they were trying to offer the best possible response and doing so required analyzing the data as it was being collected. So I think there was an interest in doing the right thing from the very start. And I think, quite impressive. There was also a recognition that this is a unique opportunity to translate the data that they were generating that was not really being generated any other way for the benefit of the public. And they did that both through engaging with scientists. And then they also tried to help local communities. So they set up testing both within Orlando and in NBA home markets to provide testing for the communities in which they were situated. So I mean, I have to say, I’ve been very impressed by not only the values they espouse, but the way in which they lived those values and really act on them.
MODERATOR: Right, thank you, Doctor. Does anybody else have a question? If so, please raise your hand.
Q: Following up on the NBA point, with the NBA restarting its season very soon, but without the bubble and assuming some other leagues as well will be restarting their season without the bubble kind of a second go around during the pandemic. What are you keeping your eye on now that some of these leagues that have been praised, like the NHL and the NBA? What do you keep your eye on as they try to work through a season without the bubble while also trying to play all the games that they want to?
YONATAN GRAD: Yeah, I think we’re going to have to see how well it works. You know, I think we’re taking a diligent, thoughtful approach to the upcoming season. What happens? There will be a lot to learn. I think one of the most interesting areas scientifically will be that a number of individuals who will be testing, I think it will be another core element to the response are really getting a sense of this, again, following an asymptomatic cohort. So doing testing and surveillance of all individuals, regardless of symptoms, I think will be a very interesting and informative perspective, particularly for those people who had been positive back in the spring or summer. Are there re-infections? And so that’s an area where we just have had very, very little data so far. So I think there’s typically an opportunity there to learn a lot. But from a practical perspective, I think we’ll really have to see how well these protocols can work in the context overall of a worsening pandemic.
MODERATOR: Are you all set?
Q: Yes, thank you.
MODERATOR: Next question.
Q: Thank you again. So just to piggyback on what I mentioned earlier, some families that are hoping to put their own NBA bubbles in place to more safely gather this holiday season, if possible. Could you throw out a timeline for them to follow in regard to putting a bubble in place? So, for example, two weeks out before your gathering get tested and quarantined, things like that.
YONATAN GRAD: So I have not thought through exactly what a timeline would be for a family or for groups generally, but notions of the amount of time you need to quarantine. I think the CDC guidelines have recently been updated somewhere. So I’d have to look at what the most recent recommendations are for an exact timeline. But the idea would be that quarantining for some period, 7 to 14 days. And again, I’d have to check and see with the most recent recommendations are to give you an exact timeline. Plus, together with testing will be a before you enter into interacting with the social circle. And then once you are within your family or social gathering, really making sure it’s a bubble. So limiting to what extent can you successfully limit interactions with people outside the bubble. I think that although the bubble itself is described as if it were a self-contained entity, of course it wasn’t right, and things had to come in from the outside. And so that involved routine testing of vendors, for example, and then within the bubble, continued use of mitigation efforts like masking and distancing. So I think that while the concept of a bubble within a family is one that, of course holds lots of people, I don’t know that it could be an NBA type of bubble. It can’t be totally replicated. Instead, I think people have to emphasize, are these the same mitigation measures? So giving an entry into a family unit and they’re coming from someplace else, including a quarantine phase where you’re really quarantining, plus testing as a way to make sure that you aren’t infected or infectious. And then once you’ve gathered for whatever duration of time, minimizing interactions with people outside the bubble, and if there are interactions, then using the mitigation efforts that we know can reduce risk, like masking, like distancing and if interacting, doing so well-ventilated spaces or outdoors where possible.
Q: Thank you very much.
This concludes the December 10th press conference.