Life After Shelter in Place: A Conversation with Stanford University School of Medicine Dean Lloyd Minor, MD

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Title card, Wednesdays with Woodward (registered trademark) A Webinar Series. Life After Shelter In Place, A conversation with Stanford University School of Medicine Dean Lloyd Minor, MD. Logos, SBE Council, Small Business and Entrepreneurship Council, Travelers Institute, Travelers, ACCION. Video feed, Joan Woodward. 

(SPEECH) 
Good afternoon and thank you for joining us for today's program. Before we begin, I'd like to take a moment to draw your attention to our disclaimer on the screen, saying to you, always seek your own medical and legal advice. 

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My name is Joan Woodward, and I will be your moderator for today. For those of you who may not be familiar with the Travelers Institute, we are the Public Policy Division of the Travelers Insurance company. We function as the educational and informational arm for the company, hosting events and publishing white papers on a variety of topics. 

This is our fifth webinar in our Wednesdays with Woodward series where I have the pleasure of speaking with thought leaders and experts about pressing topics that impact us both in our personal and professional lives. Over the next few months, every other Wednesday through Thanksgiving, we'll host these free educational webinars, so we do hope you'll join us for the future ones. 

Visit travelersinstitute.org to see recordings of our past events and to register for upcoming webinars. | want to say a special thank you to our partner organizations who helped get the word out about these programs, the Small Business Entrepreneurship Council and Accion. 

Our program today will explore the medical community's response to COVID-19 from diagnostic testing to tracing to vaccine and therapeutics. Our ability to get these components right and vaccines widely available is really the key to opening our schools, our businesses, and our communities safely. 

I'm sure many of you have followed the race to develop a coronavirus vaccine and hear the news that different vaccine candidates have reached various phases of development and trials. As governments support these research efforts financially and pre-order vaccines for their constituents, the general public is left with a lot of questions. 

How close are we really to developing a vaccine? What do different trial phases mean? And how quickly can fast-track candidates advance? Once a successful candidate is identified, how will distribution be prioritized among the population, and when will we achieve widespread distribution of this vaccine? 

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Slide, Speakers. Images, Two profile pictures. Text, Joan Woodward, EVP, Public Policy and President, Travelers Institute Moderator. Dr. Lloyd Minor, Dean, Stanford University, School of Medicine, Speaker. 

(SPEECH) 
Here to explore these questions today we have Dr. Lloyd Minor, Dean of the Stanford University School of Medicine. Dr. Minor is uniquely qualified to answer our questions about the coronavirus. We are so honored to have him with us today, and so thrilled that he took time out of his busy schedule. I hear it is opening day for med students at Stanford, so thank you, Dean. 

Dr. Minor has been Dean of Stanford Medicine since 2012 where he also serves as a Professor of Otolaryngology, head of neck and--head and neck surgery, as well as by courtesy of bioengineering and of neurobiology. As dean, he plays an integral role in setting strategy for Stanford Medicine, including the school, as well as the associated Stanford Medical Center and Health Center Systems. 

Prior to Stanford, he served as provost at Johns Hopkins University. He was elected to the National Academy of Medicine in 2012 in recognition of his professional achievements and commitment to volunteer service. These are just a few among many other impressive accomplishments which I could spend the entire hour detailing. 

I'm sure many of you have questions for Dr. Minor, which we'll definitely reserve time at the end of this program. So you can submit your question using the Q&A function. So if you hover over the bottom middle of your screen, a Q&A function will come up, and so you can type your question there. And don't wait till the end. Type your questions in as we go along. You can also send anonymously. If you don't want to give your name attached to your question, you can do that anonymously. 

So to begin our program, we are six months into this pandemic, unfortunately. Dean Minor, where are we today, and are we making good progress? 

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Slide, Speaker, Dr. Lloyd Minor, Dean, Stanford University, School of Medicine. Video feed, Lloyd Minor. 

(SPEECH) 
Well, thank you very much, Joan. It's good to be with you today. And thank you, everyone, for joining today. I think we are making progress. These past six months have been a very long six months for all of us. We've never experienced in our lifetimes something like what we've experienced these past six months. 

I'm encouraged that we understand much more about the SARS-CoV-2 virus today than we did in March. We understand its principal mode of transmission, and that is through droplets. 

And we also understand that there's a lot that we can and should be doing to prevent the spread of the virus, such as wearing a mask, observing social distancing, washing our hands, the types of interventions that each of us is capable of doing and should be doing, and that we know to be effective in the majority of cases at preventing the transmission of the virus. Also, we've made great progress towards the development of a vaccine, and we'll be spending some time discussing that today. 

Testing capacity remains challenged in many parts of the country. One key thing to remember is in most areas of the country today, for people who are symptomatic, it is possible to test quickly. And we'd encourage that people who develop symptoms contact their health care provider and get a test so if they are positive, they can isolate themselves, and also so that those who've had contact with them can take appropriate precautions as well. 

Surveillance testing is still capacity limited in our country. There is a lot of effort going on to increase capacity. And I think as we move into the fall and winter months, we will see larger capacity for surveillance testing. But it's important to remember that surveillance testing will not in any way alleviate the need to wear a mask, to observe social distancing, and to take the precautions that we've been talking about since the very beginning of the pandemic. 

Finally, I think this pandemic has really underscored some troubling aspects of health and health care in our country. This pandemic has disproportionately affected people of color. 

Depending upon the study, Black Americans are three to 4.5 times more likely to develop COVID-19 than are whites, and the outcomes for those Black Americans who are positive for COVID-19 are poorer than those outcomes are for whites. For the Latinx community, similarly, the Latinx community has been disproportionately affected when compared to whites. 

And we know that COVID-19 has underscored a sad fact about our society, and that is that the best predictor of life expectancy in the United States today is not our genetic code, but it's the ZIP Code in which we live. And I think COVID-19 has really brought these facts home and to a level of awareness that calls upon each of us to take heed to the facts that we see about this disease and its disproportionate impact on people of color, on people who come from socioeconomically underprivileged environments, and really to renew our commitment to making an impact on that and correcting these inequities in the future. Thank you. 

OK, terrific. Thank you so much for that just quick overview and insights. Before I open it up to audience questions--and again, just hover in the bottom of your screen and the Q&A function. Just type in your question, and we'll get to as many as we can today. We already have a number coming in. 

So here's a couple of questions for you, Dr. Minor. And I'm going to get right to it. I'm going to talk about vaccines. I really do believe that we are all on pins and needles, thinking about when a vaccine will be widely available for us, and how that process will go. 

So let's get to diagnostics and treatments in a few minutes. But the outlook for a coronavirus vaccine, what does it look like right now? Let's talk about the process of developing a vaccine. So actually, walk us through the different phases. 

So if you're not a medical professional, we hear we're in Phase III trials. So can you go from I to II to III or maybe even pre-trial? What is the process for a candidate to get approved? 

Great question. So in general, there are three different phases of clinical trials. They're sometimes broken down into sub-components, but three overall phases. Phase I is the safety trial. That is, is the drug safe? Can it be administered without side effects, or with side effects that are known and can be controlled? Phase I trials are typically conducted in healthy volunteers. There can be some exceptions to that. 

Then Phase II trials really look at efficacy. Does the drug or does the vaccine do what you think it should do? In the case of a vaccine, does it lead to an immune response, for example?

And then Phase III trials are large trials that involve enrollment of many, many people. And of critical importance for the COVID-19 vaccine, that involve enrollment of people who are disproportionately affected by the disease. And so we've read in the press a lot about making sure that the clinical trials for COVID-19 vaccines have enrollment from people from underrepresented communities, and that they're represented in the trial proportionally to the impact of the disease on their communities. 

And that's extremely important at really determining the efficacy of a vaccine or any drug, because it's very rare that a vaccine or a drug acts the same in every individual. There are so many differences in our immune system that we need to study the efficacy of vaccines in a large group of people, in people from different age groups, because in general, as we get older, our immune system doesn't produce as many antibody or other immune responses as for younger people. And so defining what the best vaccine is going to be for each cohort is really important as these clinical trials move forward. 

That's a terrific overview. So is there anything different about this process for a COVID-19 vaccine compared to a normal vaccine trial? Other than it being sped up and accelerated, is there anything different going on at the FDA now? 

Yes, there's a lot different going on. First, we've seen a lot of federal investment in these trials and in the pharmaceutical companies that are producing the vaccines. Also, very encouragingly, there are multiple different approaches to vaccine development that are being used by different pharmaceutical companies. 

And this is good because we're not just dependent upon one shot and goal. We have vaccines that are in clinical trial today that use the nucleic acid, the RNA, to produce an immune response. We have vaccines that are based upon attenuated virus or inactivated virus, or that are using another virus to mimic the SARS-CoV-2 virus, because the other virus has been engineered with a portion of the genetic material of the SARS-CoV-2 virus to fool the immune system into thinking that it's SARS-CoV-2, and to therefore make an immune response that will be effective for SARS-CoV-2. 

So multiple different approaches. And from concept to actually the beginning of clinical trials in humans, that can take years when we're not in a pandemic. That timeline has been shortened. 

It's been shortened, though--I don't think it's been shortened in a way that threatens safety. I think that there still has been an enormous emphasis on the preclinical studies, the studies done in tissue culture or in animals before vaccine candidates are actually administered to humans, and then in very careful monitoring of people who are enrolled in these trials. 

I do think that we are going to have by early 2021 a vaccine or group of vaccines that have made it through the Phase III trial. And that after a Phase III trial, the FDA examines all of the evidence, and then when appropriate, the FDA issues authorization for the distribution of, in this case, the vaccine. Probably for this particular vaccine, it would be done with an emergency use authorization, meaning that the FDA will define the way in which the vaccine can be used, the groups of people who are eligible to receive the vaccine, and will then monitor that the vaccine's being rolled out in the way it should be. 

And one other point to mention is that because of the funding coming in from the federal government through Operation Warp Speed and other initiatives, the pharmaceutical companies are not waiting for the results of the Phase III trials to scale up production of doses of the vaccines. There are literally tens going to hundreds of millions of doses of these vaccines that are being produced as we speak. 

Now if the vaccine proves to be ineffective, then the pharmaceutical companies are going to have a lot of vaccines to get rid of. But having the governmental backing to enable those companies to scale up production before knowing the results of the Phase III trial was critically important at shortening the time between the completion of the trial and actually being able to distribute doses of the vaccine to the people who need it. 

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Slide, United States Vaccine Investment. Table. Text, Total Investment of $10.3 billion secures 800 million vaccine doses with the option to purchase an additional 1.1 billion. Columns are labeled as companies, U.S. investment, pre ordered doses, optional additional doses. Moderna, $2.48 billion, 100 million, 400 million. Johnson and Johnson, $1.0 billion, 100 million, 200 million. Pfizer, $1.95 billion, 100 million, 500 million. AstraZeneca, $1.2 billion, 300 million, 0. NovaVax $1.6 billion, 100 million, 0. Sanofi GlaxoSmithKline, $2.1 billion, 100 million, 0. Total, $10.3 billion, 800 million, 1,100 million. 

(SPEECH) 
So let's go to the slide, because we've put together a short slide that shows the US has already invested more than $10 billion, as you just said, in pre-purchasing doses of vaccine. Also in R&D. And so this slide shows that six different companies have already got not just R&D money, but the US has pre-purchased these hundreds of millions of doses. 

Talk about the supply chain for coronavirus. So when you say these companies on their own, have they just decided to start producing these hundreds of millions? And other countries clearly are also buying hundreds of millions of doses for their people. 

And talk about the supply chain and how that gets managed by these companies, because this is not their first rodeo. They have developed vaccines and pre--as you say, they're stockpiling even before we know it's been approved, correct? 

That's exactly right. And one of the advantages of having multiple different vaccine candidates--so each one of these companies on your slide, which very nicely displays what's going on with each company's vaccine development--each vaccine is different than the other. And while there are areas of overlap in the supply chain, for example--glass test tubes, for example--there are also many unique features of the supply chain for each of these vaccines. 

And that's good, because the more common aspects of the supply chain, we have the ability to scale up enormously, and that's going on. So the production of test tubes, the production of pipette tips, for example, in order to transfer chemicals from one test tube or one place to another. And those have intermittently been in short supply. 

I think right now from what I have seen and heard from my colleagues who monitor this very closely, right now there are not any major snafus in the supply chain involved in the production of any of these vaccines. And I think there's a lot of time and effort being spent on making sure that that doesn't occur as the scale-up builds even more. 

But we have to remember that even as vaccines get rolled out in the United States--and as I said, we are optimistic that will occur in early 2021--we're going to be living with COVID for a long time, because although it's unclear exactly what proportion of the population needs to be immunized, it's a significant proportion. 

And this disease, of course, doesn't know--this virus doesn't know the difference between one county and the next, one State or the next, or one country and the next. And even though we've restricted travel a lot to really bring COVID-19 under complete control, we're going to need immunity around the world. And that's going to take a while to achieve. 

And until then, we're going to have to continue to observe the vigilant practices maybe in a different form and character, but we're going to have to continue to be vigilant about the communicability and the spread of this virus. And it's going to continue to have an impact on how we plan our daily activities. 

That is a really terrific overview, and I think not widely known about how these things--the supply chain gets managed and how governments get involved. So I have another question about countries. So who determines which countries get the vaccine first? For example, is there a framework by the WHO? 

Or does each company's CEO--so if I'm a company CEO and I was given an order by the US Federal Government for 200 million doses--which again, you say they're producing right now. Even though they're not sure if it's going to get approved or not, they're pre-producing these. How do I decide as a pharma company which countries get this vaccine first? 

It's a very good question. I think the US government did the responsible thing by making investments early in, as you saw on the slide, at least six different vaccine candidates that are very far along in the production scheme, and in making sure that those investments in the production of the vaccine assured that there would be access of people in our country to the vaccine. 

By and large, the companies have a great deal of latitude in deciding what types of investments they're going to take and where they're going to sell their goods. And that's been an underlying principle, I think, of trade for large companies that are by their definition multinational in terms of their presence, and in terms of the innovation that has led to their success. 

So I think we in the United States have benefited from the fact that pharmaceutical companies almost without exception, or the larger companies don't just have operations in the United States. I think it's been beneficial that they have a presence in other countries, and that they're receiving input on a research and development scale from a variety of different innovators, faculty members, leaders around the world. But it is an ecosystem where the companies still have a great deal of latitude in deciding where vaccines will be sold. 

I would also say, though, that in my experience, being in medicine now over the course of three decades, I've seen more collaboration and cooperation among industries--so among pharmaceutical companies-- collaboration between big pharma and smaller companies, collaboration between academics, collaboration between academics and industry. 

There's more of an atmosphere of collaboration and more effective collaborations than I've seen during COVID-19 than ever in the past with any other health care crisis. Of course, we never dealt with anything like COVID-19 in the past. But I think it's encouraging the way companies have responded. 

And while, yes, we want to get vaccine doses administered in the United States, we also have to remember that it's a threat to the United States. If we just want to look at the United States' interest, the fact that the disease is still prevalent and is growing in prevalence in many parts of the world still places the United States in danger, no matter how many vaccine doses we administer in our country. 

OK. That's also very, very helpful. So assuming we're in Q1, Phase III went well for one or two or three of these companies, and the vaccine's approved, which individuals--these are very tough questions. These are medical, ethical questions. Which individuals in our country or which regions will get priority in line to get it first? 

This question has been coming in through our chat feature, our Q&A feature a lot. Everyone wants to know, who's going to get it first? And who's going to decide that? 

The National Academy of Sciences and the National Academy of Medicine have established a panel that includes scientists and ethicists to make recommendations on the distribution of virus. That panel and others will be making those recommendations to the Department of Health and Human Services and to the FDA and other organizations. 

I think and I hope that as those recommendations come forward in the coming weeks and months that they'll be broadly disseminated and discussed within our country, because it is a critically important decision. And just in the press over the past couple of days, we've read where the FDA has been closely monitoring the enrollment in clinical trials and in at least one example has given feedback to the company that their enrollment of people from underrepresented groups and people who are disproportionately affected by COVID-19, their enrollment in the trial is not large enough for those groups, and that that has to change, or the trial may be slowed. 

So I think there's an appropriate level of governmental oversight even in the clinical trial phase. And I do think ultimately, it's going to be a governmental decision, but it should be a decision informed based upon wide feedback from society as to how doses of vaccine get distributed. I also want to point out that I read one poll, I think this past weekend, that a third of Americans said they would probably be reluctant to receive a COVID vaccine. 

I read the same thing, and it just shook me, honestly. 

Yes. And that's troublesome. We know that the anti-vaccination movement has gathered steam, not based upon science, but has gathered steam in our country. And, as a consequence, we've seen outbreaks of measles and other diseases that we'd eradicated from our society. And a lot of people become sick and injured from that. 

I can understand--we're all dealing with a tremendous amount of anxiety today. I mean, we began by saying, I've never experienced anything like this. I don't think any of us has. 

On the other hand, the more that we in the scientific community can be transparent about the results of the trials, about the ways in which they're conducted, about why when the FDA makes the decision to release a vaccine it will have studied this with incredible rigor. And we know also from a wealth of scientific evidence over the course of decades that vaccines are safe. 

And so I hope that through the communication that comes out over the coming weeks and months that more Americans will feel safe and confident in taking advantage of a vaccine once it's offered to them. Otherwise, the effects of the pandemic are going to be prolonged. 

Well, today, when we send our kids to school or when we're sending our kids off to college, I mean, they have to prove that they've had certain vaccines. And so could you see a moment in time where-- we all know the seasonal flu vaccine is voluntary and you don't necessarily need to get it to go to elementary school or go to college. But do you see a moment in time where the COVID vaccine would be mandatory? I mean, I think Fauci said over the weekend that they don't anticipate mandating that people get this. 

I think that's a prudent step initially. First of all, COVID-19 only began to exist in, we think, around December of 2019. Maybe late November. So we don't know enough about the natural history of this virus. We know a tremendous amount about the natural history of measles, and measles is much more contagious than is COVID-19. And therefore, mandating a measles vaccine before you enter a school environment is, I think, an appropriate public health measure to take. 

I think with COVID-19, we're going to have to see how the pandemic evolves, particularly once we do get larger scale immunity, whether or not it still remains transmissible down the road, say, a year from now. And that would probably govern public health officials at that time making a decision to recommend mandatory vaccination, or not to do so. 

We just don't understand or know enough about this virus and its long-term stickiness to-- that is, where it's going to acquire hosts to continue to be infectious, to know whether or not it's prudent to require a vaccination. Therefore, I think what Dr. Fauci was saying is the prudent thing to say. And that is, it's not going to be rolled out as a mandatory vaccine. 

OK. Let's talk about another vaccine choice. So all these companies we have on our chart are developing, and we hope there's more than one or two of these that get approved. Is it likely that consumers will know which vaccine they're going to get? Will they have a choice of these different companies? Or will it be basically up to their health care provider or their health care insurance to say, this is the one you're going to be getting today?

Well, certainly in the clinical trials, people know what vaccine they're getting. We here at Stanford are hoping to--or will be participating in two of the trials of the ones listed on your chart here. And we'll be receiving instructions on the enrollment criteria and be following those criteria. 

I think as vaccines roll out, it's going to be dependent upon whether or not we have one or more vaccines --or more than one vaccine that makes it through Phase III trial and receives emergency use authorization from the FDA. If we have more than one vaccine, probably the Phase III trial data will demonstrate, for example, maybe one of these vaccines is more effective in older people than in others. Well, then we'll have an age stratification most likely where the vaccine more effective for older people will be selectively channeled towards older people, and younger people will receive the other vaccine that is equally effective, say, as the vaccine that is only--or more effective for older people. That probably will govern decisions on how vaccine is distributed. 

But I expect to have a large number of guidelines coming from the government about when people qualify for the vaccine and the sequencing with which it should be administered. Because even though there are going to be hundreds of millions of doses available, it logistically is a complicated matter to get those into communities. And doing it in an equitable way, I hope, and I think is going to be a high priority. 

OK. You mentioned just quickly--I want to get back to it--is, what's happening at Stanford now in terms of this health care research? I read a recent study from, I think it was the Pediatrics Department at Stanford, finding that vaping was linked to substantially increased risk of getting COVID-19 in teenagers, as much as five to seven times more likely compared to non-e-cigarette users. Can you speak to what's going on in terms of research at Stanford for us? 

Certainly. I've been so pleased and proud of our faculty. I've always been pleased and proud of our faculty, but in particular during COVID-19. We've had a significant number of our faculty who have pivoted their research interests and their clinical interests towards issues related to COVID-19, whether it's understanding the biology of the virus itself or it's repurposing antiviral drugs where we have a number of clinical trials going on, looking at repurposed antivirals as therapeutics. Or it's looking at the societal effects of various behaviors on the propensity for developing COVID-19, as the study you just mentioned did. 

So in this study, which was done by--it was done by a survey. And adolescents who vaped or vaped and used combustible tobacco products, cigarettes, were five to seven times more likely to be infected with COVID-19 than those who didn't. In other words, some important issues raised or mentioned in the paper, that is that in general, adolescents that were vaping were more symptomatic, and therefore were being tested more frequently. 

Nonetheless, it's a stark difference that the incidence of the infection is that much higher among adolescents that are vaping. And I think it underscores the health risks of vaping. And as the authors of the study pointed out, the desire for the FDA to regulate vaping more strenuously in the future. 

Great. So I now want to turn to diagnostics and treatment and take a step back a little bit. Where does the US stand now in terms of diagnostics and tracing? And how does that compare where we kind of need to be from your perspective? 

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Slide, CDC Guidance on Phases. Flow chart, Phase 1, Downward trend of documented cases over a 14-day period using a 3 day average, If near pre-pandemic level of COVID like visits has been reached and is maintained over 14 consecutive days 2-3 day grace period then advance to stage 2. Phase 2, Downward trend or near zero new cases reported for at least 14 days without experiencing a rebound after entering phase 1, then advance to stage 3. Phase 3, Downward trend or near zero new cases reported for at least 14 days without experiencing a rebound after entering phase 2. 

(SPEECH) 
I think that's a challenging point. The contact tracing is a challenging point. Let me first cover diagnostics and then some about therapeutics, and then talk about contact tracing. 

On diagnostics, we have a number of different diagnostic tests that are coming on board. We here at Stanford were one of the first in the United States to receive emergency use authorization from the FDA for our so-called RT-PCR. And we continue to be the dominant test provider in our region of Northern California. And we're pleased to provide those services to our community. 

In order to rapidly scale up surveillance testing, though, we need different technologies. And that's why we've read about saliva-based tests and the FDA granting just a couple days ago emergency use authorization for a saliva-based test, and other technologies that can be used for screening testing as well. 

The supply chain and diagnostics continues to be intermittently challenged. And if we do massively scale surveillance testing, that supply chain is going to be challenged even further. So having a robust series of options for surveillance testing is going to be important in order to really generalize its use. 

But for people who are asymptomatic now across the country, the RT-PCR test with a swab either administered in the back of the nose, or the middle of the nose, or in some cases the front of the nose, the RT-PCR test can provide a very accurate indicate--or decision as to whether or not a person is symptomatic from COVID-19 or from something else. 

And that's critically important, because tracing the contacts, particularly the contacts in the home environment, and as much as possible, isolating and quarantining people, is the key to slowing the transmission of the virus. Most transmission is occurring among very close contacts, typically in the home environment. And being able to trace contacts and get testing for people who are symptomatic rapidly as well as do quarantining and isolation is critically important. 

Now, the challenge in the United States is an understandable one, and that is we deeply value privacy, and nothing is more valuable to us in our country than the privacy of our health records. And we have to respect that desire. 

On the other hand, tracing contacts involves a certain degree of relaxing that privacy, because you may not give the name--the health department may not give the name of the person, but it probably isn't going to take a whole lot for the person who's being called with an exposure notification or contact notification to figure out what's going on. 

And that's the dilemma that I think is being weighed by employers. Health Departments do have that statutory right to do contact tracing, if necessary, to reveal identity. But they're the only entities in our society today that have that delegated statutory right. There are a few exceptions. 

So it means that contact tracing here in the United States can be a more cumbersome process than it is in countries that don't place the same value on civil liberties that we do. I'm not suggesting for a moment, though, that our approach to civil liberties should be changed. It's just that it does introduce another complexity that we've had to overcome in the US. 

And you don't think the virus is so out of control that contact tracing is--we're just beyond that, that there's no way it can be done? You firmly believe, especially within, as you said, the family setting, it's still worthwhile to do, and we, or obviously, the Federal Government is fighting over how much money to spend on this tracing. 

Right. I do think it's valuable to do. It's also valuable to do as we get people back into the work environment, although we still need to wear masks and observe social distancing in the work environment. But if people have been exposed in the work environment, it's going to be best--even though the vast majority of people exposed in the work environment are not going to become infected, it's still going to be best for them to be prudent and stay out of the work environment until we're sure they're not infected. 

That's the way to lower this so-called or not or transmissibility, the number of people infected from an index case. And we need to keep that below one in order to continue to decrease the incidence of COVID-19 in our society. 

OK. So I have a question coming in from my good friend in Salt Lake City, Spence Hoole. Thank you for being on the line. Spence, you read my mind, because our next chart shows here the CDC guidelines forstates entering different phases of reopening. And so now, Doctor, we want to shift into--our states have reopened. Some have re-closed or reverted back to Phase 1 and 2 openings. 

But our kids. Our kids are going back to school, right? In various different ways. Some online, some hybrid, some all online. Universities--Notre Dame and UNC Chapel Hill and others have already shut down, right? So with them reopening and with the guidelines of phased here, what level of spike in cases-- it's a two-part question--what level of spike in cases should be considered acceptable? 

(DESCRIPTION) 
Slide, State Restrictions Across the US. A color-coded US map. Red is major, green is none, moderate is orange, minor is grey. California is red. Alaska and West Virginia are green. A dozen or so states are orange. 

(SPEECH) 
What else versus a shutdown? So what percentage of people out there are contracting the virus? 

And then my friend Spence Hoole asked the question, there's a number of medical professionals, including at Stanford. He's done his research. He gives me three names. Dr. Scott Atlas, Dr. John Ioannidis and Dr. Michael Levitt, who are much more in favor, if I have this correctly, and if Spence has this correctly, they're more in favor of opening schools than more of a shutdown mindset. So if I got that correct, give us your thoughts on all this. 

Thank you. Well, those are excellent questions. Let me address the first question of, what level of incidents in a community should lead to going back? In other words, away from Phase 3 and to earlier phases. 

The answer to that question is going to depend upon the specifics of the community, the population density within the community and the availability of health care resources in the community. What we saw tragically in New York City in late March and April was a level of incidence and a rise in the number of cases so rapidly that the health care delivery system became overwhelmed and there was a lot of mortality that had the delivery systems in New York not been overwhelmed, much of that could have been prevented. 

And so the capacity of the delivery systems in an area is going to vary with the area. So I can't quote an exact number, but those are the types of things that public health officials are taking into account. 

And I think California's Governor Newsom has described it well when he said, reopening is not like an on/off switch. It's like a dimmer switch. So California came back on. The lights came back on, and we saw a rapid uptick in cases. And now we've had to back up. 

And you can see from the map, many restrictions have been put back in place in terms of closing indoor restaurants and hair salons, things like that, where we know the risk of transmission is particularly high. So each location is going to need to make the decision about reopening or the different phases of reopening based upon health care delivery resources, based upon population density, and a number of other factors. 

[INTERPOSING VOICES] 

No, you go ahead. 

So you mentioned California. So we have this other chart we're going to show, which outlines the restrictions currently in place by state. And as you can see, California is the big bright red. It's the one state with major restrictions in place. 

So if you're out there, we have almost 900 people registered for this webinar today. So look at your state and see where you are relative to others. But governors have really, really stepped up, I think as you say, Newsom in California--and monitor this very closely. So in reopening schools, as you say, the key data points for governors and other local officials, it's also on a local basis. So if your state is a little dotted line on our chart, there's different phased in openings in different counties. 

So I have a number of questions coming in from the audience here on the flu season and the flu shot. So how will the presence of COVID-19 impact the way we should think about the flu season? So are you more susceptible to the flu if you've had COVID-19, or vice versa? 

It's a great question. We don't fully know the answer. The concern is that there are going to be a lot of people in the fall and winter develop respiratory symptoms, which by the way is why there's such a push to increase our diagnostic capacity, because we want to be able to identify those people whose respiratory symptoms are due to COVID-19, and we also want to be able to identify those who are due to flu. 

Now, the risk is that, yes, probably someone who has had or is actively infected with COVID-19, particularly during the infectious phase, they may be more susceptible to developing influenza as well. Again, that's a question we haven't answered yet, but it's certainly a possibility. And therefore, their illness could be much more severe. 

I think there could also be a silver lining here, though, and that is the precautions that we should be following today of wearing a mask, social distancing, those precautions are also going to block the spread of influenza. It's a respiratory virus. It spreads in fundamentally the same way that the SARS-CoV-2 virus does. 

And also, we will have a flu vaccine that everyone should be encouraged to take, assuming that they don't have a medical contraindication to taking it. So I do think that if properly managed, this flu season, although I think what the CDC has said is prudent, that this could be a particularly bad fall and winter in terms of health outcomes, I don't think it has to be if we follow measures that are appropriate. 

And I want to maybe mention one thing also about Spence's question on opening public schools. I'm really pleased that this was announced over the weekend, Sunday and Monday, that we at Stanford, as well as colleagues from Johns Hopkins University and UCLA, are going to be advising the Los Angeles Unified School District on its plan, when it can, to bring students back into classrooms. And we'll be, in particular, advising epidemiologically on the modeling and on the surveillance testing strategy that LA Unified is in the process of developing. 

I think getting children back into school is critically important. We know, however-- and the best evidence that I've seen comes from studies done in Israel where Israel was very effective at bringing COVID-19 under control early in the pandemic in March. February, March, and in early April. 

And then Israel reopened the schools. They also reopened businesses, and they saw a rapid uptick in cases. Now, I'm not saying that all those cases came from the schools, but the studies have indicated many of them did. And while we know that children under the age of 10 are unlikely to be infected with COVID when compared to adolescents or adults, we also know that adolescents and adults do develop COVID-19--maybe minimally symptomatic--that they can transmit that to adults. Although again, social distancing, masks dramatically lower the risk of that transmission. 

And then those adults can transmit it in communities to others. And particularly when there are multigenerational households, there may be a teacher that may have mild effects from COVID-19, but if that teacher is living with a parent or parents, they may have much more severe consequences from COVID-19. 

So I think prudence on reopening the schools is advisable. At Stanford, we're very much hoping to bring undergraduates back, at least freshmen and sophomores, for the fall quarter. 

But when the State, I think appropriately, issued its guidelines about no in-person indoor instruction when a county was still on the watch list, which we are in Santa Clara County, our home county for Stanford University, we made the decision that the risk simply outweighed the benefits. And I think those types of difficult decisions are going to be made at universities and school districts across the country until we have the type of surveillance, and ultimately until we have a vaccine to rapidly increase the immunity. 

OK, terrific. So I have a ton of questions coming in from our audience. We're going to go rapid fire if that's OK. So I'll just hit you with a bunch of them, and we'll get to as many as we can. 

(DESCRIPTION) 
Slide, Questions. Image, People raise their hands in front of a speaker. 

(SPEECH) 
But my first question--this is for my clarification. You've mentioned several times SARS-CoV-2. So what is, for those non-medical professionals, what does SARS-CoV-2 mean? 

Well, that's the name of the virus. So this is a coronavirus. That's the family of viruses that it comes from. It's named for that because under the electron microscope, it looks like a crown-shaped structure. It is a relative of the SARS virus from the 2003-2004 period. It's a relative in the same family of that. 

And so the official name of the virus is SARS. And SARS is the acronym for Severe Acute Respiratory Syndrome. SARS--coronavirus--CoV number 2. So that's simply the name of the virus. The illness that it causes is COVID-19. 

How is 2 different than 19? 2, 19? How is that different? 

Sorry. The illness that it causes is COVID-19. And it's just coronavirus infectious disease-- so COVID-- 19, because it was first identified in 2019. 

OK. Perfect. So we knocked that one off. All right. We're going to go a little more rapid fire. Will the COVID vaccine be more like the flu vaccine that doesn't really have 100% effectiveness, or more like chickenpox and measles, which seem to be almost 100% effective? And that was sent in by Tiffany Nolan.

It's a fantastic question. I've oftentimes said that my crystal ball has been pretty cloudy these past six months, and I think I'd have to evoke that for the answer to this question. The early results from the clinical trials that are coming in indicate that there is a robust immune response, antibody response, to the vaccines that are being reported thus far. And that's encouraging that the prevention of infection should be robust as well. 

But we won't know that until well into the Phase III trials, and we really won't know it until a very large number of people have been immunized. And then we'll get an indication of whether or not people need a booster, or maybe like some vaccines that we have today, need to be administered in two doses in order to build up the immune response. We just don't have enough information right now to answer that question. 

That was our next question from my friend Sue Espinoza. She's asking, do you think we'll have to have one and done or get a booster? So we just don't know right now, correct? 

Right. Right. Yes. 

OK. Next question coming in. How airborne is this virus actually? How airborne is it?

It's a great question. It is somewhat airborne. It is not nearly as airborne as the measles virus is. But certainly, in the hospital setting, we take a lot of precautions. There is evidence that it can be airborne. 

For example, a person who is receiving respiratory treatment in a hospital who has an active COVID infection with a large viral load--so there's a large amount of virus in their nose, in the back of their nose, and if they are coughing or they're receiving humidified oxygen, we do know that there can be viral particles aerosolized, that if health care workers are not properly protected, can pose the risk of infection. 

So can it be aerosolized? Yes. In the health care delivery setting, it's really important to keep that in mind. And our hospitals and other hospitals in the country have put into place a number of precautions when a patient is receiving an aerosolized procedure, for example, to protect health care workers. 

Outside of the hospital setting, aerosol transmission is not by any means the dominant mode of transmission. The dominant mode of transmission in the community is droplets. It's virus within mucus, virus within saliva. Then when a person coughs or sneezes, those droplets that have many viral particles embedded within them then get inhaled or get on your skin of someone else, and that's how transmission occurs most commonly in the community. 

OK. Next question. On your professional opinion, will we get to a point in the future with the vaccine being distributed where we won't have to wear masks after widespread testing and vaccine is available? So will we be able to go out? Because we just said 33% of the population has already said they're not interested in getting this vaccine. So would we even be wearing masks or not? For how long?

I think we're going to be wearing masks for a while longer. I think we're going to be wearing masks well into the spring and summer of 2021. I can't predict longer than that, but I do think it's going to take, from all the evidence we have today, it's going to take a while to build up the type of mass immunity needed to bring this virus under control. 

Now, that prediction is being refined and evolving constantly. We've talked a lot about the immune response to the virus and in a vaccine. We mainly study the immune response in terms of antibodies. Those are proteins that are produced that block--they have a variety of actions, but one is they block the virus from being able to interact with its receptor. 

But there are other ways that the immune system tackles this virus. There are cells in the immune system that tackle the virus. We understand that cellular immunity less well, but there have been recent reports just within the past two weeks that the cellular immune response may be more robust than we thought it was initially to COVID-19. And therefore, we may build up immunity faster than we thought. 

But I wouldn't bank my health on that. Given the minimum consequences of wearing a mask and observing social distancing, I think that's going to be the prudent thing to do until we really have definitive evidence that we've brought the virus under check. 

OK. That was great. That was a great answer. Great question too. Next question. Given the strength of the US biotech sector, why has fast testing been such a challenge in the United States? And what is the process for getting those tests kind of approved by the Federal Government and widely available? 

In short, I think the answer comes down to the fact that in the United States, our public health system really has declined over the past four decades, say. You know, when I was a young child, we were still in the era of dealing with highly communicable diseases like measles, like chickenpox, other diseases. And there was a robust public health infrastructure in the United States. 

Now fortunately, through vaccines, through other measures, a lot of infectious diseases we've brought under control. We don't have outbreaks of typhoid fever in the United States. We eradicated malaria from the United States. 

You know, that led to us, I think, backing away from the type of robust public health systems that we need to effectively tackle a virus like this one that, as we said before, doesn't know the difference between one county and the next or one state and the next. And therefore, when we started to see cases of this virus in February, we weren't prepared, and the CDC test methodology initially wasn't working. There a variety of reasons for that. 

And there's no reason to point fingers at anyone. It's just coming out of this; we've got to beef up our public health systems in the United States. And we've got to be much better prepared for events like this in the future, because I don't think-- although it probably is not going to be this particular virus in the future, it's going to be some other emerging infectious disease in the future that we have to combat. And we need to be better prepared than we were this time. 

And how do you suggest--what is it that the federal government or states--I mean, a lot of people don't like government regulation, right? Everyone says, we don't want to pay our taxes. We want to pay little taxes. But clearly, the government has a huge role to play. But it's also the Gates Foundation. It's the WHO. As you said, universities are so engaged, and you said they've shifted a lot of their ongoing research. A lot of the nonprofits in the health care space. 

What is it going to take for us as a country to get serious about preparing for the next pandemic? Because it is not a matter of if we're going to have a next pandemic. It's going to be when. And do you think that question of when is now for some reason accelerated, that we're going to see a lot more of these pandemics like the bird flu, SARS, and others coming one on top of each other? 

Or is it kind of like--we're in the hurricane business, right? We insure, underwrite hurricanes. And the question of these one in a 100-year events, they're happening a lot more frequently. Should we think about a virus and a pandemic happen more frequently, because this was such a big event for the world? 

I think we should think about that possibility in a very realistic way. And there are two areas we can focus on that will help us. One is scaling up diagnostics. In biotech, diagnostics have not received the same level of attention that therapeutics have received. There are variety of reasons for that. It's been very difficult to get new diagnostics approved. Takes huge clinical trials in the past to get a new diagnostic approved by the FDA. 

And the investment required to conduct those studies has been enormous, and the return has been fairly minimal. And therefore, even though there's a lot of great science in diagnostics today and a lot of great emerging technology, it has withered on the vine in many cases in that it has not gotten through to an actual diagnostic test that can be widely used. 

Now, this pandemic has changed that. There's a lot more activity going on in diagnostics. We need to make sure that continues in the future. And I think the FDA will likely be looking at its criteria for approving diagnostics in a different light than it did prior to this pandemic. So that's one area. More emphasis on diagnostics, both research and development diagnostics, and then getting diagnostics approved and widely available. 

The second is vaccinology. Vaccine development had languished over the past 10 years or so. We did have some successes. The development of Merck, for example, of Gardasil, the vaccine for human papillomavirus. A remarkable achievement. But by and large, vaccines have been put on the back burner. 

Vaccine trials are very complicated. They do carry some risk with them. And given the advances in other areas, particularly in therapeutic areas, pharma has been investing far more in the pipeline and therapeutics than it has been in vaccine development in the past. The pandemic has for sure changed that. We need to make sure that we don't back off of this. 

The new technologies on the chart that you had, Joan, that very nicely displayed those six different big pharma companies and the vaccine they're producing, those innovations that have been utilized to make those vaccines that are going to be used for COVID-19, those same innovations can be applied to other viruses. And they should be so that we're not in this predicament in the future when we have an emerging virus in the future or an emerging bacterial infectious disease. 

We need a lot more emphasis on R&D and product development in vaccines and therapeutics for emerging infectious diseases, because I think the risk is there, that we're going to continue to see these diseases that start in animals and then jump to humans. And because we do live in a world that is so interconnected, it's going to be difficult to contain--quickly to contain pandemics, as we saw with this one when it began. 

OK. We are at the top of the hour. I'm going to hit you with one last question, and then I'm going to let everyone on this call who I know is saying to yourself, oh, I wish I had told my husband, my son, my daughter to listen in today, we are going to have a replay of this conversation. I'll tell you where to go to get that. Before we thank you, I want to ask Liz Hurley's question. Is there any evidence that you can catch the virus twice?

It's a great question. I would say it's not impossible. We don't have evidence that conclusively rules that out, but we think it is very uncommon. And a lot of what has been reported in the literature is, oh, this person was infected and then they recovered. Then a month later, they got reinfected. A lot of that we believe, and the evidence seems to indicate in most cases, was people who never recovered fully the first time. 

And we also know that remnants of the virus, although those remnants may not be infectious, remnants of the virus can remain in the back of a person's nose for weeks afterwards. And this is why we at Stanford are working on tests that really identify when the virus is infectious and that then can more accurately inform return-to-work decisions and decisions about when a person is or is not infectious. So still a lot of important research to be done. 

And I just want to end by, Joan, thanking you for inviting me here today. Also, a big shout-out, a thanks to my colleagues at Stanford who are working every day to try to produce the innovations that will defeat this pandemic and provide the care to the patients who entrust their care to us every day. Thank you. 

Well, we are so grateful for your time, for your insights, and for your--this is a tough thing to talk about and predict. It's so personal for so many people. I want to thank Stanford researchers as well. We'd love to have you back in six months or so and see where we are at that moment in time. 

(DESCRIPTION) 
Slide, Wednesdays with Woodward, A webinar series. An inside look at Intellidrive, Travelers' Telematics Program to Encourage Safer Driving Behaviors. Wednesday September 2nd, 1:00-2:00 PM EDT. Learn more at travelers institute.org. 

(SPEECH) 
And again, all of our agents, our customers who joined, let me tell you a couple of places, one, where you can see the replay of this event and register for other programs. And I'll tell you our next webinar coming up. So it's travelersinstitute.org to register for upcoming webinars and watch our recordings of our past events. 

We've had five or six of these events on different ranges of topics. Our last one was on liability shield for businesses with our terrific Yafit Cohn. And that was posted not too long ago. 

Our next webinar will be two weeks from today, Wednesday, September 2, where we'll switch gears away from the pandemic and take a deep dive into IntelliDrive, which is Travelers' app to encourage safer driving behaviors. This app rates your driving based on high-risk factors and provides tips to help you become a safer driver. We'll speak to our app developer, how it works, and what telematics can--how it can be an effective tool to making our roads safer. And so please do join us on September 2 for that. 

Dr. Minor, again, we're so grateful for your time and your insights. And please let us know how we can be helpful as a company to any of your researchers. Thank you all for joining us. Please wear your mask. Stay safe, my friends. Thank you again.