A Hopeful Spring: Vaccine Successes and Outlook

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Slide. Wednesdays with Woodward (registered trademark), A Webinar Series. A Hopeful Spring: Vaccine Successes and Outlook. Logos for Partnership for New York City, SBE Council, Travelers Institute, Metro Hartford Alliance, and CBIA. A woman appears on a video call at the top right corner of the slideshow 

(SPEECH) 
Good afternoon, everyone, and thank you so much for joining us. I'm Joan Woodward, and I'm honored to lead the Travelers Institute, which is the public policy educational arm of Traveler's Insurance. 

Today's program is part of our Wednesdays with Woodward series--a series we set up to explore issues impacting our personal lives and our professional lives during these really uncertain times. We're pleased you're here today, and we hope you'll stay engaged with us. You can join our mailing list by emailing institute@travelers.com. 

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Slide, LinkedIn, Joan Kois Woodward. Hashtag, Wednesdays with Woodward 

(SPEECH) 
You can connect with me directly on LinkedIn or watch any of our replays--over the past year or so, we've done about 25 webinars--go to travelersinstitute.org. 

So before we get started, I'd like to share quickly our disclaimer about today's program. 

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Slide, About Travelers Institute Webinars. Wednesdays with Woodward is an educational webinar series presented by the Travelers Institute, the public policy division of Travelers. This program is offered for informational and educational purposes only. You should consult with your financial, legal, insurance or other advisors about any practices suggested by this program. Please note that this session is being recorded and may be used as Travelers deems appropriate. 

(SPEECH) 
We have a very special program in store for you today, and as always, we'll save time at the end to answer your questions. So you can submit those questions through the Q&A function at the bottom middle of your screen, and send anonymously if you don't want me to read your name. 

So today, we're thrilled to be joined by our partners, including the Partnership for New York City--and thank you, Kathy Wylde, for your partnership--the Metro Hartford Alliance, the Connecticut Business and Industry Alliance, and the Small Business and Entrepreneurship Council. 

Today we're talking about, arguably, the most significant issue impacting all of us right now, which is of course, the distribution of the vaccines. 

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Slide, United States Vaccine Investment, a table listing pharmaceutical companies and U.S. investment 

(SPEECH) 
And over the last year into this pandemic, the US has invested nearly $15 billion into vaccines. 

As you can see in this chart here, the FDA granted this Emergency Use Authorization for these three vaccines. And never before has the FDA, to such a large scale, pre-purchased--and the company's pre-manufactured--these drugs for all of us, even before the FDA approved of them--that's really unprecedented. So between these three vaccines, we expect 500 million doses to be delivered in the US by the end of July. And to date, we have 189 million vaccines that have been administered, which puts us at about 29% of the whole population. 

We have a terrific guest for you, Dr. Ashish Jha--in just a minute I'm going to introduce him. But Biden has already called on the states to make the vaccines available to anyone over 16 years old and May 1, all 50 states say they will meet or exceed that goal. So we're very hopeful there. 

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Slide, Speakers, a picture of Joan Woodward, Executive Vice President, Public Policy, President, Travelers Institute, Travelers. and a picture of a man, Dr. Ashish K. Jha, MD, MPH, Dean, Brown University School of Public Health  

(SPEECH) 
As I said, we're joined today for a very special guest, and I'm honored to introduce Dr. Ashish Jha, who is the Dean of the Brown University School of Public Health. Dr. Jha has become a household name over the past year, thanks to regular media appearances on all the networks and shows--really providing his insight and analysis of the US and global response to the pandemic. 

A practicing physician, Dr. Jha is recognized globally as an expert on this pandemic preparedness, his response, and as well, on health policy generally. He led groundbreaking research on Ebola and now on the front lines of COVID response--leading national and international analysis, advising both state and federal policymakers. I know members of Congress call him every day for his advice. 

Dr. Jha has authored more than 200 research publications and is a leading expert on improving health quality while also reducing costs. He is currently serving as the Dean of Public Health at Brown. Before that, he was a faculty member at Harvard TH Chan School of Public Health since 2004, and the Harvard Medical School since 2005. He was on the Faculty Director of the Harvard Global Health Institute from 2014 until 2020, and then he also served as the Dean for Global Strategy at the Harvard TH Chan School of Public Health. 

Again, we're truly honored to have you here with us, Dr. Jha. So please go ahead, share your thoughts with us about where things are in the race to vaccinate us and the different variants that are emerging. So, thanks again. 

(DESCRIPTION) 
Dr. Jha appears on the video call 

(SPEECH) 
Great, Joan, thank you and everyone. Thanks for having me and thanks for being here. What I'm going to do is I'm going to speak for about 10 to 15 minutes about the state of where we are with this pandemic in the United States. And I will talk a little bit about what's been happening most recently, obviously in the last 24 hours the big news around Johnson & Johnson. But really a bit more broad than that and then we can dig into details during the Q&A. 

So where are we in this pandemic? So starting off, I would say if you take a pretty narrow US focus--and remember this is a global pandemic, so we're going to do a little bit of discussing about what's happening globally--but in the US, things are looking really good. I think we are on the tail end of what I sort of think of as the emergency phase of the pandemic. And so let me explain those words and what I mean--the pandemic isn't going to be gone anytime soon. The virus is one that we'll probably live with forever. We've eradicated very few viruses in our life from Earth, and this virus will continue to be with us. 

But the emergency phase--the way that the pandemic, the way that the virus has dominated our lives--I really do think is about to come to an end in the United States. Certainly over the next few months, we're going to see a real shift where the virus and COVID is something that's a challenge, it's something we need to deal with, it's something we continue to work on, but no longer really dominates our lives. And that's going to happen, I think, sooner than many, many people are expecting. So that's the real good news. 

Right now, on April 14, we're what I think of as kind of turning that last corner and it's a challenging one. There's some specific short term challenges that we need to deal with, so let's talk about where we are in terms of the acute short term. Let's talk about what things will look like over the next four to six weeks, let's talk about what things will look like over the next four or six months, and then we can talk a little bit about what things will look beyond that. 

The next four to six weeks are, as I suggested, challenging because of the variants. So Joan mentioned the variants, and there are many different variants, but there are two or three that you need to know about. The primary one is B117-- that's the variant originally from the UK, and it's funny to even think of it as a variant now because it is the dominant strain in the United States. I would say yesterday we had about 70,000 infections, probably 70% 80% of those infections were from B117, so it is the dominant strain of the virus now in the United States. 

What we know about B117--it is way more contagious, between 50% and 100% more contagious than the strain that we dealt with all of last year. Though there's one paper now that questions these findings, I still think the bulk of the evidence is that B117 is more deadly--probably about 30% more deadly than the previous strain. And that combination of course, is a huge challenge and when B117 has become dominant in every country--initially in the UK, but also Ireland, Denmark, Portugal, much of Europe now, starting to happen in other places--we have seen a massive explosion of cases. 

Infection numbers have gone up 5, 10-fold, so in the US, B117 has become dominant in the last few weeks. We've seen an increase in cases, we have not seen such a massive explosion of cases--why not? Well, so what we're seeing in Michigan, for instance, is really a B117 driven phenomenon of a large increase in infections. But the reason we're not seeing things be horribly bad-- we're not seeing a massive fourth wave--is because we actually are doing an extraordinary job on vaccinating people. And that extraordinary job is what is preventing B117 from really taking over--and it is taking over in terms of infections, but really becoming so dominant and so bad that it is overwhelming our hospitals and causing massive, massive deaths. 

It's not doing that, and the reason is that we are now up to a point where about 80% of Americans over the age of 65 have gotten at least one dose. And by vaccinating people over 65, we are preventing the horrible hospitalizations and deaths that we saw over the holidays--because obviously, people over 65 are at highest risk. And we're probably about four or five days away from having vaccinated half of all American adults--we're at about 47%, 48% right now. And we will have vaccinated half of all adults, as I said, certainly by this weekend coming up, and my hope is that we keep continuing and continuing to vaccinate. 

Half of all adults--obviously, we have not vaccinated kids--means that we're probably about 38%, 40% of the population in terms of vaccinating people. If we can add another 15% to 20% points on top of that, that'll be more than enough. It won't be herd immunity--and herd immunity is when the virus is really truly-- it's not completely gone, but it's not creating outbreaks. But if we get another 15%, 20% points onto where we are right now, we will have so much population immunity across the United States that infection numbers will really drop down quite a bit. And we will be at a point where we can open up large chunks of our economy, and do so safely. 

So that's the hope, and the challenge, of course, is that there remains some chunk of Americans who are concerned about the vaccine, who have questions about the vaccine, who don't have the level of confidence that we need people to have. And I think the job of Public Health, and the job of all of us, is to work with people where they are, figure out what the questions are, figure out what's holding them back from getting vaccinated, and helping people get vaccinated. 

The other quick thing I will say about the state of vaccinations--and then I will project out kind of what life looks like a little bit as we go forward--is until now, demand has outstripped supply in pretty much every part of the country. If you wanted a vaccine, it was pretty tough to get--you'd have to get up early in the morning, you had to refresh your browser, you had to find a way into getting vaccinated. We are right at that inflection point in our country, right now or certainly over the next 10 days, where we're going to switch from demand being greater than supply, to supply being greater than demand. That we will have plenty of vaccines, and by the time we get into early to mid-May, you can almost surely walk into any CVS or Walgreens and say, I'd like to get a COVID vaccine today please, and you'll probably get an answer that says, can you wait 15 minutes. 

So you don't have to do the kind of online, trying to get an appointment--we're probably a couple of weeks away from that. But the bigger point there is while that's true nationally, it's actually playing out very differently from state to state. So a group of states is already there--in a group of states, you can walk in today, into a CVS--in many CVS's, and get vaccinated. Actually you can't walk in, they still want you to do an online appointment, but you can get one within hours, meaning that supply there has been starting to outstrip demand. In many other states, that hasn't happened, but that will all happen over the next month. The huge policy challenge, and public health challenge right now, is to make sure that we get a large chunk of people who have not yet gotten vaccinated, vaccinated because that will make this tremendous difference in terms of our ability to open up our economy and really function safely and effectively. 

I'm pretty hopeful we're going be able to do that through May and June, and that's why I have said--and I've been really saying for six months--we should be looking forward to a really, really good summer, a summer that looks close to normal. So let's talk about which ways it looks normal and which ways it doesn't. Looks normal--backyard barbecues, absolutely--trips to the beach, yes--summer travel, increasingly safe. 

So what are the things that are going to still feel different? Well two things--first, is a bunch of kids are not going to be vaccinated, so we want to be careful about that. And some large indoor gatherings are going to continue to be a challenge because even if we can get another 10 or 20 percentage points of people vaccinated, it still means a chunk of Americans will not be vaccinated as we get into the summer. And therefore, large indoor gatherings will remain a risk for outbreaks. I think we'll continue seeing some number of infections so it's not quite a normal summer, but summer of 2021 should look a lot more like the summer of 2019 than it does summer of 2020. 

Once we get into the fall, I expect us to start off really strongly in the fall, but I do expect as we get into late fall, winter--as flu season comes around--that we'll see another surge of COVID. And I use the word surge--probably not quite the right word--we'll see a bump in cases of COVID. I don't expect a surge because I'm hoping that 70%, 80% of Americans are vaccinated, maybe more. 

And if that all happens, then what we're going to see is small regional outbreaks--nothing horrible, hospitals not getting overwhelmed, and again, we'll figure out how to manage it. And then that'll be--and then that gets us into spring, and then I really am very, very hopeful that 2022 will look really pretty terrific in the United States. So let's take a minute to talk about some threats to this vision. And one particular one that we need to be paying attention to is as I started off with this is a global pandemic, and global pandemics come to an end when the globe gets vaccinated. And we are very, very far away from getting the globe vaccinated. 

Right now, we've administered about 800 million doses, that's across the world, that sounds like a lot. It's basically in five countries have dominated that, and much of the world remains unvaccinated. And the problem with that beyond the fact that it creates these huge inequities, there are two other sets of problems. We live in a global economy. And so if large parts of India are experiencing massive outbreaks, like they are right now, that's going to have a huge dampening effect on global travel and the global economy. And it's happening in India, it's happening in Brazil, places that are economically very important from a low and middle income country point of view. 

There is another problem, which is a biological infectious disease problem, which is the issue of variants. And I want to come back to talking about variants a little bit more before I finish up with vaccines. So these variants don't happen--well, they do happen randomly, but they don't come out of--like you can predict where they've been coming out of. They come from places, they come in the context of large outbreaks. Because basically what you have with SARS-CoV-2 is a pretty messy virus, it's a virus that makes a lot of mistakes. And most of those mistakes don't mean anything, but some of them give the virus a functional advantage. And put enough of those mistakes together, enough mutations together, and you start getting a variant. 

The best way to generate new variants, is to have large outbreaks. Large outbreaks give the virus an opportunity to create new variants. I remain worried that what we're going to have, is if we have large outbreaks happening in the world even if America is fully vaccinated, we're going to continue to be stressed with new variants that we're going to have to deal with. Because in a global world, a variant that starts in India, or starts in Brazil, or starts in LA, will find itself into other places in the world as we've seen over and over again. 

There is a nightmare scenario, which I think is extremely low likelihood, but I'm not feeling all that lucky these days, and we need to plan for it, and we need to have a strategy around it. And that nightmare scenario is the rise of a variant that renders our vaccines useless. Do I think that's likely? I don't. But the best way to ensure such a nightmare scenario happens is to allow large outbreaks to happen around the world. So a very critical part of global leadership for the Biden administration is going to be getting the world vaccinated. We're about to get Americans vaccinated certainly by May, June. We need to get the world vaccinated, and we need to get the world vaccinated quickly. It's the right thing to do. It's good for the economy. It's also good for protecting us against this pandemic. 

Last point around these variants and vaccines. So we have--I've talked about B117, there's 1351 from South Africa, P1 from Brazil, there are others, ultimately our vaccines seem to hold up quite well against all of them. You may have read some scary stories about 351, the South Africa variant breaking through on Pfizer. I'm happy to get into more details of the science, there's been a lot of I think unfortunate reporting of some of these things, the bottom line is I remain very confident that our vaccines are going to do very well against all the variants that we've seen so far. 

Last point is about this J&J vaccine, and the event from yesterday just because it's on people's minds. I've had several conversations with leadership in the White House and the FDA and CDC. It was a close call, on Monday night they met to look at the data of these six cases of people who had experienced these horrible, horrible maybe strong but they are pretty significant venous thrombosis. These very significant blood clots, and what they didn't know was, were they looking at the tip of an iceberg or were they looking at the entire iceberg, right? Is this just six cases out of 7 million in which case this is more rarer than getting hit by lightning, or is there a lot more that they were missing? And they didn't know. 

And out of an abundance of caution they put a pause on J&J vaccinations. My sense is again the CDC's advisory committee is meeting is at this exact moment. The FDA is having further meetings and consultations, they're looking at a lot more data. And my best guess, and this is just a guess, is that the restriction or the advice for the pause is going to be lifted in the next couple of days, and J&J vaccinations are going to get back up and running. So far the six cases have all happened in young women between the ages of 18 and 45, or 18 and 48. 

And so they may decide that that's the group that's at risk. They may decide that was random, don't know. But you could imagine them coming out with advice saying, maybe for that group that J&J vaccine be held off, and we give it to men and we give it to a people are older than that. We don't know, and there's a lot that we're going to learn over the next couple of days. But the last and bottom line on J&J, is it's a fabulous vaccine. It has a very high degree of efficacy against what we care about, which is hospitalizations and deaths. And this very, very rare adverse event that we have seen does not translate over into the mRNA vaccines. So it does--we've not seen this with Moderna, we've not seen it with Pfizer despite the fact that 115 million people have been vaccinated. 

So it's not happening with the mRNA vaccine, it's not that we've seen so far. So to finish off, I know that there's been bumps on the road. I feel very good about where we are as a country. The next four weeks or so continue to concern me, but once we get into mid-May, I feel really good about where we are June is going to be really good, and by the summer, it should be something close to a normal summer. All of this is contingent on getting a bunch more Americans vaccinated. I've gotten vaccinated, all my family, not my kids of course, but others have gotten vaccinated. And if you have not you should. And let me stop there and Joan let's get to the Q&A, but thanks for having me on. 

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Joan reappears on the call 

(SPEECH) 
Well, thank you so much Dr. Jha that was really just fascinating and really informative. Again, I want to remind our audience you can ask a question in that Q&A function at the bottom of your screen there. And I'll try to get to as many as we can. We'll do a rapid fire at the end here. So let's just pick up--I have lots of questions for you, but let's just pick up on the J&J. One more aspect of the J&J is the efficacy rate, and given this FDA halt to having the J&J vaccine out there. There's also the concern of some people in the population that 66% global efficacy is not at the level of the Pfizer or Moderna 90 plus percent. How do you think about efficacy rates? And aren't these rates higher anyway than the normal kind of annual flu shot? And was the environment that J&J was tested in different than the Pfizer or Moderna testing clinical trials? 

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Slide, How to Measure Vaccine Effectiveness, a table listing vaccine trials and outcomes 

(SPEECH) 
Yeah, yeah, that's--OK, so this is from a table I put together. I just think it was just one Saturday evening, I literally like the kids had gone off to bed, and I just went through the trials. So this is one way to think about the data, right? Which is we can talk about the headline efficacy numbers, which I do want to talk about that 66% for J&J versus 95%, but one of the things that's for symptomatic infection. But what I would argue what you care most about, what you care most about is hospitalizations and deaths from COVID. And again, based on the data that this is now maybe about a month ago that I put this together based on the data we had at the time. Here's all the data from all the clinical trials. And what you see is the people who are in the vaccine arm no one was hospitalized. No one died of COVID. And no one died from the vaccine. 

Now we do think that from J&J maybe one person out of 7 million has died from the vaccine. But the bottom line is it's incredibly effective at preventing severe illness, and that's at the end of the day what you care about. So if the vaccine turns the disease from something that has the potential to be lethal into a mild symptomatic disease where you feel kind of mediocre for a couple of days and then you're fine, I'll take that. So that's not a failure of efficacy. But I actually want to talk about efficacy, that headline number because it is a bit misunderstood. So 66% for J&J versus 95% for Pfizer and Moderna. Why wouldn't everybody want to get Pfizer and Moderna? 

And by the way Pfizer and Moderna are great vaccines, and so I have no reason to criticize them. But I will say the following, J&J was tested in Brazil while the main Brazilian variant was circulating, it was tested in South Africa while the South African variant was circulating, Pfizer and Moderna were not. So one thing that brought that headline efficacy number down was J&J was tested in different locations at a different time. The second argument for J&J is that it uses this adenovirus vector, which is a well-tested, tried and true method for building vaccines, and there is some reasons to believe that vector-based vaccines actually give you a more robust t-cell response. And the immunologic issue here is, that a more robust t-cell response means you may be better protected against severe illness. 

So it may be, and again, this is a little speculating, that J&J you lose a little bit in that headline efficacy your risk of getting infected maybe a little higher, but your risk of having a really bad outcome may be a little bit lower, plus this one shot, no refrigeration. It's a really high quality vaccine. I would feel very comfortable getting it. When I got vaccinated at the hospital J&J had not yet been authorized, but I have certainly been encouraging my family and friends getting the J&J vaccine. 

OK, that's really helpful and understanding, and I think two places we all want to stay out of is the hospital and the morgue, right? So I appreciate you putting this chart on Twitter, we were glad to use it today. Another question for you about AstraZeneca, so obviously AstraZeneca is not yet approved in the US. One, when do you expect that approval? And can you tell us they also had pull back in some countries after they saw some blood clots there, so what is your thoughts on the AstraZeneca should it be approved? 

Yeah, so we don't know when and maybe even if it will get authorized the United States. I suspect it will, the company was asked to run US trials, and US and Latin American trials, which they did. And they've got some preliminary evidence, it looks good with efficacy around 75%. And so I expect that they will file for an authorization. I expect they will get it. They also have this issue maybe at a slightly higher rate, but we don't know that J&J of these incredibly rare blood clots. And again, in the J&J the data so far just to be very clear as I said 6 out of 7 million people, one out of a million, less than one out of a million. Your chances everybody--on average your chances of getting hit by lightning in a given year is about one in 500,000. So it literally is half the risk of getting hit by lightning. 

We're talking about these exceedingly rare things. We have built up a really robust surveillance system to find this. It's also going to show up with AstraZeneca, and the best data on AstraZeneca is that these blood clots may be a little bit more frequent in AstraZeneca. So the question for American regulators is going to be, should we authorize it? If we didn't have other vaccines I would say, absolutely, The UK has, Europe has, it's a good vaccine. But when you have tons of Moderna and Pfizer and J&J, what is the added advantage for AstraZeneca? And to be perfectly honest, I don't know that there is an added advantage. I don't know that it helps once you were getting it to a point where you no longer have supply constraints. 

So I think the FDA regulators are going to think about that as well they may still authorize it. But one of the points I've made is, I see very, very few Americans getting the AstraZeneca vaccine. Largely because there isn't a good reason to get it, it's not better. And so I don't expect it to end up having much of a play here. It also means that there are about 35 to 40 million doses of AstraZeneca vaccine sitting in warehouses on ice in Baltimore and elsewhere that we have built up, we should probably start giving them away because we're not going to use them. And again, probably in about a dozen states now, we have more supply than demand, and the rest of the states are going to get there in the next two weeks. 

I think it's time to give away the AstraZeneca vaccines. 

OK, all right. Does the US FDA--this quick question that followed, does the US FDA stamp of approval, does that give other regulators around the world, do they feel better about their approvals if the FDA and the US has approved AstraZeneca? Or it doesn't matter, each country does their own analysis? 

Each country does its own analysis, but the US FDA is undoubtedly seen as the gold standard. It is undoubtedly seen as the most rigorous, does the most thorough vetting. US FDA is just tough. And again, no slight on the European Medicines Agency, no slight on the regulators in the UK, but if the US FDA authorizes things, it generally tends to go pretty quickly elsewhere. One of the things that actually a bunch of us have been arguing for, is instead of every country doing its own regulatory authorization, that we should have had more harmonization. Personally I would have put the US FDA because it is the toughest as the bar, and said, everybody should just follow them. But as you might imagine, every country wants to do it their own way. 

Right. OK, so how long is this vaccine protection going to last? Is this going to be an annual thing where we have to get like we get the flu shot every year? Or when will we know that? When will we know we need to get it every year? When is the inflection point you think, is it the next spring, is it the summer, when is that? 

So the short answer is, we don't know, right? Because we don't know how long this vaccine last, because we haven't had this vaccine for that long. We know it lasts at least six months because that's the data we have, but I have no reason to believe it only lasts six months. My best guess, and then I'll tell you how we're going to actually figure it out as opposed to me guessing. My best guess is at a loss at least a year, and probably longer than that. Is it going to last a lifetime? Probably not. Will we need boosters? Probably. But not in the next year, and not under a year. And maybe it's a year, maybe--and what's going to happen over time is, we might get a booster next year. I would not--so my best guess is, we'll all get a booster next year. 

It'll probably be polyvalent in the sense that it will have some of the variants in there, and so that not the viruses themselves, but the coding for it so that we're better protected against the variants. And we might do that for a couple of years until this virus evolves into something that is much more manageable, and we're also going to be working on longer duration. So I don't expect this to be a lifelong yearly, but I wouldn't be surprised if over the next two or three years we end up getting it once a year or once every other year. How will we actually know as opposed to me standing up here and guessing? 

There are two aspects of this are going to be really important. One is, we're still really figuring out what are the correlates of immunity. So let me explain what that term is. Correlates of immunity is what it sounds like, which should be able to draw blood in somebody, look at their antibodies, and know whether they are--and their T-cells and know whether they're protected or not. We can measure antibodies and T cells, we don't know which ones are protective which ones are less so. That's a science we need to still sort out. I think we're going to have much better sense of that over the next couple of months. And that means I believe by the fall will be at a point where you'll be able to actually tell how well protected somebody is. And when we see that starting to wane, we will know that it's time for a booster. 

Second, is we're going to be tracking people who have been vaccinated, and when you start seeing reinfections and breakthrough infections starting to tick up a little bit, you'll know, we'll know it's time for a booster. And we want to be able to identify that as early as possible because obviously we'll have to make these boosters. As I said, I'm not super worried about this being a short term problem, but in 2022 I do expect many of us to get a booster again. 

OK, that sounds good, and that sounds good to me. So let's talk about the vaccine hesitancy. Right now it looks like about 75% of us are willing to get it and ready to get the vaccine, but the rest that stubborn 25% at least in the polling right now that shows that people are really worried about it and now with the J&J pullback probably more people are concerned. I mean, how is the government, and influencers, and social media, or in Hollywood, how is the messaging to get to those 25%? And Fauci talks a lot about herd immunity at 70% to 80%, what about the people who already had COVID? Do you put that in that 70, 80% herd immunity number because aren't they already immune if you've had COVID? 

Yeah, they are two or three different questions that are really related, but in there Joan let me take them apart a little bit. One is, how good is your immunity if you've been previously infected? And is it good as getting vaccinated? And we have data on this, and the data suggests that if you've been previously infected about six months later the average person is about 80% protection against reinfection, so not as good as what you see with the mRNA vaccines. But if you're over 65 that protection drops to about 50%, so definitely not as good as the vaccines. And so I think of previous infections as kind of a weak version of having had been vaccinated. And this is one of the reasons why we want everybody who's been previously infected to still get vaccinated. 

But then when you think about population immunity, no doubt about it that, if you previously infected that does add to population immunity. And we probably do need at least 80% of people with immunity if not higher. Part of the reason we need higher and these numbers have gone up is because B117 what I described is now the dominant strain is so much more contagious. The more contagious the virus the higher the proportion of immunity you need to block that spread and to bring the pandemic under control. So 80% is probably the kind of minimum that I think we need to get to. And obviously, with people who've been previously infected but then don't get vaccinated, their immunity is going to wane much earlier I believe, than people who have in fact fully vaccinated, and that's the other reason we really need to continue. 

So I do factor the previously infected into my mental model, but I'm also I remember that it's not the same level, and it won't last as long, and that's why I think it's really important for people to get vaccinated. 

OK, so fast forward say four, six months, however many months, the government certifies that 80% of us have gotten vaccinated. So we are at herd immunity, right? But there's still many millions of people in that 20% that did not get vaccinated, are we still walking around wearing masks? Are we wearing a mask in our offices and our schools? That herd immunity environment, what does that look like for the average person? 

Yeah, yeah and well before even four to six months from now, I think you're going to see really significant changes in people's lives. So but let's stay with your 80% number for a second, that might be for the country. We're going to see large variations across places. So one of the things, I've been talking to a lot of companies about how do you bring people back safely. I was talking to a CEO of a Fortune 50 company recently who said to me, he's like, I just won't be able to have like a meeting with my senior leadership team sitting around a table. And I don't want to be wearing a mask, and I don't want to be putting anybody's lives at risk. How do I do that? And the answer is really straightforward, just make sure everybody's vaccinated. 

So if you have fully vaccinated workplaces, you can do pretty close, I mean, and we can do some tweaking around the edges, it may not be exactly what you could do in 2019, but it's so close. You don't need to be wearing a mask. You don't need to be doing social distancing, fully vaccinated people can get together quite, quite safely. And by the way, there are lots of companies or there's certainly lots of organizations where leadership is all vaccinated already. So that's not--you don't have to wait six months. In terms of more public stuff the challenge here is, there are two sets of issues. There's the biology, and then there's a sociology. 

So I have been fully vaccinated for a couple of months. I can make the case it's totally reasonable for me to walk around without a mask. I could go into a retail store. I could go into a grocery store. And I would not put myself or really anybody else at risk by not wearing a mask. So why do I even have to wear a mask, and why do I? Because that grocery store clerk has no idea whether I've been vaccinated or not, right? Because the retail shop owner has no idea. And while infection numbers are high, and while we can't ask everybody to go around checking people's vaccine status--and we can talk about vaccine passports, one of the reasons--and so this is much more social, we need to continue doing this for a little bit longer until I believe a higher proportion of people are vaccinated and infection numbers come down. 

I expect over the upcoming weeks, I mean, we've had some governors already pull back on state mandates for mask wearing. I expect most states to lift their mask mandates for outdoor activity probably by May, I just don't see any reason for it. And a lot of indoor stuff the mask mandates will go away by probably by June. And then you may have specific situations like, I want to go to the symphony, or you want to go to a rock concert, you want to go to an art gallery, and it's often cramped, lots of people together. They don't want to be checking everybody's vaccine status. 

They may do things like have testing at the door, so everybody gets tested with a rapid antigen test that takes 10 minutes, or they may require people still wear masks indoors, and that would be reasonable because they may say--a concert person may say, I don't want to have outbreaks in my concert hall, and I totally get that. So I do think mask wearing will continue in specific places. People have brought up what about mass transit, airplanes? We will see how all of that plays out, I do not expect ubiquitous mask wearing to get certainly not passed the summer, but not even into much of the summer. I expect a lot of masks to start coming off in a lot of--most of the country, but with specific areas where you can imagine wearing masks. 

And one other quick thing I'll say about masks is, I can also imagine next fall, imagine I'm in Providence, Rhode Island, imagine there is a bit of an outbreak because again 20% of people are unvaccinated. It's late November and the seasonality is bumping that infection number up, I could imagine the Mayor of Providence coming out and saying, for the next four weeks, we want everybody to be wearing masks indoors and outdoors. And that would be reasonable, right? It would be a way to intervene to just bring a surge of cases down. So I can imagine masks showing up like that every once in a while in our lives. But the idea that we'll have widespread mask wearing well into 2022, I don't buy it, there's no biology for it, and there's not even really sociology for it. 

I think that's a huge relief for everyone on this call including me to think about life without a mask. So thank you so much for that reassurance for us. All right, we're going to get to audience questions, we have over 200 audience questions. So only a few minutes left here, but let's talk a bit about the passport. So I know a lot of CEOs were considering this, the federal government said there would not be a vaccine passport for people coming into the country or people in this country. How do you think about short of wearing a little stamp on our forehead as you said, the grocery clerk wondering if I got that vaccine, how is it that we prove to the world, society, to everyone, considerations of HIPAA the privacy acts, but isn't it a good idea if we want to get back to that global recovery that you talk about to have some sort of card saying I've been vaccinated. 

Yeah, I think, Joan, it's really complicated, and I'm going to start by being a little parochial and starting where I am right now at Brown University. So we announce that we're going to have a pretty normal fall semester with normal classes, normal activities, and the only way we can do that safely is that we require that all students, and we're working on whether we can do this for faculty or staff, but we're very confident we can do this for students. We're going to require every student to be vaccinated. And we'll figure out a verification scheme for that, and we can talk about that verification scheme in a second, but let's talk about whether this is even a good idea. So Brown is a private organization, and they can make rules like this, and as long as you have appropriate religious exemptions and appropriate health exemptions you can do this. And schools and universities do this kind of stuff all the time. 

And so you're going to see that. You can also imagine airlines. I've heard from various airline executives who say you know like maybe not for short flights from Boston to D.C, but I used to travel a lot to Hong Kong from Boston, that's a 16 hour flight. I would really love it if I'm going to spend 16 hours with like 300 random people, I'm going to feel a whole lot more comfortable if I know that everybody on that flight has been vaccinated. So you can imagine for long haul flights airlines saying, we're just going to do vaccination status. So there are a lot of--and then companies may do this for their employees. And you can imagine businesses saying for certain customers or for their employees. 

So if you--once you realize that there is a huge value for private business and private industry to have authentication, then the question is who does that? And how do you do it in a way that's safe? So there are going to be countries that where this is very comfortable where the federal government is going to do a vaccine passport for the country, and people they're used to having their health card run by the national government they're going to be comfortable with this. That's not America. I don't see it, the Biden administration is not going to go there, and I don't think they should go there. So you're going to see private sector solutions on this. And I think that's great. 

There are going to be two sets of issues, how do you make sure that you don't get sort of fraud essentially, and how do you really authenticate that someone's been vaccinated? And then how do you protect privacy and security? And those are places where I think the federal government is going to provide guidance. They're going to provide set of rules that any company making vaccine passports are going to have to comply by so that their system doesn't get hacked, so that other stuff doesn't happen easily. That I think is a more appropriate role for government. I think it's reasonable for the government to set some basic rules around privacy, security, and authenticity. 

But I think those solutions are coming, I've already probably been contacted by a dozen companies who are like, we're building a passport do you want to advise us. I don't advise any of them, but the bigger picture point is, I think this is inevitable. 

OK, we're going to do rapid fire questions for you. So a lot of questions about safety in children and when is the Pfizer or other vaccines going to become available--approved by the FDA. What is your what is your time frame on that children's vaccine? 

Good question. I think if things go well I can imagine an EUA for 12 to 15-year-olds for Pfizer in June, maybe May. There's a small chance FDA may say we want two more months of data in which case it gets pushed out to July or August. But I actually think the FDA is going to probably authorize it before the end of June. Under 12 much less clear, the clinical trials are getting going, easily into the end of summer or fall before under 12 are going to get vaccinated. Unless the FDA is willing to accept a correlates of immunity laboratory evidence of immunologic response and safety data, they haven't been willing to do that so far. They might do it in kids, but I don't know. 

So that really means for those of us who have kids under 12, we still might be sitting in our living room, dining rooms, and home schooling, right? That schools might not be--elementary schools might not be completely reopened in the fall. 

So they should be, they should be, and there are two reasons they should be. First of all--three reasons, one is, infection numbers across the country should be very, very low. Second all the teachers and staff are vaccinated. And young kids don't spread the virus as much, and when they do get infected they don't get as sick. And one of the concerns have been well, they might infect teachers, well, teachers can be vaccinated. They might bring it home to their elderly grandparents, well, the elderly grandparents will be vaccinated. And schools have gotten literally tens of billions of dollars to upgrade ventilation. So the only thing I can imagine is in the fall if the kids under 12 are not vaccinated yet, you may still be sending your younger kids to school wearing a mask, and there may still be a little bit of social distancing and some ventilation work in schools. But there is no reason whatsoever that schools cannot be fully open this fall. 

OK, I think there's a lot of moms and dads on the phone that appreciate that answer. Another rapid fire for you, pregnant women, so one, should they get it? And two, when should they get it, first, second, or third trimester? And then breastfeeding women, should they get the vaccine? 

All right. So I'll start with the easiest of them, and then--though my short answer for all of them is, yes. I recommend that everybody, all four of those groups, meaning breastfeeding, third, second, and first trimester. Breastfeeding there's no downside as far--there's no data to say that there's any downside, and there's in fact, some emerging data now that women who've been vaccinated there are antibodies in the breast milk. Is that protective for the newborn? We don't know, we think probably. So there's probably a benefit to being vaccinated if you're breastfeeding in terms of preventing infections in newborns. 

Pregnancy, we're doing the studies now to measure safety. But let's be honest tens of thousands of women who are pregnant across all three trimesters have been vaccinated, sometimes because women didn't know they were pregnant, other times women who knew they were pregnant, and we have seen no untoward effect in terms of either the mom or the baby. But we also know is that pregnancy is a very substantial risk factor for bad outcomes if you get COVID. So if I have a patient who is pregnant, my advice is we don't have all the data in, but every bit of evidence right now says, you're at high risk if you get COVID, and you're not at risk of having a complication if you get vaccinated. But that second part of the data is not fully nailed down, but that's what the evidence looks like. So my take is the benefit risk here is clearly towards getting vaccinated. 

OK, you have a tremendous following on Twitter, and social media plays a huge part in getting the word out. What else could companies be doing? We saw Krispy Kreme give us all free donuts if we've been vaccinated with very generous and a very sweet treat. But what could companies be doing out there or small--we have a lot of small businesses on the phone as well. 

Yeah, look I think social media is very, very powerful, and very good in lots of ways, and a huge problem in other ways because it really creates, both is a great source of good information, but it also can be a source of really bad information and misinformation. And then there are bad actors who manipulate social media to really spread disinformation. So the single biggest thing I think companies can do overall in terms of promoting public health and American health and well-being and economic recovery is by promoting good information. 

So amplifying voices of science and evidence and public policy, and companies can do that do that in their own ways, right. And you can think about what your angle is, and what your focus area is, but I think amplifying good scientific voices is really, really important. And it also builds trust, people who trust you and your company seeing you tweet stuff from the CDC, again, when it's relevant to your business, but also finding ways of amplifying that. I think certainly promoting vaccinations is going to be critical. Look, I am deeply worried that we're going to hit a wall on vaccinations in the next couple of weeks. We're already starting to see it in about a half a dozen states. If we hit a wall in the next couple of weeks we are not going to be anywhere near the level of population immunity to open up chunks of our economy safely. 

We're going to have outbreaks, we're going to have shutdowns, we're going to have problems. We all got to move beyond this pandemic, and there really is one way to do it, which is get people vaccinated. So whatever companies can do in their own way to promote that within their own employees, within the broader community of their customers, I think that would be really, really powerful as well. 

OK, what about those who have had COVID and are experiencing what they call long-haulers disease that people really just don't feel like themselves months after having COVID? 

Yeah, it's a real issue. And unfortunately we don't know a lot about it. We don't have very good evidence on how often it happens. We do think about 20% to 30% of people who recovered from COVID do have some lingering symptoms three to six months out, but long-haulers are people who can often be quite debilitated. Obviously, thankfully, the numbers are not that high for that group. And the NIH now is doing a couple of large cohort studies where they're really actually starting to track these individuals to try to figure out what's going on, and how do we begin to address it. So if you have long COVID, go to the NIH website, and try to sign up for these studies because it's a really good way to learn what's happening to contribute to science. 

The only other thing I will say which really interesting to me is, and the evidence here is not nailed down, but there is some evidence that getting vaccinated once you've had long COVID can be quite helpful in reducing your symptoms. And there's some good immunologic explanations for how basically the vaccine retrains your immune system in a way that dramatically reduces your long COVID symptoms. It's not perfect, no one one's saying the vaccines will completely get rid of it. But we have seen now some emerging data of people who had long COVID symptoms who got vaccinated, and then got dramatically better afterwards. So if you're one of those people who are suffering from that, I would certainly get vaccinated for all sorts of other reasons, but that may be a benefit as well. 

OK, this is a question about people who have immune deficiencies currently. So I know your answer is probably to get the vaccine, but how do they tell if the vaccine works? You talked about the T-cells, what about the IGA, IGM, and IGG responses, can they trust that antibody test if they're building those antibodies? Talk about the immune deficient people on the call today. 

Yeah, there are a lot of different types of immunodeficiencies, and obviously all of those puts you at risk for bad outcomes from COVID, which is why in general, you should get vaccinated. Two things I will say, one is, because of the incredible variation of what it means to have immunodeficiency, it could be you're on a low dose steroids or it could have you some severe immunodeficiency syndrome. You really do have to talk to your doctor about this, and try to get specifics around your specific condition, but generally my recommendation has been get vaccinated because it's useful. How do you know whether the vaccine is protective for you? You can measure IGM, IGG, you can actually do some--and there are some places that are doing testing of T-cells. 

The only caution on that I will tell you is I don't know what level is protective. I don't know which sub-types of IGM and IGG, and I don't know. So that's the correlates of immunity that I said we don't totally have nailed down. I think we will in the next few months because science on that is working very, very quickly to figure all that out. So you may not get a fully satisfactory answer of whether you're truly protected, but certainly if you see a nice antibody response if you after you've been vaccinated that should be reassuring that you will. But we're just--there's a lot of science we're still sorting out here. 

OK, and I have a question coming in from Matt Gunther on, you know, the military says, they're always fighting the last war, right, and so look to the future doctor. I know the Biden administration is going to invest heavily into pandemic responses and research and preparing us one, will there be another pandemic facing us? Will there be another COVID- 20 hitting us in your view? We heard Bill Gates many years ago talk about this, and how do we handle that? Is a more coordinated response to the WHO the answer, or what in your view should--what are the five steps we should take as a country, as a world to get ready for that next pandemic? 

Yeah, absolutely. So I for about five years ago started saying publicly, and places where I said, we we're really entering an age of global pandemics, and we should expect that we're going to start seeing a lot more pandemics happen. This is a once-in-100-year event, it's not going to be another 100 years before something like this happens. And so why are we entering an age of pandemics? Massive economic growth has meant huge changes in human animal interactions, about 90% of novel infections in humans come from animals. And we're doing lots of encroachment into animal habitats, deforestation, climate change, all of that is a huge setup for more novel disease outbreaks. 

And then the second part is this massive globalization. You know China 2003 with the original SARS versus China 2019, China 2019 had about 10 times as much global travel as China 2003. So when a disease outbreak began in Wuhan probably in October and November of 2019, it was probably all through China by the end of November, and it was out by December of 2019. That's just the nature of the world we live in now. And so I think we just need to assume that we're going to have more pandemics. That doesn't bother me, what bothers me is we can't have a response like what we just had in the last year, we can't be flattened this way. 

So we need a very aggressive global surveillance system that identifies these things early. We need to have redundancies built in so we're not relying on China to report it or WHO to identify it. We do need to bolster WHO in some specific ways, but we also have to assume that agencies and organizations will fail at times, and that means there's a whole set of work that needs to go into developing surveillance and response, a lot of work which is starting to get done now. It's got to be done in the government, it will be done in the government. But it's also got to be done in the private sector, and with the private sector's help. So massive opportunity for private sector to play a really big role. 

Well, Dr. Jha with that, I am going to let you go. I know you have a very busy schedule, we're just so grateful for the time. Please do come back with us in the next year and give us an update. Again, really appreciative, and thank you again for all of your time and your thoughts. We really appreciate it. 

Thank you for it. Yeah, great. Sorry, I was going to say thank you for having me. It was a lot of fun, and I'll be happy to be back again in the future, and talking about how the pandemic is finally getting behind us, which it will. 

Excellent, excellent. Thank you. So now just to give our audience members a glimpse into what's coming up with our webinar series. 

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Slide, Upcoming Webinars. Register: travelers institute dot org 

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We have four coming up for you. April 28, we're going to have Loree Toedman talk about trends in personal insurance. May 5th, a very special event, we're going to have the tournament director of the PGA TOUR Travelers Championship along with our own Andy Bessette giving us a sneak peek behind what it takes to put on a PGA TOUR event. And then May 12, Small Business, Big Opportunity and on May 19th data-driven scientists are going to talk about transforming your business in a digital age. So catch all of those. Again, you can join me on LinkedIn, and get on our mailing list. So thank you again for your time everyone for joining in. And stay safe, wear your mask, and get vaccinated. Thank you Dr. Jha.