Public Health in an Era of Endemic COVID-19

Hello, I'm Dr. Preeti Malani, JAMA Associate Editor. I'm also the Chief Health Officer
at the University of Michigan and a Professor of Medicine in the
Division of Infectious Diseases. I'm joined by three guests who recently
published a series of viewpoints that describe a national strategy for COVID and
the idea of a new normal as we enter the third year of the coronavirus pandemic. First, I have Dr. Zeke Emanuel, who is the Vice
Provost for Global Initiatives at the University of Pennsylvania. Welcome Zeke. Great to be here. Thank you. And then I have Dr. Michael Osterholm, who's the Director for
the Center of Infectious Disease Research and Policy at the University of Minnesota.

Thank you for joining us, Mike. Thank you. And then finally I have Dr. Luciana Borio, who's the Senior
Fellow for Global Health at the Council on Foreign Relations. Welcome Lu. Thank you so much, Preeti. It's so great to be here. So all three guests are deeply
involved in policy efforts around the pandemic and have served as advisors
to the Biden transition team from November 2020 to until January 2021. The three viewpoints were published online
January 6th and are titled A National Strategy for the New Normal of Life With
COVID, A National Strategy for COVID-19 Testing Surveillance and Mitigation
Strategies, and third, A National Strategy for COVID-19 Vaccine and Therapeutics.

So thanks for joining me. I know it's been such a busy time. If you had asked me last January what
things might look like this January, I would've predicted that things would be a
lot better in terms of COVID case numbers than they are, certainly at this moment,
but even as efforts are focused on getting us through this most recent surge, most
public health experts feel that we are in fact marching towards endemicity and
that vision, the idea that transmission will eventually drop from the current very
high levels, but COVID is not going away is the premise of these three viewpoints. What I'd like to do is explore
some of the practicalities, including how to operationalize
some of the strategies presented. And the first viewpoint outlines the
idea that we are moving from crisis to control and the national strategy
needs to be updated accordingly. Zeke, you and your co-authors write,
“infectious diseases cannot be eradicated when there is limited long-term immunity
following infection or vaccination or non-human reservoirs of infection. The majority of SARS-CoV-2 infections
are asymptomatic or mildly symptomatic and SARS-CoV-2 incubation period is
short preventing the use of targeted strategies like ring vaccination.

Even fully vaccinated individuals
are at risk for breakthrough SARS-CoV-2 infection. Consequently, a new normal with
COVID in January 2022 is not living without COVID 19.” So tell me about
the vision for this new normal. And practically speaking,
how do we move forward? Well, I think the “new” there is supposed
to emphasize we're not going back to 2019, where there was no COVID, we're
going to be in a situation where COVID is going to be around us, it's going to
be one of the multitude of respiratory viral illnesses that we face and it's
going to wax and wane just like flu does, just like RSV does, just like rhinovirus.

And so we need to take that into account. Getting there, we're in far from that
situation at the moment with about 1600 deaths a day, but getting there is
going to require reducing transmission. And that's mainly going to be
done through things like air quality improvements indoors,
wearing asks, and some vaccination to get the incidents level low. Then making sure people
have fewer complications. That's partially the vaccines, which
really are very, very good at reducing hospitalization and death, as well
as the new therapeutics we have. And then it's going to look, COVID
should begin looking like a flu, you get it, you stay home so you don't
infect other people and your family. When you're feeling better, you
can go into work, probably wearing a mask for a few days to again
reduce the chance of infection. And that is going to be more common. We're simply going to get back
to the life that we've known largely with some modifications.

Thank you. So Mike, the US health system does a lot
of things well, but public health is not at the top of that list, yet rebuilding
public health is a key aspect of the strategy described in the viewpoint. What can be done realistically to build
the type of capacity you described? And is this something that should happen
nationally or is it more likely to be successful at the state and local level? First of all, we have to understand
that what we have really seen happen over the course of the past two years
is our healthcare system has been laid open publicly in a way people can see
just the challenges we have in terms of providing care of documenting outcomes
and understanding how we bring those data together to make public policies that
basically are primarily public health related and as well as treatment related.

I think what really is the challenge
here is we've lacked creative imagination to understand what a pandemic could do. A year ago, as I think Zeke just
pointed out and you did, most people thought that we were out of the woods. Some of us said, "Well, with the
variants, maybe we're not, maybe the variants are going to give us some
new challenges we hadn't anticipated." I'm not so sure that's not
the case in the future. I hope it's not, but
hope's not a strategy. And so I think that we still have to
remind the medical care system there is that you'd provide on a day-to-day
basis and there's that you provide on a day-to-day basis during the crisis. And that includes public health. And so I think if nothing else, the
silver lining, if there is one to this pandemic, is it gives us every reason
to go back and reevaluate what are we doing with healthcare or disease care? What are we paying for? What are we not paying for that
could make a difference from a public health standpoint? And so I find this as potentially
either going to end up becoming a forgotten moment we just want to move
on from or it could be a renaissance moment in which we actually go back
and ask ourselves these hard questions.

And now the lessons learned
are right in front of us. They're not imaginary. So to me, I think this is a very
critical time to look at how do we improve the public's health. The final piece, I would say I'm an
infectious disease epidemiologist, but I am very aware of all the adverse health
outcomes that have occurred because we have deferred medical care, we have
deferred many of our public health programs around the world, whether it
be HIV or malaria, polio eradication. And the cost that's occurred
there has been substantial. And so we're also going to have to
understand how to rebalance public health back to a time when basically
many of these issues were not forgotten like they have been during COVID.

And do you think this could
happen nationally or is it going to be more of a local phenomena? Well, I think it has to have
national leadership, but as like with politics, all healthcare is local
in a sense, even though it may be paid for by the federal government. And so I think what we have is
a balance of how do we bring local related activities. And right now, look at what's happening
with our healthcare systems in terms of responding to all these cases of COVID. It turns out in the end, it's local, it's
what assets and resources do you have? Which people do you have that can come to
work today or can't come to work today? So I think it's going to
be a combination of both. It can't be just a top down. And surely, the importance of resources
and national planning are going to be critical for any local group or groups
to come together and say, what is it that we can and should do so that
this doesn't happen in the future? Great.

Let's move on to the second viewpoint. And I'd like to delve into some
of the suggestions outlined, with respect to testing and surveillance. Now, a number of concerns come
to mind, and we clearly need a convenient, easy-to-access testing
infrastructure that also links results to other important data; so
the socio-demographics, vaccination status, and certainly clinical outcomes. But we're a long way from this. So, Lu, what do you think testing
needs to look like for this new normal, and in particular, how do
you build a robust system to deal with the positive results that arise? Yeah. So, that's the hard work. Sometimes we focus so much on
developing the task, the vaccine, or the drugs, but linking the
assets we have, it's the challenge. And I envision that. First of all, I think it's remarkable
that we have now a situation where people are able to do these verily sophisticated
tests at home, and understand whether they might be infected or not.

That's remarkable. I don't see us going back. I think it's going to open up a lot
of novel ways to diagnose diseases at home, at the convenience of the home. But the key, the work of government
I would say, is that they need to… We have to develop a system
around this, so that we can adequately capture the data. And it may require some incentives. There must be an incentive to report
the test; and then, somebody's going to have to aggregate this data, and
create information from this data. I think that in the near future,
one of the great urgencies is to get the results of these tests, and link
them to an action; whether it's to isolation, or whether it's to access
to treatment, as soon as possible.

Because we all know that having a result
is just the beginning, and not the end. Indeed. It'll be interesting to see
how those systems are built. And surveillance goes
hand in hand with testing. So Mike, I'm going to come back to you. What does a comprehensive surveillance
program look like in 2022? And maybe you could talk about
what would be ideal, versus what is going to be realistic. Well, we don't have to capture every case
in disease surveillance to understand what's happening in our communities,
both in terms of the actual number of cases, or the impact that it's having. But we've got to have a representative
sample, and hopefully most cases, to really make that work.

And right now, we have a
system that is so broken. It's hard to believe, but there are
health departments in this country that still receive their reports
on disease cases by fax machine. Right now, I have no sense at all that
the numbers we're getting are reliable, in terms of case reports every day. I've been talking to state and local
health departments around the country, and some of the health departments are
backed up thousands and thousands, tens of thousands of cases, that have not
yet been reported out over weeks and months, just because of the backlog.

And so, one of the things we have to
understand is, big data means also something to public health, in a way
that most people don't think of when they think of clinical medicine. We've got to have a much better way
to both document who's infected, when we do document it, and then to
be able to aggregate that quickly, just like the clinical information. That has been a priority for
public health for the last decade. And yet, it has received little attention. And I think during this particular
couple of weeks with Omicron, it's only become more accentuated.

We've had to go to alternative measures
to understand what's going on in our community: number of hospitalizations,
number of people on oxygen in hospitals, and then unfortunately, even deaths. So I think again, as we pointed out
in the earlier discussion, now is the time for Renaissance thinking,
as it relates to public health. What could we do if we had much
more timely information, and we had more accurate information. So this is going to be something that
is going to be a combined effort of the federal, state, and local governments. And it's got involve the private
sector in a big way, particularly our healthcare systems around the
country, who in the first instance, are where most of these data come from. Thank you. So, Zeke, in the Viewpoint, you write
about encouraging the use of N-95s or KN95s rather than cloth or surgical masks. And, to me, masks have been
really, probably the most interesting part of mitigation.

And if I think back to the beginning,
the message was, "Don't wear a mask. Save the masks." Even, "Masks might transmit
virus if you touch the mask." And then within a few weeks, I also
remember in the hospital, healthcare workers going to universal masking;
and that was a really extraordinary thing, because we were actually very
low on personal protective equipment. And using that mask felt a
little bit like a luxury. And we have learned that masks
are, in fact, super effective when worn properly, especially with
people around you who are masked. But masks are also perhaps the most
contentious aspect of mitigation, maybe even more than vaccines. And there's some practicalities
around distribution and training, but more simply, I just want to ask
more simply, how do you get people to actually do this, especially
when they won't wear a cloth mask? Do you think they'll use an N-95? Well, look. I think this is a case of social norming.

What is expected in society, and what
are you doing as a responsible citizen? Unfortunately, this has become, as
you point out, politicized, and made a matter of a badge of culture; and
that is the wrong way to look at it. It really is, as you
point out, protective. It reduces transmission substantially. But in 2022, we have to be clear:
wearing an N-95, KN-95, KF-94, those are the best masks, and they
ought to supersede all others. How can we social norm that? Well, one thing I have suggested, and
we suggested to the government is, what if you sent out a voucher, so people
could go to a pharmacy or grocery and get 3, 4, 5 of these masks, so that
they could use them free of charge. That would certainly improve the
thinking of the public around them. They would make them easily accessible,
free, and I think much more used.

I would say the other thing
that's very good is a mitigation measure which we have not heavily
discussed, is indoor air quality. We don't have an assurance that
when we go into a building, the air quality is of a very high standard. And if we are going to really improve
for the long term, as Mike points out, the public health around a respiratory
viral illness, is upping the air quality indoors to MERV 13 or better,
is going to be really important. And in the interim, people can use
HEPA filters in school classrooms, in other public places, while we're in
the process of getting these better air filtration handling systems.

Can I just make one other
point, which is to go to this issue of the healthcare system. One of the things that I think
is very, very important, is how we think about telemedicine. We are going to have these crises and
these workforce shortages in different places, and the overwhelming of systems. One of the ways we can pretty much not
address all of that, because a lot of medicine requires face-to-face contact,
especially if you're doing procedures. But there are a lot of things we
can do via telemedicine that we have been resistant about adopting. Medicine across state lines, where
people are able to do it if they're licensed in a state, making sure
liability insurance covers it, making sure you're going to be paid for. But for many, many things, primary
care, a lot of primary care, a lot of mental health; we need to begin
to make that standard, and make permanent the changes we did around
the regulations for telemedicine. I think that'll help us
relieve some of the pressures when a system gets overtaxed. So the third viewpoint focuses on
vaccines and therapeutics, and again, as an infectious disease doctor, this is
one that I'm thinking a lot about this.

In the U.S. at this moment, nearly a quarter of the
vaccine eligible population has still not had a single dose of a COVID vaccine. That number has come down a little
bit, mostly due to the younger kids getting their first doses. But there's very, very little
movement among adults who have not yet been vaccinated. Lu, regarding variant specific
vaccines, you and your co-authors write, "To reduce virus transmission
and infections, next generation COVID-19 vaccines that match circulating
SARS-CoV-2 variants need to be deployed. Genomic surveillance coupled with
nimble vaccine technology allow for rapidly adapting vaccines to
emerging variants.” As I read this, vaccines based on the latest variants,
they sound really great in theory. But to me, the reality feels
different, at least right now. Again, the example that we are in at
this moment, in late November, we are still in the throes of a Delta surge, and
within weeks, we're now seeing Omicron.

Of course, we're not doing
sequencing on everything. But again, who knows
what's going to come next. Is variant vaccine something that
we could do quickly and short term, especially during this phase
of the pandemic where we're still having such large numbers of cases? Yeah, it's difficult to know right
now, because the future is a little bit unpredictable, but I think that it's
important to be able to plan a parallel approach, or we have planned for variant
specific vaccines, because they are the most effective against prevailing
variants, and we have a lot of experience with influenza, for example, should
the virus become a more seasonal virus.

But we also need to pay attention
to more broadly neutralizing or universal vaccines. For one, because this is likely not
going to be the next pandemic, and it's possible that we have another coronavirus
surprise, and it would be really great to have vaccines that would work
against several types of coronaviruses. But also because we can't predict
completely how this virus will evolve. But there are trade offs, right? One type of vaccine is quite effective
in preventing all infections in addition to severe disease and
hospitalization, but very narrow in scope. Others that are broader, there may be
trade offs that may be very effective in preventing serious disease,
hospitalization, and death, but less effective in dealing with all
infections and decreasing transmission. So at this moment, because there are
uncertainties about how this is going to evolve, I think we need to go full steam
ahead with this parallel effort, and it's very important, again, for government,
for the work of government to help these companies establish a framework for how
these decisions are going to be made.

Who makes the decision about what variants
should be included in the vaccine mix, or how are we going to track that? What are the correlates of protection that
would allow us to do a rapid authorization for a strain change, if you will? That work is ongoing. You mentioned the universal
coronavirus vaccine, and you write about that in the viewpoint.

Is this something that you think is
likely in the near future, or do you have an estimated timeline on that? Oh boy, estimated timelines. You're asking somebody who spends
so many years at the FDA, and I'll say they should be as fast as
possible, but no faster than needed. You have to be very careful because
vaccines are given to healthy people, and also, in fairness, what does it
mean to have a universal vaccine? We know that it's not truly universal.

But I think the science is there for us
to develop vaccines that are very good at inducing cell immunity and protecting
us from the worst of this virus. I think the science is there also to
select the epitopes very carefully that will maximize the desired impacts. So, there's always a silver lining, right? I mean, I think that vaccinology has
dramatically progressed in the setting of COVID, because it was necessary to use all
the tools in the box that we have in 21st century science, and I can't think of any
other time recently that we had this type of scientific effort around vaccines and
immunology and manufacturing, et cetera. Agree fully, and if you just step back
and reflect on really what a miracle of science the vaccines have been and
the timeline and the safety and all the surveillance for adverse effects,
it is truly one of many several silver linings from a scientific standpoint.

Well, I would say we should
think about a year ago. A year ago, we just got the vaccines and
they weren't deployed, and we've got very effective, the most effective vaccines
in the world, and we're in the midst of developing variant specific vaccines
very rapidly in just a few months. We've got therapeutics, including
oral therapeutics that we didn't have, we've got these lateral flow at home
tests, which we didn't have a year ago. I mean, there has been a lot of
scientific and diagnostic progress, and sometimes I think in the midst of
it, when we are confronting a million cases and 140,000 hospitalizations
and 1,600 deaths, we often forget how much has changed over time. That doesn't mean we should pause and
be congratulatory, sit on our laurels. We're still in the midst
of a terrible pandemic. But we do need to appreciate the rapidity
with which those things have come online.

Yeah, truly it was unimaginable
in March of 2020, so this is really good to reflect on. Zeke, I want to come back to something
that's more mundane, which is the vaccine verification methods. Again, this is being used increasingly
as an admission requirement to performances, athletic events,
restaurants, and it's layered on mandates at workplaces and schools. Do you think we'll move to a national
electronic vaccine certification platform? We've been resistant to it
under a lot of pressure. I'm not sure I fully understand
the resistance to it. There are platforms out
there in a number of states. But we have very, very good
certification systems up and running in states, and they do work well. You're not required to get an electronic
certificate, you have to access in and download the information, but it is pretty
secure, because you have to use your phone and only you have your phone, so
I think there is some hope that it'll be widespread, even if it won't be national. Yeah, and for people listening
in, I'd encourage you to take a look at the viewpoint.

I think it was really laid out
nicely in terms of the systems. Having been on the other end of doing some
of these vaccine verifications for our students, it's very labor intensive and it
would be great if there was an easier way. We agree. Can I add? Just I think one of the important
considerations here is not what is doable in the sense of science, but what is
doable in the sense of everyday life.

I for one would love to see some
kind of a system where we could know, in fact, what one's immunization,
or for that matter, even if they've previously been infected what their
status is in terms of being protected. But I don't think that'll ever be a
reality just because of the politics. Having served for 25 years of state
and local public health, I have a sense of what plays on the ground.

This one will not play in Peoria. So, I think we've come to
understand what that means. The same reason why we have governors
today who refuse to put into place new mandates around public
events, masking, and so forth in the height of the omicron, because
they'll tell they just can't do it. The public would not accept it. So I think we have to learn from that. We have to understand what that
taught us about what we can and can't do and how we do it. I think the other piece of that is
though, and this is the humbling part about these vaccines, remember
last year, when the vaccines first were approved, we were euphoric. We had these vaccines that were going to
protect us 95% of the time, two doses, we were home free, and then we realized
over time what happens, with potential waning immunity and the potential
need for additional doses of vaccine, we begin to understand more and more
about challenges of what is protection? If you have been previously
infected, what does that mean? And so I think, in a sense, it's a
moment of great humility also, where we have to say, we still have some
really major unanswered questions about what can a vaccine do for us.

How often do you have to be vaccinated? Everyone I think on this screen would
agree, if we ended up having to vaccinate people multiple times a year, which I'm
not suggesting will be the case, but at least some are hinting towards that,
that is simply not doable for the world. It would set up an incredible
double standard that I don't think would ever be allowed. More importantly, look at the fact
that we almost have two thirds of those individuals who have received two doses
of vaccine, they're surely not vaccine hesitant or vaccine hostile, who've not
gotten their recommended third dose.

Why? We have more and more data showing
the improvement and outcomes with that third dose versus the first two,
particularly now against Omicron. So I think part of the sociology of this
issue, the psychology of this issue, is almost as important as the immunology
or the data-driven questions we have and I don't see, right now, that's
there, but I think this is another important part of how we evaluate what
we've been through with this pandemic. Yeah, those are great reflections, Mike. I think it gets back to that notion
too, that the vaccinations are really about protecting everyone around us,
not just a intervention to protect us, and that has also gotten lost sometimes,
although they do protect us very well too.

Yeah, and briefly, I'd like to add that we
have about 25 million children under five years of age in this country, and about
seven million people that are living with immuno compromising conditions, so even
though we'd like to be able to move to the new normal as soon as possible, I think
that one of the barriers to get in there is the fact that we have people that yet
cannot access vaccine yet, and there are people that, despite being vaccinated,
they do not mount a protective immune response, so until we have ample supply
of effective therapeutics, a way to link testing to diagnosis, to therapeutics,
that is going to slow us down to feeling like this is now a new normal.

Yeah, for sure, and that's a great segue
to the last topic I want to talk about, which is oral therapeutics, and this
is another place where we've seen great progress, and I think in the long term, I
am really hopeful that these agents will help decrease the risk of hospitalization
and death in those medically vulnerable patients especially, and for monoclonals,
we've been doing this for more than a year with a lot of success and there are new
data to support outpatient Remdesivir use. That's a little harder, because
the logistics in of course. Just in the last few days, oral
antivirals are starting to become available, but the demand is super high,
and right now, supply and resources for administration are limited. So not just the supply, but the
actual physical ability to get these therapeutics to people. So my last question is really
about how to make this work. These therapeutics are most effective,
as we know, early, so you need early testing, you need to connect people. So how do we do a better job, just
from a practical standpoint, right now, linking the COVID19 testing systems,
with an eye on equitable allocation of these limited resources, and Lu, I'll
start with you, and then maybe the others can add in some of their thoughts.

This is something that the three of us… The six of us, actually, the advisors
have talked extensively about, and it'll be very important, I think, as we
move forward, to make sure that there is access that is facilitated, whether
it's at the infusion center, that somebody can self-refer upon a positive
diagnostic test, if they meet criteria, they should be able to self-refer and
get assessed and treated right there, without having this need to go through
a physician, that, frankly, no, this has taken a lot of time right now for
patients, even when the drugs were in more ample supply, the monoclonals,
sometimes several days elapsed between a patient being diagnosed and then
being referred to an infusion center. So I think that's the key,
of course, in addition to increasing supply significantly. If I could just add a
piece here of perspective. We've all, on the screen here, remember,
unfortunately, very painfully, those early days in the 1980s, when an HIV
diagnosis was in essence a death sentence.

Today, we know that we can do amazing
things with therapeutics to make HIV much more a long term chronic condition,
and that ability to do that can't be lost in what I think can happen with
COVID, and the SARS‑CoV‑2 type illnesses. On a global basis, if we could do, just
as Lu just pointed out, and we can do it if we put our minds to it, understanding
with that creative imagination of just how different the world could be with a one,
two punch of vaccines and therapeutics.

We could do, I think, a tremendous
amount to reduce serious illness, hospitalizations, and deaths,
and what more can we want for? So, I think that this is
an exciting time coming up. It's our opportunity. If we miss it, people will die
unnecessarily and we will continue to deal with the social, economic and
political fallout of this disease. If we do it right, we can do
so much to bring this horrible virus under better control. One of the things that seems to me
that would work well, and it's not going to be stood up overnight, but we
need a system where someone who tests positive, initially it'll be PCR, but
then hopefully, we can get the at home test linked to, if they test positive,
they get a robo-call that tells them how they can get the therapy or the number to
call, as well as how they should isolate themselves, the mask wearing, what they
need to do to take care of themselves.

That's not impossible, right? When you go in, at least I recall, when I
got vaccinated or tested, I had to leave a telephone number and I had to leave
a email, and we could automatically, without human intervention, you've
got a positive, you get not just the result, but information about how to
get the therapy, as well as what to do in the interim to protect yourself. We haven't built that infrastructure. It's not complicated. We know that. Lots of companies bombard you with emails
or text with relevant information, and I think that would be enormously helpful. Yeah, thank you, and again, I
think this is one where different states are doing it differently. In Michigan, there is an effort to
try and provide these antivirals at point of care with testing. I hope that we can get to the
point where we are able to scale this with our community pharmacy
partners, sooner than later. So thank you for this great
conversation and thank you also for the work all of you continue to do. Thank you. Thank you. Thank you so much for having us.

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