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Coronavirus Update With Peter Piot, MD, PhD

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Peter Piot, MD, PhD, director of The London School of Hygiene and Tropical Medicine, is a legend in global health, having been involved in identification of HIV and Ebola virus in Africa. He was founding executive director of UNAIDS and Under Secretary-General of the United Nations from 1995 to 2008. He joins JAMA's Q&A series to discuss the global public health response to COVID-19 past, present, and future. Recorded January 28, 2021.

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This transcript is auto generated and unedited.

>> Howard Bauchner: Hello and welcome to Conversations with Dr. Bauchner. This is Howard Bauchner, Editor in Chief of JAMA. I'm joined today by someone who has reached legendary status in his life, and in his career. In many regards, the equivalent of Tony Fauci in the United States, although he has a different role. I'm joined by Peter Piot. Peter's a director of the London School of Hygiene and Tropical Medicine. Founded in 1899. Likely the pre-eminent school of public health in the world. Peter is the Handa Professor of Global Health. He's had many, many positions. He's often referred to as a virus hunter, which we'll talk about in a bit. And he discovered the Ebola virus in 1976. And for the last three or four decades has been intimately familiar with virtually every pandemic that's occurred worldwide. Peter, thank you for taking the time to join me today.

>> Peter Piot: Pleasure Howard, to see you again. I should say I was part of the team that discovered Ebola [inaudible].

>> Howard Bauchner: That's true. It's always nice when people give appropriate credit. So Peter -- we'll get into some of the more nuanced questions about the new variants and the vaccine, and how things are going in Europe, particularly in your home city of London. But Peter, when you look back at the last year now, we're a year actually from the first publications in JAMA, New England Journal, and Lancet, what strikes you? What do you find most striking about this pandemic?

>> Peter Piot: Well Howard, on the one hand, I'd been giving talks since the Ebola outbreak in West Africa in 2014, and the title was Are We Ready for the Next Pandemic?

>> Howard Bauchner: Yes.

>> Peter Piot: And the answer, the conclusion was no. And people I -- you know, in our field, and Tony Fauci did the same [inaudible] and so on. We were all convinced that one day there would be a big epidemic. Ebola was just kind of a rehearsal.

>> Howard Bauchner: Yes.

>> Peter Piot: And something that is respiratory transmitted, and then would -- you know, infect millions of people. But I made one mistake. I thought this was going to be an influenza virus.

>> Howard Bauchner: Yes.

>> Peter Piot: A new like Spanish flu-type. But it was a coronavirus. And now just to talk about the UK, two days we reached the really very, very sad milestone of 100,000 deaths in -- just in the UK. And so it was not a surprise that it came, but it's a big difference between how to say an intellectual conviction that this would happen, and when you're confronted with it. And that it spread so fast all over the world. I must say though, the thing that is most unexpected for me is that I caught it myself.

>> Howard Bauchner: Right.

>> Peter Piot: I -- yes. I've been dealing with viruses either as a clinician or you know, immunology, outbreak investigation most of my professional life. But I -- yes this time I got it also. And the one thing that maybe surprised me the most, certainly in the beginning, is that it's not because something is respiratory transmitted that it's just a respiratory infection. For some reason, I concentrated in the beginning on the lungs. But we know that SARS-Cov-2 the virus invades and can invade, affect about any body organ. And so we should look at it as a total infection of the whole body. I mean it's like -- a bit like HIV, where I have spent a lot to my life. If today you're treating someone with HIV, you need to know your whole internal medicine. It's not enough to -- and that's a sexually transmitted infection. So it's -- so that for me was from a clinical perspective something I hadn't fully realized in the beginning.

>> Howard Bauchner: Peter, were you surprised -- I mean we published a research letter. Lancet published a research letter. NEJM published a research letter, all in February, around asymptomatic spread. There were some questions about the validity of some of the reports. I don't think the journals did as good a job as we might've about saying what that meant. Have you -- were you surprised about what has clearly become the extent of asymptomatic and pre-symptomatic spread?

>> Peter Piot: Not really because just by extrapolation for nearly all viral infections have a asymptomatic proportion. I mean, some more than others. And with some exceptions like rabies also. But the rest, and certainly you know, respiratory infections. And of course we have really asymptomatic and then we have pre-symptomatic. And in the beginning that was not so clear. You know, it's also true that you're often most infectious just before you -- you know develop your symptoms. But it is probably one of the main reasons that the virus is spreading so fast. And that -- that's where already if -- early March I remember, I said -- you know, I gave a talk and I said masks are so important.

>> Howard Bauchner: Yes.

>> Peter Piot: And yet there was a big debate. That was one of the -- I found one of the most frustrating things were sometimes we scientists, we -- the enemy you know, they always say the best is the enemy of the good. You want evidence from randomized controlled trials preferably in our own country et cetera, and published in peer-reviews journals before we you know, we accept something. There -- this is -- particularly when you have asymptomatic transmission, you need measures that are not triggered by disease, by illness. And I mean there is social distancing, you know testing. But for many months and even today, some countries only will -- are testing of symptomatic people, symptomatic contacts, not asymptomatic ones. And obviously that doesn't make sense, and particularly now that the evidence is so strong.

>> Howard Bauchner: Was it a missed opportunity Peter, when you look back? You know we had gotten so many viewpoints from Asia saying we're just asking you to wear a mask. It's not like we're asking you to take an exotic drug, or to put your life at risk because of an unusual treatment. It was just a mask. Do you think that was a major missed opportunity around the world in February and in March?

>> Peter Piot: I really think it was a missed opportunity. I'll never forget, first time I went to Japan was in 1980 or '81, and it was in Kyoto. And in the street, I saw people with a mask, and I thought hmm, people here are paranoid about germs you know? Like germaphobes and some. But then someone said no, no, no. Wait a minute. This is just an altruistic way of behaving. Just when you have a -- your nose drips, you have a cold, you cough, you wear a mask, and it's to protect the community. And that actually historically now, that goes back to the Spanish flu. So it's about 100 years old. And I hope that this epidemic will also you know, induce that kind of civility. So that we are protecting the community, and it hardly costs anything. It's not a burden. And in nearly all countries, it's not a political issue, as it became at some point in the U.S. Here it's not. I mean, some people don't like it for other reasons, but it's not along political lines at least, which is pretty absurd frankly.

>> Howard Bauchner: I mean, there's dozens of reports of almost no flu this year in many countries.

>> Peter Piot: Yes.

>> Howard Bauchner: We've had almost no circulating flu. I mean we ended up with major problems in the U.S. in the fall, but it wasn't what people had thought it would be, which would be this combination of COVID-19 and the flu. It was just COVID-19 alone. Obviously the great scientific achievement are the two vaccines today, and there's more coming. The UK is -- has three. J and J may be approved in the U.S. in the coming months. That's the hope. That's been unequivocally the great scientific achievement. I think there's been some nice clinical advances, although there's still complicated about which treatments work, which don't. I think we know steroids is the standard of care. After that, there's much uncertainty. What do these new variants mean to you, Peter? I know you're not an evolutionary biologist, but it's -- they've really emerged quickly. They've emerged in the midst of partial vaccination. Many different treatments. What is your sense of how this -- the issue of these variants will play out, Peter?

>> Peter Piot: Well, viruses mutate. Certainly RNA viruses. That's -- this shouldn't be a surprise to anybody. I was actually surprised that it took so long. But partly we know that even very early on out of Wuhan, there was a particular variant that become dominant. And I always try to put myself in the head so to say of the microbe. This is -- I did part of my PhD work with Stanley Falkow when he was at Seattle, at University of Washington. And we worked on bacterial pathogenesis. And he said put yourself in the head of the bug you know? And then that makes you think. And what is -- what's the [inaudible] of a virus? It's to find a host and to replicate. Because they can't survive without living cells. And so, they mutate and now and then there is one mutation, one variant that has an evolutionary advantage, that will be easier to infect, and that becomes dominant. And the first one that was found was in the UK. And that's -- more I think to a large degree because in the UK, about 10% of all positive samples or PCR samples, for SARS-Cov-2 are actually sequenced certain degrees. So there's low capacity. And of course, the more you sequence, the more variants you will find. And now you've got it. Southern California, in Ohio, Brazil. Just name it. South Africa. And soon every state and every country will have their variant. And the question is of course, what do they lead to? Historically it could be a good thing that we've seen that with other coronaviruses, the one that cause common colds -- cold probably about 100 years ago or longer, they may have been far more virulent. Today they're kind of cause the common cold. But here I'm very, very concerned about these variants. And that may only be the beginning in the sense that the big question of course is will the vaccines protect against infection with the variants? I think at this -- it won't be an all or nothing type of game.

>> Howard Bauchner: Right.

>> Peter Piot: That's unlikely. But it could mean being diminished effectiveness at a population level. And one day there may be a very nasty one that's so changed because we're all using the same vaccines at the moment that are directed against the spike protein of the virus. And so there's some -- first of all we need to know, know early. The good news I would say is that the -- it's the same measures. The same non-pharmaceutical interventions that work. I mean here in the UK now, this week we had about 20,000 new infections coming down from 70,000 about a month ago. And so we're using the same methods, and that means that this British variant which is between 30 and 70% more transmissible, that works as well. But it means that you know, we have to continue to you know, respect all the rules, all the measures. We can't relax. And then the vaccines, that's -- we need to prepare for variants that won't you know, respond to the current vaccines. And that's -- for me a top priority. So I also I'm advising the European Commission at present, [inaudible]. And it's a top priority to see how can we speed up potential additional vaccine versions, or do we need to go to multi-variant vaccines? Are we going to get into a situation for like influenza? Is there a finite spectrum of these mutations? And that we can come to a system like we have for influenza where you can more or less predict and maybe artificial intelligence and so can help us. Let's not forget this, we're still in early days. Early days. This is a year old. I mean it's fantastic, the progress we've made, you know? But also it's even worse that and the progress that the virus has made is still you know, worse than the scientific progress. But we're getting there.

>> Howard Bauchner: Peter, do you think in terms of vaccine development, one of the approaches to consider are vaccines that are active, not necessarily against the spike protein? That that -- if a variant arrives that somehow is more resistant to the vaccines that focus on the spike protein, that there'd be another vaccine available? Is -- when you think out six months or a year -- because it will still take a year to develop a different approach, do you think that's important to consider or we just need different approaches? Adenovirus, heat-killed, mRNA against the spike protein. Or do we need both approaches?

>> Peter Piot: I think you need both approaches. We -- I mean let's also face it mRNA vaccines, this is new.

>> Howard Bauchner: Right.

>> Peter Piot: First time. It may revolutionize the whole vaccine development. But we don't have enough experience. But we know that it's easy to develop a vaccine with that technology. But what people tend to forget sometimes, it's not enough to develop a prototype, or a candidate vaccine. Then you have to go through some basics, immunogenicity, safety, just name it. And then you have to you know, to manufacture it. And I think at the moment, terms of vaccination, certainly Europe manufacturing is the big bottleneck.

>> Howard Bauchner: Yes.

>> Peter Piot: At the moment. [inaudible] go to scale. And that's a bottleneck for Europe, and that's a bottleneck for Africa, and so on. However, I think that we need to follow at least two paths. One is that making sure that the current vaccines that we can have a system. Therefore let's say business continuity. If I were in charge of the company, that we can -- we're ready now. Even before it's really necessary, that we put everything in place. That the regulators, the FDA, and the EMA, that they have criteria just as for an influenza vaccine. What are the [inaudible] of protection? We don't know fully but you know, we already know that utilizing antibodies [inaudible] but then also I think we need alternative vaccines. For example, if you know the subunits, [inaudible] vaccines, you can imagine a cocktail that includes several targets for the -- of the virus. And I -- in the beginning, I kind of was not so high on the classic inactivated vaccines, you know?

>> Howard Bauchner: China. I mean those are more the Chinese vaccines.

>> Peter Piot: Yes, indeed. But there's also some others. And you know, [inaudible] for example and -- but then and now I start thinking hmm, maybe that's -- we should definitely look at that very seriously because they will you know, trigger a much broader type of immune response. So yes. We'll see.

>> Howard Bauchner: Peter, does this wake you up in the morning, and are you worried about this?

>> Peter Piot: Oh yes. Definitely. Not only in the morning, but sometimes --

>> Howard Bauchner: At night [inaudible]?

>> Peter Piot: Yes. No I -- how to say this? On the one hand I -- you know, I was convinced that it would happen. But that doesn't -- but now it's -- you know, what to do about it? And it's not going to be by closing borders that we're going to fix this, to be honest. Because the variants will pop up everywhere. Particularly when millions of people are infected, and with the rate of you know, mutation it's going to happen. And then one issue that I'm very concerned about is that here in the UK, the interval between two injections of the Pfizer BioNTech vaccine is you know, 12 weeks. There are no -- there's no data. We could have suboptimally protected people which is of course wonderful for -- to develop a you know, escape mutants. It's a breeding ground. I may be wrong but nobody knows.

>> Howard Bauchner: Right. You've touched on a difficult issue in the U.S. I mean Paul Offit who's outspoken about this -- I think Tony's weighed in on this. They're very uncomfortable -- I mean they're willing to go from three weeks to four weeks. Or four weeks to five weeks. They are not proponents of moving out to eight weeks or 12 weeks between shots that are meant to be given at three and four weeks. Because of the lack of data, and they'd rather have 50 million people protected than 100 million who may not be protected at all. And it's a complicated equation. people have been struck by the UK. You have many, many brilliant people. So I would say in the U.S. the general sense is one of surprise.

>> Peter Piot: Yes but I'm with Tony and Paul on this. I mean I think like six weeks is you know, that's doable I think because also in the trials certainly --

>> Howard Bauchner: There's some data.

>> Peter Piot: [inaudible] somewhere in there. So -- but I mean you can even say you know, why bother doing all the trials if you just ignore the evidence? And -- but theoretically the risk is also very high for escaping [inaudible], that's a breeding ground. And in addition to you know, insufficient protection, the level of neutralizing antibodies that are found after the first injection with he mRNA vaccine's very low. Of course, there is protection already after one injection. No doubt about that. The data's there. But for how long in some. But it's very -- it's fascinating how the same data are interpreted in completely different way by different scientists. And -- but here in the UK it's been -- I understand it. I mean there's crisis. I mean as I said, every day like 1500 people die, but I'm concerned that it's as we say in my mother tongue is Dutch you know, playing panic football in soccer, you know? You go into all directions, and that -- what looks like making sense in the short run, and it does make sense in the short run, could be really creating more problems in the long run. So I'm absolutely not in favor of that, six weeks --

>> Howard Bauchner: We've been fortunate in the U.S., the numbers of hospitalized patients, which is what I really follow, the number of cases is important. So I follow the number of deaths and hospitalizations, but particularly hospitalized patients because that's who dies, has really finally come down in the U.S. We're about 100 to 135,000 a day. We're down to about 110,000. I'm wondering that -- if those numbers get better in the UK, and I know that they are getting better, if that will make people think twice about lengthening out the vaccine. Because I think the decision to lengthen out, or to two months or three months was made in the midst of this overwhelming number of patients who were in the hospital. And you've already mentioned that that's gotten better. And I'm wondering if that will make people reflect, maybe we should go back to a much more standard approach. But I don't have to make the decision, I only get to comment on it. And that makes my life much easier.

>> Peter Piot: Yes, same here. I'm not deciding that. Yes, I hope the same. I mean there are several factors. One the vaccination program in UK is quite good, I must say. I mean after the massive failures of test and trace, and of the whole response has been quite bad, and insufficient, and always too late. But the vaccination rollout has been really well-organized. It's not yet at cruising altitude, and once it's there, I hope that you know -- and if the supply of the vaccines is sufficient, I hope that they will come to a more science-based, evidence-based type of approach. And the number of cases are going down. The hospitalizations are still not going down, but that's in a matter of time. There is a lag time of several weeks, and even in the rest of Europe, because the UK is still -- it's part of Europe. I don't [inaudible] because there is Brexit. There is the first decline is starting now. But as a result of Draconian you know, [inaudible] and all that. So it is coming down.

>> Howard Bauchner: Yes, I would describe the vaccine rollout in the US at best as erratic, and that may be kind as an initial description. It's interesting that the data are pretty overwhelming. The rural states have done better than the non-rural states and you know, took a while, but I think the hospitals managed to vaccinate healthcare workers, but we have really struggled outside of hospital systems. Peter, I wanted to reflect -- I think you know you've been public that you were infected in March. You've been quite public about it. And we talked a little bit about it before we started the livestream. Before we get to your own disease, and I think that always is so meaningful to hear from people about what it was like for them, where's your sense where we are with treatment? You know, early on there was some reports of the value of remdesivir. It was really -- it was not very effective, and I've spoken to my European colleagues, my U.S. colleagues, not very popular in Europe at all. More popular in the U.S. We have yet to figure out if convalescent plasma is very effective. There have not been really high-quality clinical trials where we know that titers, when it was given, was it given for prevention or treatment? I think steroids, the recovery trial, and we had three RCTs and a meta-analysis from WHO. That's definitive. Where do you think we are on treatment, Peter? And will we ever know, or is the disease so variable in people that that makes it more complicated? What's your sense of treatment?

>> Peter Piot: Well as much as we -- you know, the development of vaccines was frankly beyond my expectations, that particularly when I saw the over 90% efficacy of the mRNA vaccines. That was such a -- I mean wonderful and when we -- we're going to have more vaccines, so that's [inaudible]. I've been really disappointed by progress on treatment.

>> Howard Bauchner: Yes.

>> Peter Piot: And I thought a lot about it, and I think that probably what's key is timing is going to be everything. When do you give what to whom? And that's -- that's not always popular with people who go into clinical trials, but we'll have to look into subgroups. And it makes sense that anti-virals, be it monoclonals or small molecules, will have to be given pretty early on, like for most viral infections actually. And then the key will be when to start with like say dexamethasone, or other immune suppressants, so immune modulators. Whatever can try. And you know, if it's too early, maybe you know, causing harm and if it's too late, it's too late because the impact of immune modulators and all that is it takes quite some time. So that's the -- I think that may be the big challenge for trials, and to see. So it's time now to take I think some stock and say OK, can we see a system of you know, different stages of the disease, and when to apply what? Because that makes it also so hard to compare trials. And that's where people get very passionate, because it's [inaudible] a belief. Yes, every -- I'm not saying every drug, but lots of therapies, they have a trial that shows that it works to some degree. And rarely in a spectacular way. And then there's another trial showing nothing. You know? No impact. And it's not that these are badly conducted trials or anything. It probably reflects the different patient population. And so a lot of work to do. And going back to the variants, I mean, this is where monoclonal antibody-based therapies are probably far more vulnerable to the impact of variants than let's say vaccines. Because a monoclonal, by definition --

>> Howard Bauchner: Yes, right.

>> Peter Piot: -- is very specific. That's the beauty of it, but that's the vulnerability of it now also. So again, we'll have to go to cocktails probably [inaudible]. But we need that. And we need it not only for treatment, but also for you know, as prophylaxis. I mean, you know you can -- it would be wonderful if you identified there would be all these outbreaks of someone in a care home, or in a workplace, wherever, in a household is identified as infected, and you -- it's -- as long as not everybody's vaccinated, then you can apply let's say monoclonals as prophylaxis, because they will act basically immediately in terms of their anti-viral property. But we need -- yes, we need far more work and far more systematic work. It's not going to be very -- how to say -- sexy in a sense. It reminds me in the early days when I was a medical student like treating leukemia in children, it was a you know, a death sentence. But it was like every trial or many trial, every time added 5%, 10% survival OK, with HIV also, it has to -- you know, it's kind of partly trial and error, partly rational approaches. And then a drug that's a little bit better and so on. And maybe we're in that stage now, and that's what's needed. But the problem is the time pressure [inaudible] people dying.

>> Howard Bauchner: I mean the disease to me, it reminds me much more of sepsis. I mean the critical care community's been at it for 20 or 30 years, and there's been nothing magical. But --

>> Peter Piot: Yes.

>> Howard Bauchner: But mortality rates have come down. It's very different than diabetes, or Type 1 diabetes, where you need to give insulin. Or if you have bacterial meningitis, you need to give the appropriate antibiotic. It's not that simple. Peter, you must have a particular interest, as I said, people know you've been public about having contracted the disease in March. And I've said on this show -- someone emailed me, I don't know now it could be four or five months ago -- time is so odd at the last year -- about long-haulers. And I said to them, why are you writing me about truck drivers? Because I don't have any -- and they go no, no. We're not talking to you about truck drivers. We're talking to you about people who are reporting these long-term consequences of disease. Could you say a little bit about your own experience, and then your sense of what this concept of a small number of people having prolonged symptoms may look like, or what it may be?

>> Peter Piot: Yes, well I was one of these long-haulers. And I think it's not so rare. But before that, why did I you could say come out? And that was because I got really very frustrated by the public messaging, certainly here in the UK was all about statistics, flattening the curve. We had prime minister giving, explaining the reproductive rate of infectious diseases. My God. And then saving the NHS and all -- and never about people. And I said this is about people. And you know, and I worked for many years on AIDS. And so, in the -- in HIV, people living with HIV, they're a very important component of the AIDS movement or whatever. We -- you know, they're outspoken and they -- there is [inaudible] said OK, I'll -- you know -- and I started in Belgium, because I'm from Belgium, and I'm pretty well-known there, and there was a lot of complacency. And I said, look this is not just about a little flu here and then, if you're very old or you have underlying conditions, then you end up in intensive care and 1% die, and it's just 1% and you know -- I said you know, there's a lot in between. And that's why I came out. And also this was in April last year. This long-haul or long COVID was not yet known. I mean, I was [inaudible] hospital in London and I was one of the first ones you know, with this, with the after -- so I got infected in March in the very beginning, mid-March I got sick. And the -- after you know, it was just headache and fever, being very -- I mean but splitting headache. And very tired. But I continued to work. I'm a bit of a workaholic, you know. And plus I was dealing with the epidemic and so on, and then also transforming our -- the London School into a more digital working and all that. But then I just couldn't take it any more, and I had to go to the hospital. I was hospitalized, and I had bacterial pneumonia. So I was treated for that. That at least we know. But my oxygen saturation, the lowest value I had was 79%. And so I was admitted with 83%. But what's interesting is that I hadn't thought of it. I mean it's of course when you're your own worst doctor. And because I had no shortage of breath. I mean, I live in one of those old English houses with three floors, and I go up and down all the time. No problem.

>> Howard Bauchner: Yes, that's your --

>> Peter Piot: But this is silent hypoxia you know? I was certainly one of them. But then I got very high-flow oxygen and heparin because I had racing tachycardia. And actually developed atrial fibrillation also. All related to the COVID. And I'd never been sick in my whole life. I had no underlying conditions. So that's probably was good. I'm pretty fit, certainly for a 71 year-old. And -- but fortunately I never had to be intubated, or go into intensive care. But I was always like at the limit for in terms of oxygen saturation. But then I was you know, discharged and I thought OK, now I'm going to just have to rest, which is not my greatest quality. And a week later, I was exhausted, exhausted. But then I started coughing, being short of breath, and then it's what I developed what they call here an organizing pneumonia. But they had interstitial pneumonia with some fibrosis. And I was treated with high doses of IV prednisone. Up to you know, 1 gram of a bolus of prednisone. Yes, gives you a bit of a funny feeling.

>> Howard Bauchner: Yes. You were flying for a few days [laughs].

>> Peter Piot: Yes, but no I was very disappointed. I didn't get euphoric or [inaudible].

>> Howard Bauchner: You didn't get -- no euphoria?

>> Peter Piot: No. But it was a -- yes. My head was already with -- well it was what's called a foggy head. I had that for quite a while. So I also had cognitive involvement. I had hyperesthesia. So just touching my hair was so painful. It was interesting. Anyway that took about three months.

>> Howard Bauchner: Smell? Loss of smell or taste, Peter? So common.

>> Peter Piot: Fortunately no. Because I love my wine and my food, you know? So I'm so grateful I never lost that.

>> Howard Bauchner: OK.

>> Peter Piot: But I had no appetite. So I didn't touch wine for maybe three months, which is the longest in my life I think, in my adult life. But yes. And it took about four months, five months before -- yes, five months before I could start like running again, slowly. And now I'm fine. Just totally fine, but except that I need eight to nine hours sleep. I shouldn't say "except" because I'm now reconciled that that's not a waste of time, but that's actually healthy. And it's a book by Matthew Walker, Why We Sleep, that really -- you know, I said OK. It's good for me. So now I'm -- yes. That's a new lifestyle. But --

>> Howard Bauchner: Quite a few questions have come in. So if we could just go through a few of them.

>> Peter Piot: Sure.

>> Howard Bauchner: One's a difficult one. Peter, you're a globalist. I mean, your career has been to go to difficult places and help people. I was impressed that President Biden has commented that he just purchased 300 million more doses from Pfizer and Moderna. But that means there's not 300 million doses going to other countries, low- and middle-income countries. How do the rich countries, your country, our country have to think about the world?

>> Peter Piot: Yes. It's something oh that keeps me really busy. It's probably what keeps me awake at night now more than anything else. I mean at the same level as the variants, and that is the let's say vaccine inequity. And I've been you know, talking a lot to my colleagues, friends in Africa, where there is now rampant COVID epidemic. That was one of the surprises. I thought it would start very early on, and it didn't.

>> Howard Bauchner: It didn't. It waited.

>> Peter Piot: But now it's like you know, John Nkengasong from the -- Director Africa Centers for Disease Control and Prevention you know, talked also about the mortality's going up. But yesterday it was announced that -- by the African Union that they had secured and -- I can't remember the exact number, but 300 or was it 600 doses of vaccine from the Serum Institute of India and so on. But it this a problem. This is not the only a moral hazard, a moral issue. But -- and one of the, what I think will be one of the big geopolitical issues of our time. Just imagine a world where you know, the Western world and the richer Asian countries are all very secure against the COVID-19, and then the poorer countries not. That's not only unfair, but it's also -- we should be very clear there. This problem is not going to be solved until it's solved in every single country. You can have been New Zealand and you know, and close off your country because you're an island. And -- but you can't do that forever. And you'll have to do that forever if the whole world, it's not safe. So it's in our interest. And I hope we'll have some initiatives to support the you know low-income countries. And that's why I was working with an initiative that was originally launched by Ursula von der Leyen of the European Union, and that lead to the creation of COVAX. It's now led by Gavi, the Vaccine Alliance and CEPI, the Coalition for Epidemic Preparedness Innovation. And what's -- you know with backing from WHO. And that is really trying to buy vaccines for low-income countries. But the African Union hasn't waited for that, and has done their own deals. But at the moment, the big issue I think is that we have to make sure that we are going to share some of our vaccines. And secondly, that we provide the money for it. And I think we need a -- and then that there is enough vaccines manufactured. Because that is another issue. But that's going to be a temporary problem I think. I'm quite confident that by the third quarter of the year, there will be literally billions of doses coming up and certainly near the end of the year. But that's still a long time. And let's not forget that we have a couple of million people who died in you know, in less than a year basically. We can't afford that. So it's very high on the agenda. And I hope that the Biden administration, perhaps joining forces with the EU and other countries to launch an initiative. So that there are going to be vaccines available for everybody. Because we're all going to suffer. Everybody.

>> Howard Bauchner: Yes. I think for many people, we talk about equity. Sometimes it's hard to live equity. It's --

>> Peter Piot: Yes.

>> Howard Bauchner: Last question, and it -- again came across the screen. Have you been vaccinated Peter, and should you be vaccinated?

>> Peter Piot: Yes. First, yes about three weeks ago now, I got the Pfizer BioNTech vaccine. I mean I -- just on a Saturday afternoon I was called by my GP practice you know, and they said can you come tomorrow at 9:45 in a health center for a vaccine? And I said sure. But I said I'm not over 80, because in the UK it's healthcare workers, and care home workers, and then it's first people over 80, and now they're starting over 70 and so. And they said come tomorrow. And so OK. And you don't know which vaccine it was. You know, I got the Pfizer BioNTech. And I was happy with that, 95% protection. And so the nurse explained to me that you know, there were not enough people registered already for the shots, so they went out to the next tier, yes. And the question I also wonder myself, do I need a vaccine?

>> Howard Bauchner: Yes.

>> Peter Piot: In my case, it's a boost probably.

>> Howard Bauchner: OK.

>> Peter Piot: Boost. But at some point I was concerned maybe you can have immune enhancement infection and so on. I mean, all these theoretical possibilities but then I was quite satisfied by the -- you know, the safety profile. They looked into that. And I'm not just keen that I'm getting my second injection within six weeks, and not 12 weeks. But I think that we will have data also soon I believe from not only the trials, but from vaccine deployment, like in Israel, where all they're really ahead of everybody else, and they're rigorously following and monitoring people. And a lot of people vaccinated must have had the infection. Because frankly, we have the official data from WHO and so -- they're pretty meaningless, you know? They're probably closer to a billion people who have already been infected with this virus. So a lot of those vaccinated are -- you know, will have had the infection. So that will be very interesting to see. But the fact is also that we can be re-infected. I mean, it seems to be rare, but maybe with this you know, variants and the more diverse they are, maybe the higher the risk for re-infection. Thats another research question that I'm very keen to see an answer to, and that will take -- I guess in a few months' time we will know the answer to that.

>> Howard Bauchner: Yes, I know. Sadly in the U.S. given the numbers of cases over the last few months, we're probably close to 15% of the U.S. population has now been infected. So that's -- you know we're 330 million so that means 50 million people in some regards have some protection. Not everyone but most have protection for some period of time. I always have one last question, but this will be the last question. I apologize, Peter. When a new vaccine -- say some new vaccines are approved in the coming months, and they're 60% or 70% effective, versus Pfizer and Moderna at 95%, how do you think that's going to play out in the public?

>> Peter Piot: Yes, that's I think a reality. I mean look at the AstroZeneca vaccine. OK we -- it's not totally clear how much, but they say average 70% --

>> Howard Bauchner: Right.

>> Peter Piot: And although I must say when it comes to severe disease mortality, the numbers were too small, but severe disease and mortality, it seems that effectiveness is really high.

>> Howard Bauchner: For AstroZeneca? I didn't see the data. For AstroZeneca?

>> Peter Piot: Yes. The numbers are small.

>> Howard Bauchner: OK.

>> Peter Piot: When it comes to mortality.

>> Howard Bauchner: And we haven't seen the final reports from the China vaccines.

>> Peter Piot: No.

>> Howard Bauchner: But the preliminary data say lower.

>> Peter Piot: Yes. Yes, exactly. So -- and that in itself will be very important, and I think we should stress that. And so the first impact of vaccination should be seen in terms of mortality and severe disease hospitalization. And frankly that would make a whole difference. I mean OK, we may continue to become infected, but if you don't end up in the hospital, and you don't die. OK, that's fantastic. But in terms of the you know, vaccine confidence, that's -- that will require some good communication. And I think we need to distinguish between people who are let's say hard core anti-vaxxers who are against vaccination because they want the natural way or whatever. They're against big pharma and so on. They prefer that their kids get encephalitis and so on you know, or die. But most people who hesitate, I think they have questions you know, to say hey, how do we know within 10 months whether this is totally safe and efficacy? So it's something where we need to make sure that we're transparent in everything that happens, and that we are you know, listening to people. My wife Heidi Larson, she happens to work a lot on that, so I hear a lot about it at home. You know? On vaccine confidence. It's not just by giving more information, and we need to take people seriously. And it's particularly an issue -- I don't know about the U.S., but in this country, in Black communities, and in other ethnic minorities, that there is quite some suspicion. And yet they may need more than anybody else, because there is also a lot of inequality in face of death in terms of COVID, because we've seen it in ethnic minorities in the U.S. and in the UK. So yes, it's not over. And I also don't believe that we will go back to totally normal in a few months' time. We'll probably have a gradual expansion of vaccine coverage with fewer and fewer people dying. Wonderful. But we'll need to keep some of the -- you know, the other measures. And certainly wearing masks and so on. That's what I'm going to continue to do in any case.

>> Howard Bauchner: This is Howard Bauchner, Editor in Chief of JAMA. This has been Conversations with Dr. Bauchner. What a privilege. Peter Piot is the Director of the London School of Hygiene and Tropical Medicine, a legendary school in public health, founded in 1899, where he's the Handa Professor of Global Health. Peter, thanks for sharing your wisdom, your insight, and your personal stories. I think we should never, ever forget the power of narrative in trying to explain prevention and disease to people. Thanks Peter, for joining me today.

>> Peter Piot: Thanks Howard. Pleasure.

>> Howard Bauchner: Stay healthy.

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