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Coronavirus Update With Carlos del Rio and Preeti Malani

Coronavirus trends, variants, vaccines, treatment, and more. JAMA Associate Editor Preeti Malani, MD, MSJ, also from the University of Michigan, and Emory University School of Medicine's Carlos del Rio, MD, return to JAMA's Q&A series to discuss the latest in COVID-19 medicine and public health. Recorded March 15, 2021.

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>> Howard Bauchner: Hello and welcome to Conversations with Dr. Bauchner. Once again, it is Howard Bauchner, editor in chief of JAMA. I'M delighted to be joined by Carlos del Rio. Carlos is a member of our editorial board, a distinguished professor of medicine at Emory, where he's also an executive associate dean and a member of the infectious disease group. The other guest today is Preeti Malani. Preeti is an associate editor, chief health officer at the University of Michigan, where she is also a professor of medicine in the school of medicine. Carlos and Preeti, welcome.

>> Preeti Malani: Thank you.

>> Carlos del Rio: Happy to be with you.

>> Howard Bauchner: It's early March, almost a year from the huge, extraordinary march of disease across the world from China to Europe to the United States to the rest of the globe. Carlos, before we get into your viewpoint that you've written with, Preeti, I think it's your, I was trying to figure out, is your fifth one, it's these like --

>> Preeti Malani: Sixth.

>> Howard Bauchner: Sixth.

>> Carlos del Rio: Six

>> Howard Bauchner: Five monthly updates. So, I enjoy it. But before we get into it, because it's set up like the others as questions, all around vaccines, Carlos, it's been a year. Your impressions?

>> Carlos del Rio: Well, you know, I've reflected, Howard, a lot on what has happened over the past year. The first thing I would say is I don't think any of us in our most wildest dreams would have even think about the devastation that we've seen as a result of this pandemic, both in the terms of human loss, you know, over 500,000 people dead in this country in terms of economic loss, you know. But I think, also, we would have never predicted that we would have effective vaccines so quickly and that we would be, as of today, with over 100 million shots given globally. So, I'm going to -- in the United States. So, I'm at a point of guarded optimism. I have still a lot concern that, you know, a lot needs to happen, but I'm optimistic that we are, science is getting us out of this pandemic. We're still going to need a lot of work globally, though, I mean, you know. We have millions, 300, Preeti and were talking, 300 million doses roughly given globally, and that's 100 million in this country. So, the reality is many countries have not even started to vaccinate their health care workers or the most essential workers. So, we have a long way to go, and I think there's going to be, so this year, in my mind, is going to be the year of really thinking about global collaboration and cooperation and how do we work globally to actually end this pandemic, not just locally.

>> Howard Bauchner: Preeti, when you think back to the last year, you saw all the papers with me. You helped. You know, they all came to me, and I'd send out my emails. Preeti, help, what do you think, to you and a few other people, when you look back over the last year, Preeti, what's your impression, your reflections.

>> Preeti Malani: Yeah, Howard. A lot of the same things that Carlos said. You know, for me, I think that the interesting thing is is how quickly it changes. Even this viewpoint, which came out a couple weeks ago, 10 days ago. You know, what we know in the morning changes in the evening, and I think that that's, it's an interesting place to be, and you know, for me, a lot of my perspective has been the campus and trying to get students back to face-to-face learning and all the benefits of that. And you know, what I would say is that a year ago it was only about viral transmission. Nothing else mattered, and it was like we just closed the light, shut the door, and sent everyone home. And you know, getting back has been really complicated, and you know, at some point, the virus is going to be in the background. It can't be everything, and we're going to have to live with some residual risk, and we're going to have to cooperate and trust in science and sort of take care of each other. But it's a remarkable year, and I think it's, for a lot of people, students, health care workers, everyone, this is an emotional month. You know, when you think, wow, it's been a year since we were "normal."

>> Howard Bauchner: Yeah, yeah.

>> Carlos del Rio: And I think that's the one thing that I do worry about is that there's going to be post-pandemic PTSD, and the mental health consequences of this pandemic are not trivial, and it's something that I think as a society we're going to have to really work hard at.

>> Howard Bauchner: Yeah, I think, you know, we had a piece by Charlie Marmar and others that talked about the psychological consequences, harm, challenges, of 500,000 deaths in a year of just total disruption to what life is like and what that will mean over the course of the next few years. I'd like to turn to the viewpoint, work our way through the questions. I'm sure others will come up. Feel free to banter between the two of you if you'd like. Preeti, I'll start with you. Modern, Pfizer, J and J, I always think of them as the Band-Aid company, Johnson and Johnson, which is the same as the Jansen vaccine. People sometimes get confused. So, Moderna, Pfizer, J and J Jansen, which vaccine, Preeti, are you recommending?

>> Preeti Malani: Yeah, and I've heard it called Yansen, if want to really [inaudible].

>> Howard Bauchner: Yansen. So, I may be mispronouncing it.

>> Preeti Malani: Just to confuse it. So, Howard, whatever vaccine you can get into people's arms, and I think this is a really important question, not just, you know, for health care workers, a lot of us have been vaccinated. You know, for me, there wasn't a choice. It was Pfizer, partly because we had the minus 80 freezers on site. For everyone, like whatever you can get, whenever you can get it, as soon as you're eligible. A lot of focus that I'm hearing is oh, this vaccine efficacy, and this, and all of them work beautifully with severe disease. And that notion of vaccine efficacy, and I know Carlos can talk about this some more too, but I worry that the public is taking those numbers and comparing them the way you might compare another number, and that's not at all what those are. You know, the 60% doesn't mean you have a 40% risk of getting COVID. And so, I think, again, I frankly think that Johnson and Johnson or a Jansen vaccine has a lot of advantages as a single shot, particularly in younger people who might be mobile and might not want to come back for a second dose.

>> Howard Bauchner: Carlos, and vaccine preference?

>> Carlos del Rio: I have no vaccine preference. I agree with Preeti, but I also like, I want to add that we know that people that already had COVID may not need two doses. We're still recommending two doses of those vaccines that are two-dose vaccines like Pfizer and Moderna, but in somebody who's already had COVID, young people, who already had COVID, you know, problem Jansen, the Johnson and Johnson vaccine may be great. You get one shot and you're done. So, I think what we need to go now is we are done, well we have data on efficacy. Now, we need to move to effectiveness. Now, we need to really look at population level effectiveness, and that may be totally different. And I think getting that movement from efficacy to effectiveness is something that we need to get the population to understand, and if you get, if you get a vaccine, you get some effectiveness, especially when you start talking about herd immunity and other things, other benefits. If you get no vaccines, your vaccine efficacy may be 95%, but your effectiveness is zero because you still haven't gotten the vaccine. So, any vaccine is better than no vaccine.

>> Howard Bauchner: Not surprising, the first question has already come in, I'm not surprised. You know, it's interesting, about a month ago, we must have gotten 10 papers on variants. Then the last week or two, it's been just a little quieter about the various variants. Carlos, anything new about the variants? Is it just continuing to churn or evolve, and it's really hard to get very specific information about the different variants.

>> Carlos del Rio: Well, first of all, as you know, RNA viruses tend to mutate. So, we're going to be seeing variants, but I think, I heard the other day, I think something, Monica Ghandi or somebody talk about we need to stop calling them variants and hear them and talk about them as scariants. People are getting scared by them, and let's not need to just use this to get scared about things. We know certain things, and I think the one that I'm more concerned about, honestly, is the UK variant because we know it's more transmissible. It's probably going to be the dominant variant in our country by the end of March. So, I think it's just a reminder that what we need to do is shut down transmission, and how do we do that? We do it with vaccination. We do it with masking. We do it with social distance because if we stop transmission, we stop viral replication, we stop variants from occurring. So, to me, variants are, yes, a reminder to tell people this is not over. I was telling a group the other day, I feel like we're landing the plane, right. And we had a very rough takeoff. We want to be sure that the landing is smooth. And when you're landing a plane, the captain doesn't say, oh, were almost there, take off your seatbelt, we're fine, no problem. You know, that's what I'm hearing a lot of governors say, oh, were almost there, take off your mask, open the state, we're done. We want to be sure that we land successfully and we [inaudible] this problem. And we have to, and I think the variants are a good, and my point, in my mind, a good opportunity to talk about why we need to continue to practice nonpharmacological interventions while we vaccinate everybody.

>> Howard Bauchner: The very second Q and A is your viewpoint is entitled, Do Vaccines Protect Against Infection and Prevent Transmission? Preeti, this is all yours.

>> Preeti Malani: Yeah.

>> Howard Bauchner: Because this is so confusing to people.

>> Preeti Malani: Yeah, and you know, I think the one thing is is that these are difficult things to ascertain quickly, and part of it is we just need to see, and I would say the data from Israel is really encouraging. And I know Carlos knows the data well. It's encouraging both in terms of variants with B117 circulating widely there. You know, today, this morning, actually the New York Times Daily talked about Israel and the fact that they've done a really good job at least within Israel proper of vaccinating a lot of people. And they're back to a lot of prepandemic activities. And you know, I would say that there's at least a suggestion that infectivity, if it is there, is low, and you know, in our viewpoint, you know, we said it's unknown, but I don't think anyone feels like it's going to be exactly the same. It'll be less and maybe it'll be very low or zero.

>> Carlos del Rio: Well, it's a little bit like what we were talking about, right Preeti? We wrote this 10 days ago, and there's already new data. When we wrote this, we said, we don't know. Now we have better data. There's some very nice data showing that even if you get infected, the amount of virus in the nose, the production of virus is a lot lower, so you may be less infectious. So, what we need to know is what happens. Again, I think we need a lot more population studies to really understand this, but I feel, I feel better today saying these vaccines likely protect against infection, likely protect against transmission, and even if you get infected, you may not produce an odd virus to really make it a difference. So, I think it's amazing that those vaccines are actually doing that. And the data from Israel, you're right, is great.

>> Howard Bauchner: I'm not sure we're going to get through viewpoint, because there are so many questions. So, I'm going to bounce back and forth. I'm not surprised, and I'm not, I'm quite --

>> Preeti Malani: Well, people can read the viewpoint, so.

>> Howard Bauchner: They can read the viewpoint, that's true, and I can ask the questions. I'm not surprised. Oxford, AstraZeneca news from across the pond, could both of you reflect on it? Carlos, I'll start with you.

>> Carlos del Rio: Well, I mean, I first reflect by saying I want to look at the data, right, because I haven't seen the data. I want to see data because that's, I tend to be data driven. Having said that, you know, when you're vaccinating millions of people, and you start seeing things in the background, you need to pause for a second and say, is this association or is this just causation, and you know, association doesn't mean causation. At this point in time, there is millions of people have received the vaccine. There's a few events that have been reported, and we need to look at it. I want to see the data. I'm not yet convinced that there is an association. So, I am still recommending that people receive the AstraZeneca vaccine in places where the vaccine is available. I think the risk of getting a thrombotic event is much, much lower than the risk of getting, for example, COVID, in countries like Mexico, Brazil, and others, who are actually vaccinating using precisely that vaccine. So, in fact, today, I recommended to a friend in Mexico to go ahead and get vaccinated.

>> Howard Bauchner: Were you surprised how many countries have so quickly suspended use of the vaccine? You know, when I picked up the newspaper, by the afternoon, I think three or four more countries had suspended use. Is it because they're concerned about only then increasing vaccine uncertainty?

>> Preeti Malani: Yeah, I can weigh in on that. You know, actually I think as we were sitting here my alerts were going off that Germany has also paused it. And, you know, with a new vaccine, that hesitancy and those concerns do have to be taken into account, and you don't want to undermine confidence, but I agree with Carlos that when you talk about 17 million, 20 million, 50 million people getting vaccines, you're going to see certain things, and then, you know, you just have to stop, pause, look at the data, share data, but the Astra-Zeneca vaccine is something that worldwide this is expected to become, you know, produced in the billions, you know, with a B. And because of its cost and because of its temperature stability, this is the vaccine that's going really be used everywhere. So, it is important to ascertain that, but all of this is in the backdrop of the risk of COVID, and if there happens to be a slightly elevated risk of thrombosis, and I don't think anyone knows that right now, it may be that this is completely nothing, association. It wasn't seen in the earlier studies, but that still can be weighed and looked for and prevented. So, I think, you know, frankly, we're a little bit, we're sort of surprised that we have multiple safe, highly effective vaccines. I don't think anyone expected that. I mean we would have accepted, you know, less effectiveness. We would have accepted potentially even some safety things. So, hopefully it's good news, and hopefully it's just for a short time that we're paused.

>> Howard Bauchner: Preeti, I want you to take the next question because it's permeating U.S. society as schools reenter and reopen, and as I said, you're chief health officer at the University of Michigan, I don't know, 50,000 students? The distance, three feet versus six feet, and ventilation within rooms. Now, this has become a really major focus for K through 12, but I can't imagine on a college campus that this is not an issue. Can you comment? It's a question about this three feet versus six feet.

>> Preeti Malani: Yeah, I would love to comment on that. So, one thing I would say is last fall we didn't really know how a lot of this was going to turn out, and one thing that's been very consistent K through 12 and the higher education space is that classrooms are safe with mitigation, and by that I mean masks more than anything, making sure people who are sick stay home. We actually on campus are doing routine surveillance testing. We weren't doing that when we started, but that was something we were able to ramp up. Now, in classrooms across the country, teachers are being vaccinated, fortunately, and in my community most of them, anyone who has been wanting to get vaccinated pretty much is now, which is not the case a few weeks ago. So, that's good news. And this three feet versus six, you know, when you think about six feet and what that's based on, it's based on like sort of old data, models, you know, how do droplets function. It's not like at five feet, you know, the droplets fall on you, and at six feet they don't. All of it's a continuum, and all of it is a little bit practical. There are a number of classrooms that are closer to three feet than six feet, and they have been okay. And one of the studies that came out earlier this week, Howard, was in a clinical infectious diseases. This is from Massachusetts, and they looked at this, and your home, your home state, still your home state, I guess, but they actually found that there wasn't, you know, if they could ensure masking and good ventilation that the three feet was acceptable. And, you know, I know Collis and I were chatting about this is that, you know, the hope is that the CDC is going to follow up with a more formal recommendation in this regard, but my sense is that moving forward, as we have lower incidence of infection and we have more and more people vaccinated, especially if we can ensure a good adherence with masking, that we can probably decrease that six feet distance.

>> Howard Bauchner: Carlos, this question comes up all the time, and it's interesting, someone, I'm glad to see, is reading JAMA. We published an article, a research letter, Immunogenicity of a Single Dose of SARS-CoV-2 Messenger RNA Vaccine in Solid Organ Transplant Recipients. I think every time I do a podcast around vaccines, people who are immunocompromised in many different ways have said, can you talk to the millions of people in the United States that are immunocompromised, and they're immunocompromised in different ways, drugs, chemotherapy, underlying disease. Can you talk about vaccines in immunocompromised adults, or is it so heterogeneous that it's hard to make a definitive statement?

>> Carlos del Rio: You know, it's very hard, Howard, to make a definitive statement, but at the same time, we know from different data that people who are immunocompromised with certain conditions they're at particularly high risk of COVID, and there is no problem with them receiving the vaccine. There may be an issue as far as side effects. There may be an issue they may not respond as effectively to the vaccine.

>> Howard Bauchner: Right.

>> Carlos del Rio: And that is my biggest concern. So, I tell people, get immunized, but you need to be careful. I mean if you happen to be on a, you know, a monoclonal antibody that wipes out your B cells or you happen to have, you know, a lymphoma or something which your B cells are not as effective, you may not respond to the vaccine in the way somebody else would respond. So, the protection you get from the vaccine will be very different. And again, that's where we need the studies of saying do these vaccines actually protect people who are immunocompromised. So, I see no reason to tell them not to use the vaccine, but I see not enough data to tell me, yes, and once you're vaccinated you are good to go, you're going to be protected. Because we didn't enroll those people in the clinical trials.

>> Howard Bauchner: Preeti, you know, it's diseases a year ago, are we out far enough yet, vaccine trials started in July. We know that people were infected all through last fall. Do we have enough information about how long protection, although it's poorly measured because it's often just neutralizing antibodies, and so we don't have a very good assay for T and B cell memory. Are we beginning to have a sense about how long immunity will last either from the vaccines or from naturally acquired disease?

>> Preeti Malani: You know, I, this is a good question, Howard, and, you know, I would say that we still are uncertain and partly because the early cases, we didn't even know a lot of people who were infected, unless they were really sick and in the hospital, but there was clearly a lot of transmission in the community. And, you know, so far, the vaccines, it's unclear. What will happen is we'll get everyone vaccinated. Hopefully, we'll get good numbers, and then we'll see if we start seeing increases in infections in people who have been vaccinated. And we are seeing a few of those. A lot of what we're seeing are people getting routine screening before a procedure, for example or when they get hospitalized for something else. We're not seeing a lot of symptomatic infection, which is encouraging. As you know, neutralizing antibodies, I mean that's one correlate of immunity, but there are many more that are hard to measure. So, I'm hopeful, but if I had to guess, we're probably going to look at some sort of booster next year.

>> Howard Bauchner: Vaccines become more widely available, I think, Carlos, you mentioned 100 million doses given as of this morning. I know all of the last two weeks or last 10 days it's been almost 2 million doses a day. Any deviation from the three- and four-week plan from Moderna and Pfizer or are both of you supportive of the current EUA and recommendations from the CDC?

>> Carlos del Rio: I tend to be supportive that, you know, use medicines as they were studied, as they were prescribed. I also do tell people that if you need to wait a little longer for whatever reason, then it's not a problem. You can still get your vaccine, get your second dose, you know, as soon as you can, because you know, if it's Pfizer, it's not 21 days, it's 27, 28, 30, you're fine. I mean nothing is going to happen, but get your second dose. I think it's going to be very important that you still do that, because precisely what Preeti was saying, we don't know how long your protection will last, and we do know that that booster event actually raises significantly at least your neutralizing antibody levels.

>> Howard Bauchner: There's a number of other questions, but I wanted to touch on two issues, and then we'll go back to some of the questions. Vaccine hesitancy and equity and distribution. It's been a struggle in the United States, more pronounced in some areas than others. I saw Massachusetts data this morning about the Latinx community, the least vaccinated community in Massachusetts. Massachusetts has finally caught up and now exceeded the national average for the percent vaccinated, although it was very slow, slow going. The technologically dependent approach to vaccination created a lot of struggles for certain communities that are not technologically as intense as other communities. Do either of you have thoughts about this persistent problem?

>> Carlos del Rio: I mean as you said, we made it complicated, right. You made it complicated to get vaccinated, and by having to, you know, go to website and sign up and do this, and then there's this problem that we created of scarcity. So, you have millions of people who want to get a vaccine. Governor Cuomo said we have 10 million people, you know, chasing, you know, 40,000 vaccines every day. I mean I think that creates a problem, right. You have, so the people that are more savvy are going to get them. The people that are going to be out there are going to get them. I think you really need to do certain approaches. I think DC has an interesting approach in which they went by zip codes, it went by specific areas, and they went to the most, you know, needed area, and they said, we're going to vaccinate, in order to get vaccinated, you got to live in that zip code. You cannot be travelling from a different zip code, because, for example, in New York, when they put a vaccination site in the Bronx, it was people from the Upper East side that were driving out there to get their vaccine. We need to be sure that we're intentional. We need to be sure we're specific. We need to make it easy. For example, where I work, at Grady Hospital, when we realized very quickly that having people make appointments just made it complicated. Make it open access so people can just show up and get their vaccine. If they're here for a clinic, just have them go downstairs and get their vaccine. So, you've got to make it a lot easier. But we also have to work with trusted messengers in the community. So, if a trusted place for you to get your things is the church, let's work with the church. If your trusted place is, for example, this weekend I'm working with Latin American Association here in Atlanta, vaccinating people over there, because that's a place where they go for multiple services. It's a trusted place. So, let's put the vaccinating site there rather than having them, you know, get on a bus or getting transportation and go to a place that they are not familiar with, which is the hospital or the health department to get a vaccine. Many of them have never been to the health department, and now we need to tell them you need to go there and get your vaccine. So, how do we make it easy? How do we make it accessible to people. And I think access and trust is really critical in achieving this goal.

>> Howard Bauchner: I didn't see the interview over the weekend that Tony Fauci gave, but it was about, you know, a certain group of Republicans who didn't want to be vaccinated, and I think the quote I saw, "I just don't understand this." Preeti, I'll let you comment on, you know, my sense of vaccine acceptance has gone up. I mean we watch the polls. It's 50%, 55%, 60%, 65%, 70%, and then you have groups that just refuse to be vaccinated. Is there a way forward?

>> Preeti Malani: Yeah, I hope there is, and, you know, again, just to follow on Carlos' comments, you know, vaccine hesitancy is not one thing, and you know, we sort of label certain communities, and I think these are really important measures. For example, Detroit's going to have a big site at Ford Field with FEMA where there's going to be incremental vaccines seven days a week for eight weeks straight. But, you know, we're not talking as much about hesitancy in rural communities and among more conservative voters, and frankly, those groups probably have more hesitancy than some of the communities that we think of in urban areas. And I think getting at the reasons for hesitancy. One thing that we found in some of the work I did with the National Poll on Healthy Aging is that people really trusted their doctor's recommendation, and I think it gets at what Carlos said is like when people come for their regular appointment, try to make it easy for them to get their vaccine. I know that some hospitals are also vaccinating people as they're being discharged. But, you know, it really comes down to having those lengthy conversations with someone who is trusted, because if you don't believe that the virus is real or everyone around you doesn't believe this is real, you may not want to go get this. The other thing is, if you don't see any benefit to this, if well, I get vaccinated with this experimental vaccine, and I still got to wear a mask and I still can't go anywhere. So, I think we need to have all those types of conversations and also continue to show people the way forward.

>> Carlos del Rio: But that, I think, gets to an issue in our viewpoint, right. We actually put recommendations of what to do if you've been fully vaccinated ahead of the CDC recommendations.

>> Howard Bauchner: Right.

>> Carlos del Rio: And I was very pleased, because when I showed our viewpoint to colleagues at CDC, one of them said, did you, somebody leak our recommendations to you, because they were very in line, but it was really important that as Preeti said that we tell people what can you do if you get vaccinated, because to tell people the things they cannot do, but yes, you still need to get vaccinated, but everything is going to be the same is not going to get people vaccinated. You really have to give people some positive things as a result of vaccination. Because, you know, if you're 65 or older, you know, being told you're not going to die sounds like a good benefit, right. But if you're 20 or 20 or 35, and you're told, well, you're going to get vaccinated, and your life is not going to change, well why should I get vaccinated, because most people my age that get COVID have not problem, right? So, I think certain things are going to be important to tell people, and I think as we know more, telling people the kinds of things you can do if you've been vaccinated, I mean the idea that, you know, you can gather in small groups without wearing a mask indoors is fantastic. I mean I think all of us really are very happy to hear that.

>> Howard Bauchner: Yeah, I was going to ask, don't leave me hanging, Carlos, but I'll give you a personal experience. I saw my brother, my nephew, and my sister-in-law this weekend. Josh kept his distance, but my brother and sister-in-law were both vaccinated. No masks, in the house, having a conversation, having a meal, the first time in six months, and it felt normal, you know, that there was a sense of normal, but don't leave me hanging. So, what are the other things that you and the CDC now recommend that vaccinated people can do?

>> Carlos del Rio: Well, I recommend things that the CDC has not recommended. The CDC continues saying don't travel, and as you know, this past weekend was the weekend that had the highest number of travelers going through our airports. So, Rochelle, this morning, Rochelle Walensky said she was pleading with Americans, you know, to be careful, but spring break is coming, so we got to tell people how to travel. We have to tell people what to do if you've been vaccinated, what kinds of things you can do, whether you need to continue -- for example, I travel, and I'm not wearing an N95, but I'm wearing a cloth mask, and I'm not wearing anymore a face shield on a plane, but I still wear my glasses. I still get, you know, tested before I travel and after I travel, but there are certain things, a sense of feeling a little more relaxed when I travel. There are certain things you can tell, and I think telling people, yes, it's a lot, you can travel if you've been fully vaccinated and wear a mask, etc., but its going to be safe to get on public transportation. It's going to be safe to, you know, get on a subway, etc., by wearing your mask. I think there are certain things around travel that I think is going to be really important that they tell us what to do soon, because continuing telling people not to travel is not going to help us. People are just not listening.

>> Howard Bauchner: Preeti --

>> Preeti Malani: And I would just --

>> Howard Bauchner: Yeah, well, I was going to ask, I'm going to ask you specifically, because you get to advise the president of the University of Michigan about what 50,000 people can do. So, like on a college campus, what does vaccination mean?

>> Preeti Malani: Yeah, so right now, our students are not highly vaccinated. We have the ones in health sciences and then a, you know, handful of others, and this semester, we're mostly remote, but our campus is full. Like we've got kids everywhere, including my own kid is on campus, but they're not in classrooms very much. And, you know, my message, and this kind of builds on what Carlos was saying, you know, a lot of it, for vaccination one thing is is they don't have to be quarantined now. We are still doing routine testing on people, but that's a discussion we're having right now, especially in light of athletics, and I know both Carlos and I, he advised NCAA, I advise the Big Ten, this is something as we move forward, we're going to have less COVID to find, and especially after we get vaccinated. So, I think the testing is going to change. Right now it's still in place, but I also take kind of a view of like instead of saying you can't do anything, what can you do? You know, we can't have an abstinence only view on this, particularly with young people. And so, what I talk about a lot with the president and with, you know, the students is stay in your groups as much as you can. Stay outside as much as you can, and if you go home, please don't take COVID with you. I worry a lot about the students going back and forth, because there's not enough to do on campus, frankly. So, you know, I think we're moving, you know, right now it's March Madness. Michigan number one seed. And also, it's St. Patrick's Day. These are high-risk times. I think we also need to remember that COVID is not the only risk in our life, and that all the other risks need to be balanced with this. And frankly, there's a risk of you not interacting and not going to a party. So, I think it is very much a balancing act, but we need to keep the community safe. We need to keep our faculty and staff safe. We need to keep anyone else vulnerable safe.

>> Howard Bauchner: I have one more question here, and then I want to transition to the last. I'm conscious of your time. There's been a number of questions about myocarditis following the second shot. I have not seen any of these reports, but three or four questions have come in. I don't know if it's linked to one particular vaccine or not. Could either of you comment on that?

>> Carlos del Rio: I have not seen the data either. I'm hearing it for the first time. I think, again, I think about association, right. I mean, again, when you're vaccinating millions and millions of people, like we've done, 100 million people, there may be one or two episodes of myocarditis here, and somebody is going to say, well this person just got vaccinated, but they're true true nonrelated. So, I think this is why we need to be very careful. This is why, you know, following cohorts, following individuals, doing science, doing research actually is what matters, because at the end of the day, the clinical trials, as big as they were, allow you to pick big issues, things that are very common, but it is something that is going to occur, you know, one in a million or something like that, and you may not pick it until you vaccinate millions of people. So, I would say whenever there is a signal like this, as Preeti said before, be vigilant, be ready to study it, but take it, you know, with a grain of salt until you have really understood what's going on.

>> Howard Bauchner: Preeti, have you seen any of these reports?

>> Preeti Malani: No, I haven't. And the first thing that popped in my mind was the myocarditis post-COVID that we were concerned about.

>> Howard Bauchner: Right, right.

>> Preeti Malani: And JAMA has had a number of papers on that, and even that is actually sort of, as, you know, they're getting more data, it's not clear that that's as big of a concern. So, I have not heard that, and I'd be interested in learning more.

>> Howard Bauchner: I want to finish with a major transition. Just over the last couple weeks, for the first time, I think, there's been much more talk about the global effort to vaccinate the planet, individuals around the world. There's a specific question about Africa. Before we came on, we were talking about India, a little over a billion people of the 7 billion. I think China has probably vaccinated most of their population. But for the first time the Biden administration is beginning to talk about shipping vaccines that are in the United States outside the United States. Production by Merck of other vaccines may help the global effort. How critical is this, and how can you imagine this rolling out? I think most countries have been very nationalistic, not just the United States. Most countries have been nationalistic early on, but how do you see this actually rolling out in July and August and September? Preeti, I'll start with you, and then I'll finish with Carlos.

>> Preeti Malani: Yeah, and Carlos, of course, has got deep expertise into the global health piece.

>> Howard Bauchner: Yeah.

>> Preeti Malani: You know, I'm just going to say a more general thing, which is that public health is about like what I do affects you and what you do affect me. And with vaccination in particular, we're often thinking about our own benefit. Like I'm going to get vaccinated, so now I won't get COVID. But it really depends on all of us getting vaccinated, and my getting vaccinated keeps everyone healthy, and that's not just true for the United States. We're not like a island in and of itself. We need the rest of the world also to come along on this, and you know, it is complicated, because there's only so much vaccine available right now. I think that these are, and I know COVAX is sort of set up to try to help with that, but it's, you know, it's like a drip right now. I know India is at, you know, with their Serum Institute, they are vaccinating. They're doing a pretty good job of it. China, Russia. But the EU, there's a lot of the world left.

>> Howard Bauchner: Carlos, this is, global health has been your life. How do you imagine this rolling out over the next three to six months?

>> Carlos del Rio: You know, Howard, I need to think, go back to my roots, which are HIV, right.

>> Howard Bauchner: Yeah.

>> Carlos del Rio: And when we started PEPFAR, when we started getting antiretroviral therapy globally, a bunch of people said, you can't do it. This will never happen. This was insurmountable, and yet, nowadays we have more people, it's the only disease for which you have more people on therapy where the disease is than in the developed world, which is really fantastic. That's what you need. So, I think we can do it. We've done it once with PEPFAR, and this is not about charity.

>> Howard Bauchner: Right.

>> Carlos del Rio: As you know full well, global health is about, it's about diplomacy. It's about security, and it's about, you know, keeping people safe and our economy. It's in the best interests of Americans to get everybody immunized. It's in the best interests of our economy. If we want travelers from other countries to come here and spend their money here, we better get them immunized. If we want them to buy our goods, we better get them immunized. But it's also about diplomacy, and I don't want to abandon that. You know, as the U.S. has retracted as being a global leader, China, Russia, other countries are stepping in, and there's a lot of diplomacy happening right now through vaccines in which China, Russia, and other countries are giving their vaccines to countries, Latin America and Africa, as good will and as global health diplomacy. We have to get back in there. That is what the U.S. has excelled on. I mean I think about going to Africa and people knowing and loving the United States because of PEPFAR. So, I really think it's in our best interest as citizens of the world, but it's also, as Preeti said, it's in our best self-interest that we get everybody immunized. So, I'm really happy that, you know, President Biden has taken that route and taken it seriously. I want to just say though that I really worry about Latin America. I don't want to forget Latin America. It is the region most impacted by this epidemic. We have a problem really seriously right now in Brazil, in Mexico, in Argentina, in Columbia. We have to make sure that in Latin America we get those vaccines. So, I just hope that as we start vaccinating the world that Latin America becomes a priority for the United States as well.

>> Howard Bauchner: This is Howard Bauchner, editor in chief of JAMA. This has been Conversations with Dr. Bauchner. Two good friends, Carlos del Rio. Carlos is a distinguished professor of medicine at Emory. He is also a member of our editorial board. And my good friend, Preeti Malani. Preeti is the chief health officer and professor of medicine at the University of Michigan. And I just want to thank her for the extraordinary leadership she has shown in taking over the Piece of My Mind section in JAMA. I think for people who read it, week in and week out, you know, her leadership in surfacing the incredible issues that have arisen in the United States over the last year, equity, racism, structural racism, implicit bias, and the pain and suffering associated with COVID-19 has been remarkable. So, Preeti, a personal thank you.

>> Preeti Malani: Thank you.

>> Howard Bauchner: Thanks Carlo. Thanks Preeti.

>> Carlos del Rio: Thank you, guys.

>> Howard Bauchner: Stay healthy and I'll see you again in about two months.

>> Preeti Malani: Yes.

>> Carlos del Rio: Absolutely.

>> Howard Bauchner: Bye bye.

>> Preeti Malani: Bye.

>> Carlos del Rio: Take care.


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