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CDC Director Robert Redfield, MD, discusses recent developments in the COVID-19 pandemic and US response, including prospects for dual outbreaks of COVID-19 and influenza in the fall and winter.
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>> Howard Bauchner: Hello, and welcome to Conversations with Dr. Bauchner. I'm delighted, once again, once again to be joined by Robert Redfield. Bob, who is director of the CDC. Welcome, Bob.
>> Robert Redfield: Thank you very much, glad to be here, Howard.
>> Howard Bauchner: So, Bob, you know, so much data crosses your desk, what new data have you seen over the last couple of weeks that have been interesting, that you think clinicians and the public would want to know about?
>> Robert Redfield: Well, I think Howard, probably the most important thing is we are beginning, I think, to turn the tide on what I call the Southern outbreak in the nation. I think I've seen pretty strong data that the mitigation steps that we've advocated, something as simple as a face mask, social distancing, washing your hands, closing bars, and having limited indoor dining at restaurants, if you see how Arizona, for example, put that in play--
>> Howard Bauchner: Yeah.
>> Robert Redfield: And literally, you saw, you know, about two to four weeks later, you really see that we can get control of this pandemic. We don't have to close retail, you don't have to lock down, we really just need to wear face coverings when we can't social distance, wash our hands, and be smart about crowds. Particularly, obviously the over-crowding that occurs in bars and indoor restaurants, and we can get this outbreak under control. We are now starting to see that take effect, I think, more broadly across the south. And I think it's really important. We are going to talk more about, you know, my big concern about the flu and COVID coming together, clearly we'd like to see these mitigation steps really slow the impact of COVID now, so we can get those, and get those in full practice, and full operation, as we move into the fall, while you and I talk more about the importance of what we can do to prepare for flu, with flu immunization.
>> Howard Bauchner: Yeah, I mean, when we talked last time, we were up around 60,000 cases. The deaths are still high, over 1,000 a day, but now we're down to about 40,000, maybe 50,000 cases, I think your comment about Arizona is interesting. You know, people can't expect that we put these mitigation strategies in place, and tomorrow the cases go away. And that's preventive medicine, and preventive health. It prevents it in the future. And I think that has been difficult. Where do you want us to be? Where do you want us to be in September or October? 10,000 cases across the U.S., 20,000 cases. What--is there a number that you have a sense where if we were at that number, it would be, it would create a greater sense of safety as we move into the fall?
>> Robert Redfield: Yeah, clearly I'd like to see us get down under where we were in June. I'd like to see us down into 10,000 cases, and obviously see fewer and fewer jurisdictions that we would consider in the red zone. Like to see the prevalence of positive testing around 3% across the country. I mean, it's hard to believe, I was looking in New York data today.
>> Howard Bauchner: Yeah, it's amazing.
>> Robert Redfield: One percent!
>> Robert Redfield: One point three percent for the state. Well we're at 42%.
>> Robert Redfield: So, and I don't think New Yorkers are any more adherent to the mitigation strategies that we are, to show us that a combination of events, obviously being impacted by the outbreak, and probably some increased immunity that occurred as a consequence of the infections, coupled with many people probably have been impacted, and understand this is serious. So the mitigation steps, to see New York now, under 1%, under 2%, 1%, 1.3%, just sheds the rest of the nation when you ask me where do we want to be? That's where I want to be. I want us all under 3%. I want to see mortality rate under 250 people, and then I want to see it lower than that.
>> Robert Redfield: I think you're going to see, if you [inaudible], when we looked at Arizona, when the governor put in these mitigation steps, for the next two weeks, everything kept going up, up, up, up--
>> Howard Bauchner: Right--
>> Robert Redfield: And then for the next two weeks, it started to go down, but so four weeks after he started, he was where he started, and some people could say see, nothing works. But they stayed with it, they stayed with it, and now you've seen the progressive drop and Arizona is really moving in the right direction. So it is important to understand, these interventions are going to have a lag, that lag is going to be three, four weeks. You and I are going to see the cases continue to drop, and then hopefully this week, and next week, you're going to start seeing the death rate really start to drop again. You know, we got down to under 500. We actually got as low as 250 one day. I think we're going to start to see the client mortality across the country now, next week, as we continue to get control of these cases. I will say that there is a warning sign, that we all have tried to put out there. Ambassador Burke, I think she's got back, I think she visited 21 states that we're starting to see some of the cases now in the red zone areas are falling, but if you look at those states in what are called the Yellow Zone, between 5 and 10%, they're not falling. So middle America right now is getting stuck, you know, and this is why it's so important for middle America to recognize the mitigation steps that we talked about, about mass social distancing, hand washing, closing bars, being smart about crowds. It's for middle America too, the Nebraskas, the Oklahomas, we need to see those--we don't need to have a third wave in the heartlands right now. We need to prevent that. Particularly if they're coming on the fall.
>> Howard Bauchner: Bobby, you had mentioned herd immunity. Different things have crossed my desk more recently, you know, CDC had a paper in JAMA Internal Medicine about 10% of the U.S. population, that was the best estimate. There is 330 million people who live in the U.S. You know, if we have an infectious rate of 10 to 20%, that's about 60 million people may have been infected. I think--do you have a sense of what that percent is around the country? We see isolated reports, but we don't see really good national data, on the percent of the population that has been infected. Do you have any sense of what that may be?
>> Robert Redfield: We are, we are in the process of obviously following up with the report that we did in JAMA, to kind of let us understand that you know, maybe from the 2 million cases we diagnosed, we had an estimated 20 million people affected.
>> Howard Bauchner: Right.
>> Robert Redfield: We've now expanded that throughout the country. So very large surveillance, work in progress. So I don't want to speculate. And I really want to be data driven, but there is enormous geographic variation here--
>> Robert Redfield: I can tell you we have some areas that we're looking at less than 1% and we have other areas that we're looking at 20%. So we are going to be calculating that. I think if you're going to do a crude estimate, somewhere between 30 and 60 million people, but let's let the data come out and see what it shows.
>> Howard Bauchner: There has been some question about what we would need for herd immunity. Now, we know vaccines are coming. Some people have said as high as 60, 70%. Other people have said as low as 40 or 50%. You care to comment on the varying figures? Or it's all speculation?
>> Robert Redfield: Yeah, I've learned this, you know, CDC's not an opinion organization [laughter], we're science-based, data driven. It's great to stay in that discipline. But what I will say is this, is how much herd immunity we need to get the Arnot under 1, really also depends partially on how effective the mitigation strategies are that we are using. And we may find that, you know, even if we are at a 30 to 50% history of immunity, like that combined with the mitigation steps that I just told you may really take us under the Arnot of 1, and really have impact. So I'm not one that is going to say hey, listen, if it's not 70% or 85%, it's not going to help. But as I'm a believer now in this what I call partial herd immunity. You know, the impact of pre-existing immunity on the ability of this virus to maintain an Arnot greater than 1. And again, the importance of the mitigation steps. But I do think there is growing evidence, you know, this week, a number of papers came out again to provide more data about the importance of T-Cell immunity and net immunity, and as I mentioned, unfortunately, there is great variation, you know, but there is a reasonable speculation that the reason the northeast is doing so well right now is not 100% because they're more adherent to the mitigation steps. There may be, in fact, an impact of immunity that, combined with mitigation gets to a threshold that keeps his fire. So, I think that we're going to learn a lot more about it. I think, you know, I think it's going to contribute more than some people realize in certain areas, to our ability to have better slowing of the spread as we go through the fall.
>> Howard Bachner: Yeah, I know, there are certainly certain areas of New York City boroughs where it was clear that well above 20, 25% of the population had been infected, and I think we're--the story about neutralizing antibodies, and then T and B-cell responses are still uncertain, so we will see how it plays out. Now, as happens, I had forgotten that your paper was coming out today. It's entitled addressing influenza vaccination disparities during the COVID-19 pandemic. Three CDC officers, Lisa Grohskopf, Leandris Liberd, and you're the senior author, probably the critical issue for the fall. You know, we hover somewhere around 40, 50% influenza vaccination and I know people would really like to see it at 70 or 80 or 90%. Do you want to talk a little bit about that for the fall?
>> Robert Redfield: Yeah, I appreciate it. I appreciate the Journal publishing this, and I appreciate the time to talk about it because this is so important. I think people have heard me talk before about the importance of vaccination in general, being one of the most important, if I use the term, gifts, for contributions of science to modern medicine, I think this fall nothing could be more important than to try to increase the American public's decision to embrace flu vaccine with confidence. We've gone through the, you know, the hesitancy. I want to move people to vaccinate with confidence. As you commented, you know, less than 50% of the American public get vaccinated. And when we look at that, we obviously see even significant disparities among Native Americans, you know, African Americans, Hispanic populations. This is just going to add to the health disparities that we see. Leandris Liberd is my Chief Equity Officer for our response, and one of the reasons we did this together, and we're working on building campaigns to increase the acceptance of vaccination. Particularly vaccination with confidence. You know, you've heard me say that this fall and winter could be one of the most complicated public health times we have, with the two coming at the same time. On the other hand, I'm an optimist that if the American public heeds the advice that we've set out about the face covering and the social distancing, the hand-washing and being smart about crowds. This could be one of the best for the seasons we had. And particularly if they do one more thing, and that is to embrace the flu vaccine with confidence. And that's really what we're trying to do. Normally CDC, you know, has a very good program for uninsured children to be able to provide vaccinations including flu, but we have a limited program for uninsured adults, only about 500,000 doses do we provide to the state's local and private territory health departments to help them with the uninsured adults. This year I purchased an additional 9.3 million doses, because I believe that it's important that all individuals get access to the flu vaccine this year. So I do appreciate the opportunity. And because the key to that, a lot of it is going to be obviously healthcare providers, to remind people to do it. I was glad to see the secretary of health yesterday added pharmacist to not only be able to vaccinate adults, but now pharmacists can vaccinate children 3 to 18 in addition to adults, so we can expand the accessibility of vaccines. So think it's really important. I'm happy to have specific questions, but we really, we've got--my goal this year is to get us up to 65% vaccine acceptance across the board, and children, we usually get in the 60s--
>> Robert Redfield: But you know, in adults, we're frequently in the high 30s, and I think this is a critical year for us to try to take flu as much off the table as we can, as a respiratory pathogen, it's going to cause people to be sick enough to have to go into the hospital. The biggest fear I have, of course, by the COVID and flu at the same time is that our hospital capacity could get strained. And when you really look at the impact that we saw in New York, where we had very high mortality rates, if you go back and look at New York.
>> Howard Bauchner: Yeah, very.
>> Robert Redfield: It wasn't that the practice of medicine was not as good in New York. It was probably better than in many parts of the country. But when the health system gets overwhelmed, we find that with COVID this is where the mortality seemed to be the greatest. So my goal is to have--ask the American public to do their part. Ask our, obviously the American Medical Association, doctors, healthcare providers, to do their part, let's--let's get the American public vaccinated against flu. And the flu vaccine is now available, and hopefully, you know the viewpoint that we put out, will just help remind people that they're--this is the time, don't leave this enormous advancement of medicine on the shelf for yourself, for your community, for your family, for your patience. You know, to really push forward about the importance of flu vaccination.
>> Howard Bauchner: Bob, I spoke to Zeke Emmanuel yesterday, and we were talking about both flu and then the other vaccines and one of the issues that came up is a delivery system. It's hard for people to get to see their position now in many places, and that's often where they did get their--their vaccination. And people aren't coming to work. Work was another place, so a lot of people are working from home. So the nine and a half million doses that you purchased were flu vaccination in general. Have you thought through delivery systems. Because that same delivery system ultimately could be used for vaccines for COVID-19. So I'm wondering if you've begun to spend some time thinking through a delivery system for 330 million Americans.
>> Robert Redfield: Yeah, very important. Clearly we can talk about COVID in a minute, but clearly taking advantage of expanding our capacity to deliver flu vaccines. So I mentioned already, you know, there was skepticism a number of years ago when the decision was to allow pharmacists to give vaccines, but I think what an important decision it was. Our access to vaccination, particularly flu vaccine. I'm very excited that just this week the Secretary of Health and Human Services put through that not only can pharmacists do adults now, they can do children 3 to 18, so if you have a pharmacy, you know, you can be able to get your flu vaccine in the context of the pharmacy. I will say my wife used to let me give her a flu vaccine, but every since pharmacists could do it, she always goes to the pharmacy to get her flu vaccine. You know, it's convenient. We also are looking, you know, in our campaign right now that we're dealing with flu, they are trying to increase our ability to close some of the discrepancies that we're seeing, particularly with Native Americans, African Americans, and Hispanics. We're looking at other strategies in terms of expanding our flu campaign. Initially we were looking to expand a lot of vaccinations back the way we did it in the olden days, back in schools. As you mentioned. Well, not all the schools are open.
>> Robert Redfield: So we are continuing to look. Look at the same thing about providing mobile units that may be in particularly rural areas, to be able to get expanded vaccination. In terms of COVID, you know, CDC sort of has the--has the ball in terms of developing the distribution system for when a safe and efficacious COVID virus vaccine is approved, which I am cautiously optimistic will happen this fall. Then how do we operationalize that?
>> Howard Bauchner: Right!
>> Robert Redfield: You know, in a priority way, but eventually for the whole nation, it's not as the same as we do for flu, where it's already relationship between the pharmaceutical companies and distributions in physician offices, so we are in process of setting up in partnership with the state, local, tribal, territory health departments, a distribution system when that vaccine becomes available. Recently the same group that helps us with our immunization program was just awarded about, I think, a little over $300 million dollars to start working with us. We've done what we call micro-distribution plans in five states that we started last week to work through all the mechanics, and as soon as we do that, then we will be expanding across the nation, because it's not going to help us to have a COVID vaccine if we can't get it distributed into the arms of individuals. But I do think, you know, don't underestimate the additional gift we have as doctors and nurses and nurse practitioners and PAs that we now have by our pharmacist colleagues being able to also distribute vaccines, particularly now that their ability has been expanded to include children.
>> Howard Bauchner: Yeah, no, you know, I go and pick up my med once a month. It's the perfect time for me to get the flu vaccine, and pharmacies have remained open, so I think there is quite a few of them. It has been a rough couple weeks for schools and colleges. You know, I think colleges began to open and then it didn't work very well. Schools have been very--highly variable around the country. Most of the major school districts, I live in Chicago, are not opening for in-person education. People are particularly concerned about younger children. How do you see that playing out for schools and colleges, Bob? You know I--you know my position that if you really understand the importance, the public health importance of getting these schools open, K through 12 for sure, obviously for our nation it's important that our institutes of higher learning get opened, you know, we don't need to do an educational pause as a nation for a couple of years. But it has got to be done safely and it has got to be done sensibly. It has got to be done with an understanding that COVID cases are going to occur, in K through 12, and they're going to occur in universities, and we try to enter dialogue with technical assistance with both that help people understand how, what is the reaction, and the response. Because if the response is the first time they have a case is they're going to close the schools, well then, well we're not going to get to where we need to get. The other thing I will say and it is interesting, I was just looking, this is in a meeting, where we looked at the number of states, if you look at the combination of hybrid and in-state learning about 80% of the schools are either offering hybrid or face-to-face learning. There is only a smaller percent that are only offering the distance learning. That said, it has got to be done safely and sensibly. It has got to gain the confidence of the teachers, the students, and the parents. I try to tell people the most important thing we can do to help get our schools open and keep them open is control the community transmission in the community because I do try to get people to realize, that's where diagnosing these cases in schools, now in K through 12 in particular, those cases are not being acquired in the school. They're being acquired in the community and obviously we're working to evaluate those with the number of schools, so we can reinforce the importance of controlling; universities--I think they really do have to have a strategy, a surveillance strategy, a testing surveillance strategy. Obviously just testing students when they come on campus, that's not a strategy that's going to get you to the end of the game. You know, we're there to keep working with the schools, the higher learning schools, to help them develop that strategy, but I do think there is an area that can still benefit from dialogue, how to develop that strategy. How do you open that university. How do you use the mitigation strategies we talked--how do you use surveillance testing to help you keep that school open? How do you respond to these clusters? So it is a challenge, but I do think, and my biggest focus is the K through 12 because I do believe that it's not only central to the child's academic success, these schools provide really important mental, nutritional, emotional support for children and their families. It's really in our nation's best interest to get this face to face learning back. And we've got to do it safe and sensible. It's got to have to be flexible, based on communities. And I just reiterate that the commitment, the CDC is available to provide technical assistance to any school, any school district that wants to try to work through this. But it has been a rough week, because I think there is tendency when there is pieces in the schools, for people to react as if it's the school that is the source of the transmission, not the community.
>> Howard Bauchner: Right, right, well, I think it relates to your first, first point, you know, if the 40,000 cases a day was 5,000 or 10,000, then there is going to be less cases in schools and in colleges. It all relates to each other. Pritki Melani is our I.D., Associate Editor, Chief Health Officer at University of Michigan, and she has repeatedly reminded me, testing isn't the strategy. It's what happens after you have a test positive.
>> Robert Redfield: That's the strategy.
>> Howard Bauchner: That's what she's got to figure out, not that she's testing everyone who comes back to Ann Arbor, but what do you do when you have a positive case, and how much ring testing you have to do. Your staff is very clear. I have five minutes.
>> Robert Redfield: Wow, are they controlling my time, now?
>> Howard Bauchner: They are, they are.
>> Robert Redfield: Howard, was that ever stopped? I mean, I thought I was a Director, I don't understand [laughter], I don't understand why the Director is always the individual who is directed--I mean, there's definitely something wrong with that formula, isn't there [laughter].
>> Howard Bauchner: It's 170,000 deaths. This is a, it's a difficult number. Any sense where that will end?
>> Robert Redfield: You know, Howard, first I've got to say, you know, every loss of life, you and I, we're physicians, you know, you as a pediatrician, you know, I know that I lost my first son shortly after birth, and I responded by doing pediatrics out of Tripler, taking care of sick children was even harder. Every loss of life is tragic. I do believe that although I don't think that critics will necessarily give us the benefit of the doubt, but when we had the first CDC models that were presented to me in late February, early March. They said that we were going to lose somewhere on the low end of a million and on the high end about 2.4 million before October. You know? And I looked at that data and I kind of said, you know, it was very difficult, you know that, you know, I knew the power of a respiratory pandemic. You know, clearly this virus appeared at the time to have higher mortality than say influenza, and I think you know, we'll see how that comes out, once we see. Clearly an individual with co-morbidities has higher mortality. You know, you've seen our estimates, you know, we're close to coming up to, you know, up to about 200,000 this year, but I don't really like to do estimates or models, because I don't know what they mean, and they're based on assumptions. But you know, the fact that we're coming up on 170,000 people is a lot of people. I do think we're going to start to see significant declines in mortality across the country, in the next, hopefully next week we'll start to see a decline. It's going to lag cases by around two, three, to four weeks. But this is a big loss of life, and this is why you know, if there is a message from us from a public health point of view, the most important thing we can do is to do everything we can do to protect the vulnerable around us. Not just those in nursing homes, but also those of us that are elderly, that might have certain co-morbidities, you know, diabetes, hypertension, obesity, kidney disease, lung disease. We all had an important role to play. I always say the reason I wear my mask is because not to protect me, to wear my mask in case I'm infected, to protect you, because I want COVID to stop with me. And if we could, if we could, control the community spread, so when you're that young 30-year-old and you don't think there's a big deal if you get COVID, the problem is if you're jogging through Central Park and there's two 85-year-olds sitting on the bench, and you have to, you know, sneeze when you go by them, it's an important thing that all of us try to control the pandemic to protect the vulnerable. I am saddened that we've lost as many lives as we've lost. On the other hand, I feel that the response that we've done collectively as a nation has really saved a lot of lives. And that we need to stay vigilant to the mitigation steps right now, because come the fall, if we have flu causing its problems, and we have COVID causing its problems, and they build on each other, we could end up with another loss of significant life. I'm hopeful that steps we take to prevent COVID are going to prevent flu and other respiratory viruses, people are going to realize this is the year to get flu vaccines, and we will begin to see our nation get through this pandemic as we then, and I do anticipate it will happen, begin to deploy an efficacious and safe COVID vaccine, and hopefully when you and I talk next spring, we'll have this pandemic behind us in this country.
>> Howard Bauchner: Last question, and then I will let you go. Nationally we are incredibly dependent on data from the CDC. It's the greatest resource that we have for national data, so for example, you, there's some delay, but you've produced the number of deaths per month in the United States. Will those data continue to flow from the CDC? They are critical for people to have access to.
>> Robert Redfield: Absolutely. I mean, it's the blood of CDC.
>> Robert Redfield: But it's even more than that, Howard. One of the first things that I recognized when I became CDC director was that for a variety of reasons, our nation has failed to invest appropriately over the last 20, 30, 40, 50 years in what I call the poor capabilities of public health. I had a presentation that was made to me, an early priority obviously was opioid related deaths. I almost lost one of my six children from contaminated [inaudible] with Fentanyl. So priorities are present. Priority to the secretary and I got briefed on it, and when the briefing was finished, I asked what the data was through and they told me March 2015, and I said but it's April 2018. And I was told that I didn't understand all the complexities of getting all the data. And then I remembered, like you, reading the NMWR, and frequently, the NMWR was telling me what happened a year ago or two. Getting data so it's real-time and actual is a big thing. I can tell you now we get data within 48 hours on opioid deaths across this country. And we are on a big push. Congress has started to realize the need to do what we call data monitorization. Recently gave me $50 million dollars, and recently another $500 million dollars, to begin to--modernize, not just CDC's data, but we need to modernize the public health data system for the whole country. States, local health departments, territories, tribes. So we are deeply committed. We are expanding and modernizing, so our data should not just be real-time. I want data to get to the point that it's predicted data analysis. And so we're actually predicting, using data to predict, you know, and I'm confident we're going to see data monitorization that is currently being driven into CDC. It's going to obviously happen past my watch, but that's going to, you know, have tentacles into the public health data system across this nation, so it's definitely the lifeblood of CDC's data, and that lifeblood is meant to be available to the American public, to have that data, and I can guarantee you that will continue, and it's going to--I think, be an exciting time, as there is greater investment in the core capabilities of public health, particularly in a data monitorization, you know, when we think of where we are right now, with the ability, like we did, with opioid overdoses, and overdose deaths. What we did was we brought some surveillance into it, so that all of a sudden, every medical record was a public health tool. All of a sudden we had thousands and thousands of new public health workers, nurses, doctors, PAs, nurse practitioners, social workers, anything that was in that medical record now could be a public health tool if we just take that electronic medical record and be able to use that. So bringing electronic medical records direct reporting from laboratories, putting all of that into an integrated public health data system, I think is going to revolutionize the ability of data to be actionable. When we had the Abali Syndrome, you know, the ability to use that syndromic data system to go back and look and say wait a minute, where are we seeing this severe pulmonary illness? And all of a sudden, we didn't have to wait, you know, 30 days, 60 days, 90 days, 120 days, six months for reports. We could go right into the electronic medical records, and pull out. So critical. I think it's just going to get stronger and stronger. And it is one of the critical roles that CDC does play as a group that can really, you know, pull that data, and do the analytics that need to be, so there is a public health response to that data that they can improve the human condition in this nation.
>> Howard Bauchner: Yeah, well, I think one of the--excuse me, one of the things that underpinned the success in Taiwan, Korea, Singapore, was just this remarkable electronic health infrastructure, in part. They have other things that are more problematic than, problematic to the U.S. But they have an underpinning of data, that we still are struggling. Many questions, but I'm five minutes over, your staff will never let you come on my show again. So I have to say thank you, Bob. You and Steve Hahn at FDA, it has been a tough six months. I mean, you and Tony and Steve have really been in the limelight on a regular basis, so I just wish you good health.
>> Robert Redfield: Well thanks a lot. And Howard, thanks for your continued opportunities to share our public health messages. We really appreciate JAMA, you know, and the opportunity to get these viewpoints out. Some of our publications, and you taking the extra time to let us communicate with you and your listeners.
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