A Conversation With Rochelle Walensky

Dr. Rochelle Walensky discusses CDC’s response to the COVID-19 pandemic, CDC’s role in coordinating global health initiatives, and the future of public health in the United States.

COLES: Thank you. Good afternoon and good morning, wherever you may be in the world today. We are delighted to host Dr. Rochelle Walensky in today’s conversation. She needs no introduction because we have seen her in several venues helping us better understand the pandemic and the government’s response to the pandemic and what we, as ordinary citizens, can expect. But very briefly, she’s the nineteenth director for the Centers for Disease Control and Prevention. She previously served as the chief of infectious diseases at the Mass General Hospital and she’s recognized internationally for her work to improve HIV screening and care in South Africa and nationally recognized for motivating health policy in a variety of circumstances and situations.

So, Rochelle, welcome to the program. I would say Dr. Walensky but you and I have agreed that we’ll be on a first-name basis for the interview. So, welcome, and it’s great to be with you.

WALENSKY: Thank you so much. I’m delighted to be here, Tony—yes. (Laughs.) Very much appreciate it.

COLES: Well, we’re really anxious to dive right into our conversation and to have what I think will be a good, substantive conversation. We’ve all become experts, in a way, because we are reading the breathless announcements and the pace of advancement that is sometimes dizzying and difficult to figure out, but hopefully we’ll bring some clarity to those things in today’s conversation.

If we were to have had this conversation last week, I would have asked you about mix-and-match vaccines and heterologous and kids and all those things, but in the short span of just seven days, we’ve had most of those questions answered. So let’s go a slightly different direction, if we can, because I think we understand what’s happened there. And we have a simple view of the landscape. The FDA advisory panel yesterday recommended vaccinating kids aged five to eleven; we all know that. The CDC meeting is upcoming for that. There’s a recommendation by both the FDA and the CDC to recommend boosting eligible adults, so this has now become part of the common parlance.

But here’s something that I think people will be interested in—I certainly want to understand. We all know people who are not within the guidelines for getting boosters. So if it’s safe enough to boost anyone above the age of sixty-five or those at increased risk, why wouldn’t it be safe enough to boost otherwise healthy adults?

WALENSKY: Yeah, that’s a great question, Tony, and a lot of this is sort of where we are in the context of our recommendations for boosting. So, really, a lot of this is related to risk-benefit ratio and how your risk is versus how much benefit you’re going to get. And having pored over many hours of FDA advisory meetings and many CDC hours of advisory meetings, you know, there’s a lot of discussion about what we’re working to try and prevent here. Our vaccines, as they were analyzed in clinical trials, were working to prevent symptomatic disease, severe disease, and death, and that’s exactly what we want them to do. But there’s a really important societal impact in preventing infections, in preventing transmissions, and in trying to keep our society open and working. And so we may be willing to sort of vaccinate more people for whom the individual benefit may not be perceived in order to make sure that—or the individual benefit is simply prevention of an asymptomatic infection or prevention of a transmission in a household. We don’t have, even, data on that yet. We think it might be true but we don’t know it to be true. But, for example, if you are a health care worker and your presence was important to keep an ICU bed open, and your absence, even though you weren’t that sick, might mean that you couldn’t be in the hospital for two weeks, then, really, a lot of those risk benefits we are working to weigh.

So as we look at the—certainly, it is absolutely beneficial to elderly over the age of sixty-five who are at high risk of severe disease and death; certainly for people over the age of fifty who have underlying medical conditions and are at high risk of disease and death. And, really, our recommendations were a little softer for many of these other demographics so that we could keep in mind some of the other risk benefits that people are feeling in this very moment. And that was the reason for the flexibility there.

COLES: OK. So that’s terrific and that’s a very pragmatic approach, and I think the public really appreciates that because if you’re otherwise healthy but not in those risk groups and you want to get a booster, obviously, most people are just going to the pharmacy or asking for their health care provider to do that, so I think the flexibility is appreciated. But because we sometimes live in a data- and evidence-based world, or we try to, in any case, I just wanted to have the conversation about the data that’s behind or supporting the decision. So there is no real data to suggest that if you’re not in those risk groups that you’ll be harmed; you’re just prioritizing and setting a preference in trying to be flexible around the guidelines. Is that a fair characterization?

WALENSKY: Well, I would say that we have a lot of data but some of this is values-based. Right? And so what we do know is that vaccine effectiveness wanes against severe disease and death for our most vulnerable. It wanes against infection for some of our less vulnerable, for people who are well. We are starting to see that waning against infection. And we also know that the younger you are the more likely you are to get one of the very rare side effects. And so, to be very clear, these adverse events are extraordinarily rare but they are happening in our younger populations more often than our older populations. And this is really where it’s important for people to understand their own values. How much am I willing and wanting and needing to be at work to avoid a transmission in my own household if these vaccines work to do that, versus, you know, a slightly higher risk of a very rare adverse event, and those are really important. We have the data. But a lot of these are values judgments.

COLES: OK, well, that’s actually very helpful. So let’s take off on that particular point, this point about values, because you did something that I think—that some would call courageous, in a way, in that you went against the advice of your own advisory panel in extending the flexibility for boosters to frontline workers, those who live or work and are at high risk. Why did you do that?

WALENSKY: Wow. That was a hard evening. That was a really hard evening. So I’ll tell you sort of what I was receiving. In a singular moment, I had real consensus from the FDA advisory committee that they wanted and felt that this was a group—we’re talking specifically—just to be very clear: There were four pieces of booster advice that day, three of which—two were unanimous, three were for boosters, and then the fourth one was this group of people who are between the ages of eighteen and fifty and work in high-risk settings or live in high-risk settings. So these are people who have been on the front lines—our police officers, our firefighters, our health care workers, our grocery store workers, people who live in homeless shelters, people who live in long-term—well, long-term care was already out there, but—people who live in prison settings. So all of that population has been pretty vulnerable in terms of at-risk-of-infection, and FDA advisory panel—so that’s the population we’re talking about. FDA advisory panel came out and said that they believe that those people should get a boost. CDC advisory panel came out six to nine that they felt those people should not be eligible for a boost right now. Whichever way I went—(laughs)—I was going to be in a position—

COLES: You were going to make someone unhappy. Yeah. (Laughs.)

WALENSKY: I was going to make someone unhappy. So I recognized that as the position. But what I was really hearing from a lot of—and I had done a lot of canvassing and talking to people—is—that was September 24th, I believe, maybe September 23rd. We were still knee-deep in a Delta wave. We are still knee-deep in a Delta wave. And what we were hearing, especially from our colleagues in Alaska and Idaho, is they couldn’t keep their health care workforce staffed and that they had young health care workers who were not coming in because of mild infections. We had seen from our epidemiologic studies—there’s a particular study called the HEROES-RECOVER study that actually takes swabs once a week of people involved in the cohort and their frontline workers and health care workers, and we had seen waning of immunity against infection—not severe disease, and even asymptomatic infection. And through those epistudies and through what I was hearing on the front lines, I felt like people who had been out there on the front lines, especially for equity reasons, merited the opportunity to get a boost. And so just to be very clear: One of the things that was really on my mind is, however—because this is a vaccine that was under emergency use authorization, there was no flexibility to go outside the guidelines. So if I said you are not eligible, this population is not eligible, they would not be eligible. They would not have access to it. And so I didn’t feel like in this moment I should deny access to a booster for people who are in that category. And that’s what—it was interesting; I put my phone outside the door, I had a lot of incoming—(laughs)—and I said—

COLES: I’m sure. (Laughs.)

WALENSKY: (Laughs.) I need to understand what I really need to do in this moment. So yeah. (Laughs.)

COLES: So I want to come back to this because I think that’s a great example of pragmatic leadership. You know, we’re clearly living in unprecedented times, and thoughtful, wise, pragmatic leadership is really warranted to manage the nuances of circumstances we’ve never really had a pattern to address. So I want to come back to that because it’s going to bear on some of the things we did well and some of the things we didn’t do quite so well in managing the pandemic. But let me continue, if I can, with the vaccines and the boosters, for a moment.

WALENSKY: And if I can just say, it’s an important tension that we’re hearing all the time and that is, these are pandemic times; we have to do things differently. But we don’t have any data for that. Right? So we’re feeling that tension all the time right now.

COLES: And—

WALENSKY: Go ahead.

COLES: No, no, no. I know. And given what you do for a living and what I do for a living, we operate on data and on the basis of evidence, and sometimes we have to proceed carefully when there’s no data, no evidence, or no precedent. And I think that’s going to be an important rubric for us to talk about in the conversation.

But let’s go back to the vaccines for just a second. I think most people understand this notion of waning immunity. But just, if you can, provide a little bit of color because you made an important comment a moment ago about the swab, the sample swabs and the frontline workers. Talk just a little bit about—I don’t want to—not necessarily a need for a booster, because I think the world understands that, but do touch on that and then talk about the various mix-and-match strategies that are becoming popular. People are, I think, somewhat confused. If I had Pfizer times two, can I get Moderna? While the authorization or the FDA has recommended that, is that the right thing to do? So cover the general area about why boosters are important and why, in this case, a mix-and-match strategy could be warranted.

WALENSKY: Yeah, there’s a lot there. So, first of all, I think we should just recognize that, as you have noted, everybody now is a vaccinologist and everybody’s an infectious disease doc. (Laughs.)

COLES: Right. (Laughs.) You’ve got a lot of company. (Laughs.)

WALENSKY: And with everybody thinking through the needs and desires of the vaccine, I mean, when—I can tell you literally where I was, the steps I was taking, when I—when my phone buzzed as to how well Pfizer worked, 95 percent, and I got goosebumps; like, who would have ever thought that this vaccine would work so well?

COLES: Well, put that in—(audio break)—flu vaccine efficacy. Right?

WALENSKY: So flu vaccine: 40 to 60 percent in a given season. Right? So nobody ever expected that we’d have this vaccine that worked 95, 96 percent against symptomatic disease. Once we had that bar and then Moderna came in and said exactly the same thing, the expectation would be that these would kind of be bulletproof—right?—that we’d be able to get these vaccines and then we’d be fine. And turns out there’s, you know—and then when we started having this whole dialogue about breakthrough infections and that, you know, “I know somebody who has a breakthrough infection,” and the answer is, well, you probably will; you probably know a lot of people, and that should be the expectation, especially when we have so much disease out there. So the dialogue in the epidemiology and the sort of math around the fact that a breakthrough infection is not just one—five out of a hundred; it’s your chance of potentially running into somebody with disease, and that’s pretty high right now because there’s a lot of disease out there.

The other issue is, what is it that these vaccines were meant to do? Some people believe they were meant to allow us to take off our masks. (Laughs.) Right? That is not what they studied in the clinical trials. What they were meant to do was prevent symptomatic disease, severe disease, and death, and they do it really, really well. They’re starting to do it a little less well in our older populations, our vulnerable populations; we saw a tragic passing in the last week related to that. But were they really meant to prevent virus from circulating in your nares? (Laughs.) You know?

COLES: No.

WALENSKY: And that was not—no. And in fact, the clinical trials didn’t even measure that. So when we say the word breakthrough infection, if we detect virus and you were vaccinated but you’re well, is that really a breakthrough? It is—you know, we can call it a breakthrough because you now have disease; you now could potentially could transmit disease. But I do think it requires us to manage the expectations of what these vaccines were intended to do, which is why it’s so interesting to do these studies of weekly swabs so we can really understand what’s happening with people who’ve been vaccinated, because those weekly swab studies were, in fact, not done during the clinical trials.

With regard to mix-and-match, I think we should acknowledge that we know a lot more about these vaccines than we did when they were initially authorized. Four hundred ten million doses have been given in this country and six billion vaccine doses have been given around the world. So we know a lot more about them. We know a lot more about the exceptionally rare side effects. And so, in terms of mix and match, the general feeling is you should probably get the one you got if you did well. And that’s what most people I think are doing.

There were some important areas we wanted to make sure that people knew and understood, that you knew and understood if you happened to be in an age or gender demographic that puts you at a little higher risk for a really rare event. You should probably know that. Maybe you should stay away from that vaccine. So, for example, these exceptionally rare TTS events that occurred with the J&J happen more frequently in women under the age of forty. You know, those folks should probably avoid a J&J.

COLES: And TTS, just for the audience, are the clotting events that—

WALENSKY: Yes, thank you. Right, and people at risk of clotting. So we didn’t know that at the time. We did a huge amount of due diligence when we started to see those signals, due diligence I’m proud we were able to do. We found I think six events in eight million, which just gives you a sense of how well our safety systems are working and our surveillance systems are working. But now we know a lot more. So as you think about which vaccine you should get, you know, maybe think about some of those exceptionally rare events, and that’s—the other thing that was really important is, we are using these vaccines now in nursing homes, so we need to go—we acutely need to go to these nursing homes and make sure folks are protected. If the pharmacy that happens to arrive in a nursing home meets a patient who got Moderna and they happen to have Pfizer with them, we wanted to make sure that they could get vaccinated.

COLES: Sure. Sure, because coverage is better in any event.

WALENSKY: Right. Or if you happen to show up at a pharmacy that you got Moderna but Pfizer’s the bottle they have open, you should get vaccinated. That was a lot of the purpose on that.

COLES: So that makes perfect sense. But the J&J vaccine does seem to be a little different; the recommendation is two months after the initial vaccination for a booster, perhaps J&J followed by an mRNA vaccine of either Moderna or Pfizer because that might boost the antigen—antibody response. So there does seem to be something a little bit different and we could probably wax on on that.

But let me lateral, if I can for just a quick moment, to vaccine mandates, because this is now, as we are wrestling with how we move through the world and live with COVID, because I believe—and I don’t know if you’ll agree with this—that we’re going to have to live with COVID, perhaps for a very long time. It may be the new flu, in a sense, where we’ll have to think about strategies for managing it. But in the immediate kind of post- or peri-pandemic period, you know, this conversation around vaccine mandates has been partisan, it’s been politicized, and I don’t want to talk too much about the politics; I just want to talk about the public health aspect of it. So obviously, vaccine mandates have been implemented for schoolchildren since the 1980s. Right? Your kids can’t go to public school or private school, in most instances, unless they’re vaccinated. Most institutions of higher education require meningococcal vaccine and papillomavirus vaccine, for instance. So we’ve lived with mandates before. What’s different about COVID, politics aside, that suggests that we shouldn’t have vaccine mandates today?

WALENSKY: So we’re in a moment where I think people are thinking about “me” and not “us,” and I think that that’s a challenging moment because I think if we were thinking about community and each other, we’d be in a different place. Let me tell you a little bit—you know, CDC makes recommendations; we do not make mandates. Let me just reflect, though, on something you said, and that is, about four or five years ago—I couldn’t tell you exactly when we at MGH had a new influenza vaccine mandate, and several health care systems—many health care systems around the country basically said, you do need to get vaccinated for flu if you’re going to be caring for patients in the hospital. We looked at our data this year on flu vaccination mandates. So hospital systems that required vaccination for flu: 96 percent of their personnel were vaccinated. Hospital systems that didn’t: 46 percent of their personnel were vaccinated. It’s extraordinarily different.

COLES: Wow.

WALENSKY: Yes. And some of that is, your hospital system believes it’s important, and if they believe it’s important, you know, you should believe it’s important too. So there’s sort of trust—and, you know, when we talk about these trusted messengers and vaccines, part of the trust in messenger is your employer or your hospital system. Right? So maybe we can learn a little bit about that sort of moving forward. I do think the newness of this is a little bit harder. I think that these—the fact that these—despite the fact of decades of research, people are still saying they’re new. Several of them are not yet approved; only one is approved. So I think that that’s feeding the conversation as well. But I do think we now—we have extraordinary experience with these vaccines, perhaps more than any other vaccine except some of the childhood vaccines that we’ve been using for decades. And our surveillance systems are bigger, tighter, stronger than we’ve had. We’ve bolstered our surveillance systems in extraordinary fashion. So I think, you know, we have this capacity.

The other thing I will say is: Importantly, these mandates are not intended to be punishing. These mandates are really intended to provide information, to sort of talk to people, the counseling, the information you need. I do think many people, when they are faced with a lot of misinformation would believe misinformation and they don’t necessarily know where and how to access right information; many don’t want to get it from a governmental site; they’d prefer to get it from a professional society; they’d prefer to get it from their own physician or from their own pharmacist, and so a lot of this is making sure we focus our attentions on the people who actually need proper information and to deliver that information and counseling.

COLES: So we’ll likely come back to this; obviously, the administration has put forth a set of draft guidelines for their employer mandates. We’ll look at those. We’re all implementing them in different ways. Certainly my company, we’ve just announced that we are moving to vaccine mandates, as one of those employers, so—we’ll come back to this topic, I am sure.

Let’s just—and then I do—you’ve been such an interesting leader for the CDC because you’ve had really interesting moments in your young career.

WALENSKY: (Laughs.)

COLES: And one of the interesting moments occurred when—and I remember the day that this happened. I was really struck by it. It was a moment of human compassion, and you said you had this sense of impending doom. Now, when I heard that, I actually agreed with that because I really did think that we were trying to return to normal too early. But you got lots of feedback—

WALENSKY: (Laughs.) I sure did.

COLES: (Laughs.) So let’s talk about that, and I’m really more interested—you know, it’s back to this whole notion of leadership and compassion and the humanity that you’re bringing to this role, but just a little bit about that and how you view that in retrospect now.

WALENSKY: Well, I’ve learned a lot since then. (Laughs.) You know, I might have done things differently now from what I’ve learned than what I did then. I don’t remember the exact date of it; you probably do.

COLES: (Laughs.)

WALENSKY: You know, the feeling of what happened in March of 2020 at Mass General was raw, and for places and people who hadn’t experienced how raw that could be—you know, I have to say, one of the most nauseating moments of my last two years was opening a document that said “crisis standards of care” and how we were going to manage crisis standards of care in Massachusetts. So I’ve done a lot of work internationally and we think about crisis standards of care internationally, but it never—we never can see that we would have to do that in Mass General Hospital. What do we do when we run out of dialysis machines and what do we do when we run out of, you know, sedation meds and ventilators? And walking to work or driving to work to Mass General and seeing that morgue truck outside the hospital, those feelings were really pretty raw as numbers went up. So I probably—(laughs)—knowing what I know now might not have done it exactly the way I did. But I did want—it was intended to be a stop-and-think-about-this moment. Like, that was—

COLES: And that’s what came across because I read the headlines at the time, but in preparation for this conversation, I went back and I looked at video and C-SPAN covered it and it was really quite compelling because you were speaking not just as the CDC director but as a human, as a mom, as a daughter, as a wife, and it was a really interesting moment. And I’d encourage our listeners to just juxtapose that with everything that we know today. But, in a way, it was prescient perhaps, maybe not intentionally, but —because Delta was just a glimmer in our knowledge base at the time that you made the statement and, obviously, those words turned out to be true, in a sense, minus a little bit of a hyperbole with them, but the words turned out to be true because we really were entering a more dark phase of this with the rise of Delta.

So as we wrapped up the summer—and I have one other really quick question—two really quick questions and then I want to take some questions from the audience. But as we were ending the summer, there seemed to be a collision of the rise in Delta as the predominant mutation and everything we know about that, and waning immunity. So those two things, in a sense, almost collided to create the late summer/early fall instance numbers that we saw. Is that a fair characterization? Because I think it will help. People talk about breakthrough infections, but concomitant with that, Delta was really an important theme.

WALENSKY: Absolutely. So I think there’s the hyper-transmissibility of Delta, the fact that Delta was less forgiving. If you were—and interaction that Alpha might not have transmitted, Delta would. Right? So there was that. There was the waning immunity. There’s been a lot of science that has really been tried to disentangle, well, do we think that this is waning or do we think it’s Delta? From a booster perspective, it almost doesn’t matter because the more—which is good news—but there’s been a lot of science and we think it may be a contribution of both. And then importantly, this was, you know—(laughs)—keeping you humble, right?—importantly that the breakthroughs could transmit. We didn’t see that with Alpha, and that we learned from the Barnstable County outbreak and numerous others, and, you know, that was another jaw-dropping Friday night where I saw the cycle thresholds of the Barnstable outbreak, and I said, you have got to be kidding me. (Laughs.)

COLES: Yeah. Wow. Wow.

We’re now thinking a little bit about the Delta variant itself, or the mutation of the Delta. You’ll know the exact acronym.

WALENSKY: AY.4.2. (Laughs.)

COLES: Thank you. Thank you very much. The one that’s really ravaging the U.K. at the moment. Talk a little bit about that but largely through the lens of something I learned, which was quite interesting, that the CDC has categorizations of strains of interest and strains of concern, and talk a little bit about this new Delta variant and what you think it might mean. And is it a strain of interest or is it a strain of concern?

WALENSKY: I think it’s a strain—and we also have—we call them variants of interest, VOY; variants of concern, VOC; variants being monitored, VBN—(laughs)—or VBM. So, you know, a lot of these concern—how they get characterized is essentially our concern about them. So are they known to be more transmissible? Are they known to evade our vaccines? Are they known to evade our therapeutics? And all those sorts of things we keep in mind as we sort of categorize them. Right now in this country, we are well over 99 percent Delta. There is this sublineage of Delta, this AY.4.2, and what we’re starting to see in the U.K. is that that is emerging as more and more of the Delta lineage. You know, 5 percent one week, 10 percent, 12 percent. It’s not all of what’s happening in the U.K, but we’re seeing more of it. And that has begged the question, what is it about the characteristics of that variant that is allowing it to emerge? Right? Because the more you see the more you worry, is it more transmissible? Is it evading something? There are two mutations on the spike protein related to that variant, that sublineage, and neither have actually demonstrated an ability to evade vaccines or therapeutics, which is good news.

COLES: That’s good news.

WALENSKY: Yeah.

We have started to see early data from the U.K. that it might be a little more transmissible; not clear whether that’s actually meaningful or not or whether it’s statistically different than what is the regular Delta strain. Importantly, we have had a handful of those strains here. They haven’t taken off. We’ve seen it here, and we are doing an extraordinary amount of genotypic sampling. We get samples from every state. We get samples from commercial labs. We get samples from academic centers. So we’re doing a lot—we’ve scaled up our genomic sequencing a lot in the last ten months. So we’re monitoring this very, very carefully, and we are intentionally doing our monitoring strategy to make sure we have geographic diversity in our strains.

COLES: So variant of interest perhaps?

WALENSKY: I don’t—I think it’s been classified there in the U.K. Here it’s still sort of in the—

COLES: Just monitoring.

WALENSKY: Yeah.

COLES: OK. Now we’re going to open the floor for listener questions, but before we do, because I suspect much of that will be about this particular topic, I just want to lateral to something that’s personally interesting and important to me. You talked about racism as a public health issue, and given that we’re living in this what I call the triple pandemics of the viral pandemic, the pandemic of—you know, the need to address the social justice issues and the economic inequity issues, in this country and around the world, what do you mean by racism as a public health issue? I have an understanding of that, as trained in public health as well, so it means something to me. But talk about that, because we’re used to thinking about malaria and TB and Ebola as the purview of the CDC. Talk about why racism is so important as a public health issue.

WALENSKY: Wow. So maybe I’ll just reflect and I think that this is really important. So as an infectious disease doc, we know—so for all of you who are home-grown infectious disease docs—(laughs)—I’m going to let you in on a little ID secret. Nearly all of our infectious diseases hit vulnerable communities. That is how it happens. And when you talk about TB and malaria, those hit vulnerable communities. I like to tell the story that the people who brought COVID-19 to this country came on planes and cruise liners, and the people who have it now are more often people who can’t afford plane trips or cruises. And that is how infectious diseases travel because they are often in congregate settings, they often are in crowding, they’re often in people who can’t afford other, so this—when we talk about social vulnerability and racism related to social vulnerability, it is true for infectious diseases. It’s true for non-infectious diseases. It is true that people who are living in lower-income places are more likely to be the ones threatened by a hurricane or threatened by—and in fact, they’re also more likely to be the ones who are on dialysis and might die because they don’t have electricity. And so I think that there’s—so I think, from a public health standpoint, we very much know there’s access issues; there’s nutrition issues. There are so many issues related to race and social determinants of health that are really—we have to fix. There’s a really important sort of overview that I think was done that looks at how long from a time that a paper is about to be published to its getting to communities. It’s about seventeen years. So you can get a really new drug, really fancy, and it will get to people who have resources, but by the time it gets to people who don’t have resources, to those who are marginalized, it takes too long. And we can see, time and time again, our cancer screening, our heart attack rates, all of these things fall along racial lines. And we have to fix that.

COLES: Well, that’s compelling in a lot of ways and we may have time to come back to that because there’s a lot in that answer, but why don’t we actually take some questions from the audience and start that portion?

OPERATOR: We’ll take our first question from Seema Mody.

Q: Good afternoon. Thank you for the conversation. This is Seema Mody, global markets reporter at CNBC.

I’m wondering, restrictions on fully vaccinated foreign travelers are set to lift on November 8th. Rochelle, do you see the use of travel bans, restrictions as a necessary tool going forward to stop COVID from spreading, or do you think the economic pressures are just so large that implementing such rules again is just not possible?

WALENSKY: Yeah, that’s a really important question. You know, we have known that we’ve needed to reframe where we are in terms of foreign travel, and I’m really enthusiastic that we’re going to be able to do this on November 8th. And part of that is really to just make sure where we had been was really a country-by-country based on how much disease we had in that country, and given the ebbs and flows of where we are with peaks and surges, that was not a, you know, epidemiologic (full-sound/fulsome ?) way that we wanted to do this. So, really, what we’re doing now is, with few exception, to try and make sure that we’re keeping international travelers safe and we’re keeping Americans safe so that we have both testing, vaccination, and contact tracing to do our best to keep all of the communities safe. And that, I think, is actually a more full-proof way to be able to facilitate travel, actually.

COLES: Operator, we’ll take the next question.

OPERATOR: We’ll take our next question from Brett Zbar.

Q: Hi, Tony. Thanks for moderating.

COLES: Hi, Brett.

Q: Hi. How are you?

COLES: Good. Thank you.

Q: Thanks for moderating a great discussion.

And Dr. Walensky, thanks so much for your service. I’m also, by the way, a former Longco (ph) president. (Laughter.)

Coming back to Tony’s point—

COLES: And a physician, Rochelle, so—

WALENSKY: Well, that—yes. (Laughs.) The firm. (Laughs.)

Q: It’s great to see you.

Coming back to your question, Tony, about COVID-19 as an endemic virus: Clearly it feels like one of the biggest tensions between COVID-19 as an endemic virus and flu is the potential for longer-term consequences. What do you think we actually know about long COVID in the vaccinated population? Thank you.

WALENSKY: We’re learning more. I think now we’re starting to see early data that demonstrate that if you are a breakthrough—we’ll call it a breakthrough case with COVID that—there were data out of the U.K., I believe, that demonstrate that your rates of long COVID are about half. I think we have—you know, long after we’re beyond these acute peaks of COVID, we’re going to have a lot to learn about the neurologic manifestations, the cardiac manifestations, all the other manifestations of this disease; long COVID will be one of them. My understanding is we’re starting to see less long COVID in breakthrough cases in people who get sick with COVID, and I think we have a lot more to learn there. One of the other questions that’s come up is—and this has really come up in the context of the pediatric vaccination discussions—is, if kids are getting less sick than, you know, elderly, will it prevent long COVID in these kids? I think that that’s—we don’t know the answer to that yet, but that will be among the many studies that we’re looking to conduct.

Interestingly, there are some anecdotal data, actually, that people with long COVID who get vaccinated feel better, so I think that that’s another piece of this that we’re going to have to study as well.

Q: Thank you, and—

COLES: Well—oh, go ahead, Brett.

Q: I was just going to ask—and when you think about how Portugal is handling kind of their status relative to the U.K., do you think Portugal has it right? Is that a model that you like?

WALENSKY: Yeah, I—you know, it’s interesting—I’ve spent a lot of time with the U.K. data of late. You know, they’re—they have more cases and they’ve vaccinated fewer young people. Their death rates also lower. So I think there’s a lot that we can learn from every individual case study.

COLES: Very good.

Q: Thanks.

COLES: Brett, thank you for the questions.

Operator, we’ll take the next question.

OPERATOR: We’ll take our next question from Hani Findakly.

Q: Thank you very much for a very interesting discussion.

I have a quick comment and a question. Comment is Dr. Walensky’s suggestion about the racial implication of this virus is that it’s now the rich that are giving it to the poor, rather than the other way around, if that’s the way I understand it. My question is, given the waning effect of the vaccine and the fact that Dr. Coles suggests that this may be with us for a long time, does that mean that we’re going to have to have shots and multiple shots per year for the foreseeable future? And is there any work that’s being done about dealing with this issue and comparing that to, for example, to what happens in the case of polio and others where this virus will be—at least will be a much smaller impact on society and less—(inaudible).

COLES: Very good. Thank you.

WALENSKY: You know, the short answer to your question is we just don’t know. There are many vaccines where your full series is, one, another one, and then a boost in a couple months, and then you’re done. And so, measles could be one of those; Hepatitis B is two shots and then a six-month boost. There are several where we don’t really believe that you actually need to keep getting boosted every single year the way you do for flu. We have to sort of keep that option out there. And part of the discussion there will be related to, does COVID continue—or SARS-CoV-2 continue to evolve to variants that are going to need that kind of updated boost? We haven’t, fortunately, seen it yet. Our wild-type vaccine, it turns out, is working really robustly against all the variants that we have. But that’s certainly something we need to be prepared for, and that may be a situation where another, you know, kind of vaccine—the same vaccine but targeted towards a different variant may be needed. I think we don’t know how durable our six-month boost is going to be for these mRNA vaccines. There are many folks who are hopeful, many immunologists who are hopeful that we may be done with our boosts after that.

COLES: Great.

Operator, we’ll take the next question.

OPERATOR: We’ll take the next question from Jay Markowitz.

Q: Thanks. Hi, Tony.

COLES: Hi, Jay.

Q: Wonderful job leading this terrific discussion.

Rochelle, I want to thank you for your inspiring and inspired leadership on this. I think you and Tony Fauci will be viewed very favorably by historians.

I wanted to expand on Tony’s question about racism, and my question is this: As a parent, as a physician who has seen, you know, trucks outside the MGH to house the dead, we’ve seen trucks in Central Park to keep up with the corpses. We’re rationing dialysis, ECMO machines, even ventilators. We’re at a point where what we want to do for individual patients in this country is everything we can do, and as an organization, the CDC is recommending boosters, as I think it should. But there are other places in the world at much greater disadvantage than the United States that have not gotten any vaccines. So, for instance, the continent of Africa: 1.2 billion people; 1.1 billion or so unvaccinated. So do you balance this need to control the pandemic, which can only be controlled on a global level, with the need to protect individuals, patients that we’ve all taken care of, you continue to take care of, and the public health of the United States? How do you achieve that balance? Thank you.

WALENSKY: Thank you so much, Jay. You know, I spent a chunk of my career doing work in Africa, so so much of what you’re saying has rung true for me and the balance is absolutely true. It is the case that as we’re starting to—maybe—the big picture, I will say, is we have to do both. They can’t be mutually exclusive. And we are working to do both. We are feverishly working to do both. We have donated—we have shipped over two hundred million vaccines already to over 106 countries. We at CDC work in sixty countries and we are working to provide the technical assistance—the surveillance, the vaccine confidence, the vaccine safety—to assist in rolling out that. We have a huge international task force and working with folks in country—in fact, I’ll be speaking with them tomorrow morning—to be able to do this. And we have to do it by ramping up manufacturing abroad, by building sustainable supply chains, increasing capacity globally, because we very well are—likely may not be done after this—you know, after this current moment. And we need to make sure that we leave durable capacity in these countries to make sure—and around the world to make sure that we can keep them protected.

That said, it is also the case that if—you know, from a pure operations standpoint, if you have—if it is the case that three doses of that vaccine will give you lifelong protection but two doses does not—we would never say we should only give two doses of an MMR and not the third. Right? You want to give the full package to make sure that people remain protected. And so I do think that this very well may be the full package of this vaccine and we should—it would be lost if we only gave two and then we had everybody wane. So I do think we have to think of both of these perspectives as we’re thinking about rolling this out. And we absolutely can’t keep—take our eye off the ball of the fact—I personally think we need to do it for humanitarian purposes; that doesn’t sell with everybody, but if it doesn’t, then, even for our own protection. Anybody who is encountering COVID right now anywhere around the world is at potential risk of bringing it home to us. And so if the humanitarian need doesn’t move you, then just know that, you know, the more virus that is out there circulating the more likely it will mutate to something that our vaccines can’t control.

COLES: So, Rochelle, let’s—before we take the next question, let’s pull the thread on Jay’s question just a little bit.

One of the things I’ve pondered, and of course, you’re aware that the Council published a task force report on the pandemic and potential implications for managing “the next one,” in quotations. And this is the topic I wanted to come back to when I talked about kind of your compassionate leadership. But as we think about the CDC and other multilateral organizations, the WHO, for example, how should we be thinking about coordination, not just for the delivery of the distribution of vaccines, which is Jay’s specific question, but more broadly, from the beginning of the pandemic, the exchange of information? I’m not certain that we were at our best in terms of multilateral collaboration at the beginning of the pandemic. We were all scattered and frightened and didn’t know which way to really manage our way through this. But as you think about this “for the next one,” talk a little bit about multilateral organizations, the collaboration, and the opportunity the CDC has to play a leadership role there.

WALENSKY: Yeah. I mean, I think you’re absolutely right and this is one of the things that the playbook and history will—we will learn from—right?—and that we have to have—we need to have a mechanism by which we all go to the table and understand where we can leverage our assets and where we can bring people together, and how we can use each of those assets to improve the health around the world. Our assets at CDC—you know, one of the things I think people don’t necessarily realize at CDC is, you know, how important our longitudinal presence in country is. So I give the example of India. When India was surging with Delta and that was really difficult times, CDC had an office for twenty years there; we had actually set up our twenty-year—we had our twenty-year anniversary of that office. So we had connections with the people and with the foreign ministries, with partner organizations, with multilateral entities so that in India, so that when somebody said, should we be doing genomic sequencing, how can we help with rollout of vaccine, we were trusted people on the ground; that is one of things I think that—you know, what are the—what are the assets that each individual organization in these partnerships can bring and how can we leverage that and how can we pivot on a dime when these pandemics happen, when there is a threat to make sure that we leverage our own individual assets?

COLES: Good. Thank you.

Operator, we’ll take the next question.

OPERATOR: We’ll take our next question from Sonya Stokes.

Q: Thank you, Dr. Coles and Dr. Walensky, for this wonderful discussion and for your guidance.

As we go into the winter, what role will masks or respirators play with respect to keeping people safe in the workplace? This is a topic of particular interest for employers that have mandated vaccination. Given a fully vaccinated workforce and locations that, if they do achieve low transmission rates, would you foresee that workplaces can safely forgo mandatory masking for their employees, or would this precaution still be recommended at least in the short term? Thank you again.

WALENSKY: Yeah, this is a question I get a lot. You know, we are in a better place with Delta. Our peak in cases was around September 2nd or 3rd; we’re now down from about 150,000 to about 65(,000), 70,000—70,000 new cases a day. We still have eleven hundred deaths every day from Delta—eleven hundred deaths every day from Delta. So what happens is, with each surge, as we come down, we get more and more complacent at a time when our cases are still pretty high.

So what I would say is, in this moment, we can’t get complacent. We have sixty-four million people in the country who are eligible for vaccines who are not vaccinated; that’s about a third of the eligible people. We have about twenty-eight million five- to eleven-year-olds that we’re going to need to work to get vaccinated. We have, you know, about 20 percent of our sixty-five-year-olds and over who have gotten a boost. And so with the amount of circulating virus that we have right now, going into winter, I think we should just not get complacent. Certainly if you’re in an area that has very little disease out there, that will be a locally driven policy. But I would also say that there’s a reason that we all get runny noses in the winter and that is because when air is drier and when it is colder, the humid particles don’t fall to the ground, the virus circulates longer, it can travel further distances, and that’s true of all respiratory viruses; that compiled with the fact that we’re all moving indoors and doing more things indoors during the cold season—so that is why, you know, respiratory viruses tend to thrive.

So I would say now is not yet the time to be complacent. And, you know, I know people want to get rid of their masks. And I’ll say again what I said earlier to Tony and that is, the vaccines were intended to work to prevent you from going into the hospital; there was no trial to prevent you from wearing a mask. (Laughs.) And the masks are working. We have 96 percent of our schools open. That’s amazing. Right?

COLES: That is stunning. Really stunning.

Operator, we’ll take the next question. And as we’re queuing that up, Rochelle, you should know, we have a reputation and a commitment for being exactly on time.

WALENSKY: OK. (Laughs.)

COLES: Just a few more questions and then we will wrap because I’ve got one final one for you. But let’s take the next question. And Operator?

OPERATOR: We’ll take our next question from Deborah Harding.

Q: Thank you both very much.

Dr. Walensky, I wonder if you could talk a little bit about the rapid antigen tests and the limitations of them. Specifically, are vaccinated people—do they tend to test negative or positive?

WALENSKY: Yeah, I think that’s a great question. I think the rapid antigen tests have a really helpful role and we’ve been seeing them being used in schools; we’ve been seeing them used in business settings and other settings. I saw one—weddings and, you know, many different roles. It is not perfect. The PCR is more sensitive at knowing whether you have virus there. But in fact, one of the things that the rapid antigen test is really helpful for is knowing whether you potentially could transmit because, in fact, your virus can stick around for a long time, but if your antigen is positive and truly positive, you’re probably in a window of time where you might be transmissible, and I think that’s really helpful information to have. You know, it is most often positive when you are in that window. I haven’t seen a lot of data demonstrating that the rapid antigen tests don’t work as well during—in breakthrough cases. I could imagine it may not work as well in early asymptomatic breakthrough cases because they’re just not as sensitive, but it’s also going to depend on the individual rapid test.

COLES: Thank you.

Next question, Operator.

OPERATOR: We take our next question from Lee Cullum.

Q: Thank you very much. It’s been a fascinating discussion.

Dr. Walensky, there was a lot of interest, and perhaps still is, and new interest in these advisory committees that advise you and advise the head of the FDA. And I’m interested, of course, in that sixteen-to-two vote to deny those under sixty-five a booster unless they were immunosuppressed or got lucky because they—I got your decision if they were in a vulnerable position at work. I heard someone who’s involved in transparency work say that actually we really have a right to know who those eighteen people are, maybe not by name but who they are, what the questions were that were posed to them, how they answered those questions and their reasoning, sort of like the minutes that the Federal Reserve publishes after its meetings. What do you think?

WALENSKY: I think that’s actually publicly available. So the FDA advisory committee was—and in fact, that’s actually one of the issues that is—it’s been hard and challenging because not everybody who is used to reviewing all of these data is watching these advisory committees. But our Advisory Committee on Immunization Practices is publicly available, it’s taped, and you can find it on YouTube. The VRBPAC, the FDA advisory committee, is also publicly available. I’ve watched it as a consumer, with everybody else yesterday. So I believe—and in fact, yesterday at the advisory committee they called each person; you heard how they voted, and then for about an hour afterwards, maybe forty-five minutes afterwards, they reflected on why they voted that way. So I believe that that’s actually all available for anyone to see.

COLES: Operator, let’s take one last question and then we will move to wrap up.

OPERATOR: Take our next question from Margaret. If you could please state your last name before stating your question.

Q: Hi. Can you hear me?

COLES: Yes, we can.

Q: Hi. I’m Margaret Woodbury and I have a couple of quick questions.

One, why hasn’t the CDC updated the percentage of Americans with natural immunity? I believe it’s May—correct me if I’m wrong—since Delta has circulated so quickly, also with kids.

And then the second thing is, the FDA has stated that the risk of myocarditis outweighs the risk of the jabs in—you know, with serious illness so you have a greater risk from myocarditis in under forty. And he said that very clearly on the meeting. And I believe that there is a great—the numbers that are out are one in five thousand, and the twelve—let me just doublecheck this; I think it’s the—so the average of this happening is one in five thousand age sixteen to seventeen. So my question is, have we been fully transparent in terms of this and we don’t know the long-term risks for these children and if they have no risk of serious illness? These are very important questions that I think the public deserves an answer to.

WALENSKY: Yeah. Maybe I’ll—I don’t know the details of exactly which of the pieces you’re talking about, but let me just say this about youth. We had 745 deaths from COVID among people under the age of eighteen. An average flu season, where we vaccinate our children, takes about a hundred children a year. So we have had more than sevenfold the number of deaths. What has become the dialogue is that young people do well. Yes, young people do well compared to eighty-five-year-olds. Young people—this is the eighth-leading cause of death among young people, COVID has been over the last two years. So the issue is that there is—there is severe disease and that doesn’t account for long COVID and many of the other manifestations. Children do better than elderly. Children do better than those with underlying medical conditions. But this is not something that has not affected children.

We are working—I think the other question was related to infection-induced immunity and we are reviewing that science right now.

COLES: Very good. Thank you.

Well, that, unfortunately, was all we had time for in terms of audience questions, but I’ll, Rochelle, give you the set of final comments. I have thoroughly enjoyed our time together. You’re wonderful and, I’ve said a couple times, not just pragmatic but compassionate; I think that combination is really powerful at this moment. But as you look ahead, and none of us have a crystal ball, but gaze into the future just a little bit. You’ve had a lot of experience with viruses. You’re trained in that. You’ve been a leader at the academic level. What’s on the horizon for us for the next two to three years with regards to COVID, and what should we be on the lookout for, perhaps something that we’re not thinking about today? What’s in our future?

WALENSKY: You know, I think a lot of what is in our future depends on how we mobilize together as a society against not each other but against our common enemy—(laughs)—which is the virus. And so, you know, I think it’s very hard to predict behavior. We certainly are going to prepare for the worst and anticipate and work towards the best.

Maybe one of the things I’ll say in the years ahead, and just a quick plug for this agency that I’m just getting to know, and that is, you know, coming from a world of academia, you get to be on the podium when it’s your paper or you get to go to a meeting and meet, and the twelve thousand people at the CDC, I have an on-call data team; on Saturday night at eleven o’clock I can call and say I need a data point on this, and I’ll have it in an hour. And those are people whose names you’ll never know and whose work is to protect the American public. So it’s been an extraordinary gift for me to get to know the people of this agency. And what I will say is, we owe it to ourselves and our future to protect our public health. Resources, longitudinal, disease-diagnostic dollars to assist in our public health workforce infrastructure or laboratory infrastructure or data infrastructure are critically needed at this moment to protect us for whatever may come two to three years down the line.

COLES: Well, we are exactly on the hour. I won’t break our record. It’s been a delight, and thank you for joining us for this fascinating conversation. We really appreciate it. And we wish you every best as you manage the months and years ahead. Thank you so much.

WALENSKY: Thank you so very much, Tony. Great to chat.

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