Health

Pharmaceuticals and Vaccines

  • COVID-19
    Latin America’s Vaccination Efforts: What to Know
    Campaigns to vaccinate Latin America against COVID-19 have sparked debate about the region’s dependence on outside suppliers, including China and Russia, and the threat of new variants.
  • Pharmaceuticals and Vaccines
    Good News Emerges About a Malaria Vaccine
    In Africa and elsewhere, COVID-19 dominates media attention. Yet malaria has probably killed four times as many as COVID-19 over the last year in Africa. The disease is caused by a parasite, plasmodium, not a virus or a bacterium. The disease confers no immunity and an individual can catch it repeatedly; in parts of Africa, individuals catch malaria on an annual basis. Europeans had no immunity to malaria, and the disease killed so many that it, in effect, closed West Africa to them. The good news is that early trials of a new vaccine, R21, show an effectiveness rate of 77 percent. Still to be determined is how long the vaccine will be effective. Work on a vaccine against malaria has been underway for years, with remarkably little success. Part of the difficulty is related to the parasitic nature of the disease—parasites are more complex than viruses or bacterium. Part of the answer has been relatively low investment in the search for a vaccine by pharmaceutical companies; the disease mostly affects the poor in lower-income countries. The new vaccine is a further development of Mosquirix, a vaccine with a 56 percent effectiveness after one year, falling to 36 percent after four years. Mosquirix was developed by GlaxoSmithKline in collaboration with the (U.S.) Walter Reed Army Institute of Research and PATH, a nonprofit health organization. To spread, the disease requires an insect vector—a female Anopheles mosquito—and human blood. In humans, the parasite migrates to the liver and from there to the bloodstream. A mosquito can bite an infected human and then spread the disease by biting another human. In adults, the disease is rarely fatal, except among pregnant women and those with weak or compromised immune systems, and the severity of the symptoms decreases as individuals age. Fatalities are primarily among infants and children, not the elderly. Among adults, the disease resembles influenza, with fever, chills, and fatigue. In terms of loss of human participation in the economy, malaria is a huge burden on Africa. Up to now, malaria prevention has been centered on the mosquito: insecticide-treated bed nets are an effective, low-cost intervention, while various prophylactics can also blunt the disease’s progression following infection.
  • Sub-Saharan Africa
    Supporting African Vaccinations Is in U.S. and Global Interest
    When it comes to fighting COVID-19, the Biden Administration has made it clear that tamping down the threat domestically is its first priority. While early moves to commit funds to COVAX and reengage the World Health Organization demonstrated a welcome understanding that solutions must ultimately be global, the United States has been outpaced by other major powers when it comes to vaccine diplomacy. Earlier this week, the suffering in India finally moved the United States to action, triggering new bilateral assistance and a more general commitment to share up to 60 million doses of the AstraZeneca vaccine with other countries. But with regard to improving the outlook for Africa, the aid focused on India is a bank shot at best. It’s true that getting the virus under control in India would free up the South Asian giant’s formidable vaccine production capacity to assist the rest of the world, but helping India, while right and necessary, is insufficient to address the problem in Africa. Only about one percent of African adults have been vaccinated for COVID-19, and supply, distribution, staffing and public education campaigns are all in need of bolstering. The public health case for vaccine equity is clear: unchecked transmission anywhere increases the chances of new variants emerging that can spread everywhere, including variants resistant to existing vaccines. Though many African countries took early and admirable steps to protect their populations, evidence suggests that COVID-19 is more prevalent in Africa than early reports suggested. Cities like Nairobi and Addis Ababa have lately experienced painful surges, stretching the limits of healthcare capacity and exhausting overstretched communities over a year into the pandemic.  The political case ought to be equally apparent. As the Biden team aims to bolster multilateralism and reassert American leadership in pursuit of solutions to thorny international challenges, the lack of palpable urgency regarding Africa’s COVID fight strikes a dissonant note. To build the coalitions we seek, the United States needs to paint a picture of a future in which the priorities of African partners are respected as we tackle critical challenges together. But the sincerity of this effort is called into question when our path out of the shared misery of COVID-19 diverges so sharply with that of Africa. For our own safety and our own long-term interests, the United States needs to bump support for African vaccination efforts up on the priority list.
  • Pharmaceuticals and Vaccines
    Vaccine Passports: What to Know
    Some governments and businesses are starting to use digital and paper passes that certify a person has been immunized against COVID-19, spurring debate over the ethics of vaccine passports.
  • COVID-19
    Academic Webinar: Equitable Vaccine Distribution and Pandemic Preparedness
    Play
    Sonya Stokes, assistant clinical professor of emergency medicine at Mount Sinai’s Icahn School of Medicine and fellow at Johns Hopkins University’s Center for Health Security, leads a conversation on equitable vaccine distribution and pandemic preparedness. FASKIANOS: Welcome to the CFR Winter/Spring 2021 Academic Webinar Series. I'm Irina Faskianos, vice president of the National Program and Outreach at CFR. Today's meeting is on the record, and the video and transcript will be available on our website, CFR.org/academic. As always, CFR takes no institutional positions on matters of policy. We're delighted to have Dr. Sonya Stokes with us to talk about equitable vaccine distribution and pandemic preparedness. Dr. Stokes is an assistant clinical professor of emergency medicine at Mount Sinai’s Icahn School of Medicine. She's also a fellow at Johns Hopkins University's Center for Health Security. She specializes in health systems strengthening in low- and middle-income countries, and her research focuses on increasing access to trauma and acute care in resource-limited settings. During the initial outbreak of COVID-19 in New York City, she was part of the frontline response treating patients in the emergency department. In addition to her clinical work, she served on the Mount Sinai Health System Best Practices Committee for evaluating and managing COVID-19 patients and contributed to the COVID-19 mass casualty triage protocol. She's a term member at the Council on Foreign Relations and she contributed to the CFR-sponsored Independent Task Force report that was released and titled Improving Pandemic Preparedness: Lessons From COVID-19. We released that last fall. So Dr. Stokes, thanks very much for being with us. It would be great if you could talk about pandemic preparedness, what we've learned, and what you're seeing in terms of the vaccine rollout and how we can make it more equitable. STOKES: Thank you so much, Irina. And I also have to say thank you to the Council on Foreign Relations, to Tom Bollyky, and to all the members of the Independent Task Force on preparing for the next pandemic. It was a wonderful learning experience for me, and I hope that we can share some of those lessons today. But before we begin, I would like us to first define our terms. What do we mean by equity, especially when we're talking about equity with respect to vaccines? Do we mean equity for the purpose of averting excess mortality or excess death? If so, how are we measuring this? I want us to begin by looking at some of the different metrics for mortality because what seems like common sense can quickly become more complex. I'm going to be looking at information from Johns Hopkins’s mortality analyses. So in their tracker, they look at the twenty countries most affected by COVID-19. And they report on a specific metric called case fatality ratio. Interestingly, that's called CFR. I will try not to use that term specifically so we don't get confused today, but that is looking at which countries are having the highest number of deaths per hundred confirmed cases. We go to the tracker. What are the top five countries there? So that looks like, as of the last twenty-four hours, Mexico, Bulgaria, Peru, Hungary, and Italy. Okay, is there another way of measuring this? Yes, we can look at the overall deaths per one hundred thousand of the population. According to Johns Hopkins, those top-five countries are actually some of the same, including Hungary, Bulgaria, Italy. The United States makes the top five there. But then what are we talking about again? Are we talking about averting excess deaths? Well, that does not necessarily immediately correlate with the places that have the highest number of deaths. We also have to look at other metrics, like the overall burden of disease, the number of cases, right? When we start looking at that, the number of countries that make the top five start to shift. But maybe we also shouldn't be looking at just the number of cases total, maybe we need to be looking at which countries have rising numbers of cases, right? And then that starts to change as well. In fact, actually, if you look at the daily number of new confirmed cases, which countries are having a doubling of cases? The actual top five there is very different. For example, you have Papua New Guinea that's making the list there. Somalia makes the list there. So again, when we start talking about the terminology of equity of averting excess mortality, we need to make sure we're being very specific on how we're measuring it because the real-world implications of this when we start talking about vaccine equity have some consequences to that. This is something that was talked about very early on in the Independent Task Force on preparing for the next pandemic. In fact, it was anticipated in the report, and I highly recommend that you look at some of the recommendations that were made specifically in the report. But these were the concerns for the reason of the formulation of the coalition that's looking specifically at global vaccine equity, or COVAX, and that includes an alliance between the WHO, CEPI, Gavi, amongst others. These are the people that are trying to make sure that we are addressing all of these metrics and making sure we're getting vaccines to the places that need it the most. And then when we look at those numbers we can see because there are comparisons that we need to make absolutely direct factual statements about. So, as of now, we have almost 460 million doses of vaccine that have been administered; 76 percent of this has been in the high-income countries. And then, of course, if we're looking at COVAX, what have they been able to do? Thirty-two million vaccines to fifty-seven countries that they have been able to distribute or actually, I apologize, they've been able to cover the cost for in terms of the actual logistics of how that happens. That even gets more complex than that. And again, these are actual conversations that we need to have, because the real-world implications actually translate to this issue of increased mortality of excess deaths. That is the purpose of what we're trying to avoid here. And so from here is where I want to make sure that we're opening up the discussion leading from this position. It is a discussion, guys. This is not me lecturing at you. We call this a question and answer, but I actually want to make sure this is a conversation. There are aspects about equitable vaccine distribution administration that I might not have the answers for but you may. And so I want to make sure that we keep the conversation going in that respect. And from here, Irina, I want to start things off and see if there are any questions I can answer right off the bat. FASKIANOS: Great, thank you. For all of you, you can raise your hand. Click on the “raise hand” to ask your question or else you can type your question in the Q&A box. If you choose to write out your question, please identify the school that you're with so that we can identify you properly. And let me see. We have a first question from Babak Salimitari. Q: Hi, Dr. Stokes. My name is Babak. I am a second-year econ student at UCI. I have a question. What we know about COVAX, which is trying to get vaccines into countries that are more, I'd say, are less developed than us, but one thing that we've also seen is vaccine diplomacy. We've seen how countries like China are using their supply chain in order to get vaccines into countries that don't have the means of getting them. And they're giving away vaccines like Halloween candy. My point is we don't really know what's in those vaccines, those Chinese vaccines, because they've never had peer-reviewed lab studies or actual scientific data behind them. How do we know that those vaccines are safe and aren't going to jeopardize the lives of the people that they give them to? STOKES: Thank you so much for the question, Babak. You actually highlight several different points. I want to see if we can unpack each one of those and then actually answer your question. So you do bring up a good point about COVAX, about areas where we're still going to have disparities even in the advent of COVAX. For example, COVAX only plans to vaccinate 20 percent of the global population, right? So we're still going to see shortfalls, and then even within that 20 percent, they have a funding gap. There's approximately a $27 billion funding gap right now that WHO's framework for COVAX is trying to make sure that they address. If anyone is interested please look up the ACT Accelerator through WHO and then you can see some of the ways in which, from an economic standpoint, people are trying to make sure they address those shortfalls. But then with the question about vaccine diplomacy, the converse of that is vaccine nationalism, right? We're seeing that everywhere. Part of this is actually, I think, that we want to bring up how China has been aggressively pursuing vaccine diplomacy, but that doesn't happen in a vacuum, right? They're able to do so because we are not offering what Tom Bollyky calls a compelling alternative, right? We are not engaging. So to a certain extent to answer some of these questions, I mean, we really do need to come back home and address our lack of engagement. And again, that's partly due to just overall, I mean, every country is going to want to vaccinate their own populations, of course, but then this issue of vaccine nationalism that, again, we need to be sure that we're doing our part to remain engaged to offer those compelling alternatives so that when we do then go to these conversations of your question, how do we know that, for example, Sinovac and the different vaccines that they're offering from China, what do we know in terms of what is the components in them? Are there any safety issues? There are multiple governing bodies, for example, that are analogous to what we have here in the U.S., the Food and Drug Administration, FDA. They have their own in China and the independent way that we would look at this is through peer review. I agree, we still need to go do peer-review processes. I would say that part of making sure that we do not engage in the misinformation or vaccine nationalism that is actually hurting us overall is to allow us to have those channels of peer review so that we can have very clear, very direct discussions that are about safety. Your concerns are valid. Those are concerns that we should have for all drug formulations. And again, the answer to that is not necessarily making it more about politics but making it more about the science. FASKIANOS: Great, thank you. I'm going to take the written question from Elizabeth Alfreno, who's a student at Ohio University, "Seeing as though it is difficult to make the vaccine mandatory for everyone or not everyone is able to take it, how are we able to move forward in this pandemic to help bring it to a close? If not everybody universally is able to have equal access to the vaccine, does that counteract the progress we're making towards overcoming the pandemic?" STOKES: Thank you so much for the question. And vaccine mandates is something that I found interesting, because it's been happening even before we had vaccines available, right, this discussion on how we actually operationalize distribution and administration of the vaccines. The reason that I don't think that we're anywhere close to having this be a real-world discussion is because, again, exactly how you point out, this coming back to it has to be not just available, but accessible to the global population as a whole before we start talking about things like mandates or even vaccine passports or any of these discussions. It gets even more complex than simply making sure that we're distributing equal doses. I'm going to run through, for example, again, you're talking to somebody who's an ER doctor that looks at health systems strengthening, right, and specifically looking at areas that are low- and middle-income countries, areas of armed conflict. I'm going to take one place that I worked in eastern Congo back in 2017-2018. So let's run through how we might actually go through from now that we have the vaccines where the technology is there, how do we actually get them to the people that, say, for example, in places where I've been working in North Kivu Province, right? Well, again, as pointed out by Tom Bollyky and the group at Think Global Health, there are some supply-side issues that are going to be massive problems that we need to address. So that is manufacturing issues and raw material issues that are just about the production of vaccines, okay? Let's assume that we actually fix that. That's a really big assumption. Now, we also have to deal with who is actually then going to be getting those to people, right? We do have several agencies that do this very well, UNICEF being one of them, Médecins Sans Frontieres being one of them. But let's say we actually employ those agencies to get those to people. There are issues about the accessibility in terms of the logistics, cold chain, where are you storing this? How are you protecting the supply? Who's actually going to be administering it? Then you come out against some of the other aspects of demand. So it's about awareness and acceptance within the communities. That's where misinformation has become such a big problem. So again, equity becomes these real-world bottlenecks all along the way that we have to address, both individually and then collectively. So vaccine mandates, I think, is not something—I know that we talk about it, but again, and it's not that we shouldn't talk about it, but in the real world of where things are going right now, until we address all of those other bottlenecks along the way, I don't think that this is something that is, again, a real-world discussion that has a lot of operational relevance. I don't know if that actually answered your question or just gave you more questions, but it just shows you just how complex this gets really quickly. FASKIANOS: To follow on that, a question from Wendy Hahn, who's a student at Georgia Tech. Just talking about the recent surge of anti-vaccine sentiments and paranoia, how do we deal with that and layer on to that the misinformation about which vaccine is safe, which one isn't? You know, there's been a lot of talk about the AstraZeneca data and how is all of that playing into this herd immunity that we hope to be building globally? It's not just enough to have it here in the U.S. We are interconnected, and we need the rest of the world to be vaccinated as well. STOKES: I love this question. It's a question that I ask all the time. And actually, the interesting part about this is that it's not actually a new question. This has been an issue going on for a very long time, well over a decade. With the advent of social media, it's just become more apparent. And the speed with which misinformation is happening is definitely something I don't think we've actually seen before in terms of the healthcare setting. But in terms of how we address it, I would highlight, for example, in Think Global Health, they did publish one of my articles looking at this because I think we can learn more, not necessarily from what's going on with COVID-19, let's learn from past outbreaks, right? There is an article, and I will send all this information to you guys so that you will have actual access to it so you can look through the information that I'm seeing myself. But, I think, let's learn from the people who've been doing this for a really long time that actually have given us some actual ways in which we can get around this. Vinh Nguyen, who is a physician who was working in some of the same areas I was working in eastern Congo with the tenth outbreak of Ebola in eastern Congo. So in 2019—this was published in the New England Journal of Medicine—he was working at an Ebola treatment center for MSF. There was an interesting discussion that actually came about while we were having a problem with people—they're not just reluctant to get a vaccine, they're not just resistant. We had over three hundred attacks on Ebola treatment centers. A lot of this came from misinformation, people getting into the community thinking that community health workers, people running these ETCs, these Ebola treatment centers, were doing so for the purpose of hurting the population, maybe even purposely infecting people with Ebola, which obviously not true, but again, once the misinformation gets out there, it is really hard to counter. Dr. Nguyen actually had a great solution to this. They were saying, “Well, of course, in a community where there's been problems with trust, with violence, it is really hard to come in as an outsider with potential new medications and vaccines to say, ‘Here, this is good for you. You should take this.’ Well, let's actually listen to what they're asking for what they need.” Their solution at MSF and what Dr. Nguyen wrote about was let's give the people what they need, what they're asking for. Treatment for malaria, measles vaccination, right, measles, which has killed so many more people in central and eastern Africa than even COVID-19, right? Let's actually do that. And when we do that, we actually build trust with those communities over time. That trust is one of the best ways you can counter misinformation. The Center for Health Security at Johns Hopkins actually just recently published a great report about how we need a more coordinated effort on how we manage medical misinformation, at least from the national standpoint. But again, I think that while those points are absolutely wonderful—and I highly recommend that you read that report—I think there is some core issue we do need to address here and that is how do we actually just reestablish trust within our communities from us as clinicians and public health practitioners, listening to people, giving them what they're asking for what they need, right? I think that is actually one of the more powerful tools that we can use to combat misinformation. FASKIANOS: Thank you, I'm going to go next to a raised hand, Mojubaolu Olufunke Okome. Q: Thank you very much. I find your presentation excellent and really what we need. Well, what I just wonder is why there is so little learning from past experiences. Because a lot of the ways in which the pandemic, the current pandemic, has unfolded resembles the 1918 flu pandemic. A lot of the responses that people have in spite of the passage of time is very similar. So lot of harm has been done as a result of, you know, muscular nationalism. So how really quickly can a lot of the harm that's been done be undone to—because there's a deficit in trust as a result of people believing the anti-vaccination rhetoric. I mean, WhatsApp for the Nigerian community has become this director of passing on this bad information. I'm Nigerian. I teach at Brooklyn College in political science. And I’m Nigerian. I wonder what can really be done to knock out the bad information in a quick way that would enable people to embrace the vaccine. And it's not only there in Africa, there are people here in the U.S. also who are dead set against being vaccinated. So, that being the case, somebody else asked, how are we going to get to herd immunity? How are we going to build trust? And then in terms of equity, there are many of these vaccines that you need refrigeration at a level that is not available in many developing countries. So, how do these obstacles gets surmounted? Then patents, a lot of pharmaceutical companies are holding on to their patents tightly. You saw this also in the HIV-AIDS pandemic. So, what can be done to persuade the loosening up of patents so that affordable vaccines, generic, can be produced and then disseminated? STOKES: Thank you so much for this question. And actually, I would love to find a way to continue the discussion with you offline because I have a suspicion that you will probably have better answers than I have to give to you. But what I will say is this, we do have some amazing resources out there right now and people who are advocating for those. I would like to say that, specifically, there was a meeting that was just held recently. They call it the “Panel on Panels” that had the head of the WTO, Ngozi [Okonjo-Iweala], speaking with Tedros [Adhanom Ghebreyesus] and it was a wonderful thing what they were talking about. They were addressing some of these specific issues. They had a very clear plan. One is trying to connect vaccine manufacturers with other companies who have excess capacity to ramp up production. Two is a bilateral transfer of the technology between companies as well as production. So that we've actually already seen between AstraZeneca and places like in South Korea and in India. They also talked about a third point of coordinated technology transfer licensing. Again, what you're talking about in terms of both patents and issues related to the information that we have from the amazing innovation from the pharmaceutical companies who have come up with these vaccines. So I think, again, there are ways to do that. There are people who are advocating for it. I highly recommend that you go to the people who will be the greatest advocates for that. So you're going to see that from people who are supporting those proposals from the WTO, as well as the people who are supporting policies outlined in the Global Fragility Act. So that is one side. Second, again, that's perspective, right? But how do we do this in the short term? Again, I'm your operations person so it's not just long-term thinking, pandemic preparedness. I'm thinking of right now. So not for the next pandemic, not necessarily even for the next wave. I'm thinking for next week, right? How do we do that? And so again, I'm going to circle back to that question I asked you from the very beginning. What do we mean by global vaccine equity? Is it for the purpose of averting excess death? How do we avert excess death, right? Well, again, some of these conversations are going to be better dealt by people who are from your background, the economics, or people who have the background in ethics. But if I look at the operations and then also the issue of misinformation, and I look at the guidance that was given by Dr. Nguyen from that amazing insight from just the Ebola response in DRC, why not actually—let's figure out some of the mechanisms that we can avert excess death right now to build trust in communities. So the World Food Program has actually highlighted a huge problem that's going on globally and that's food insecurity. And so why not address that issue that's going on? I have a suspicion that if we were to go out and say, “We're going to look at the funding shortfall that they have at the World Food Program,” which I believe right now is somewhere in the ballpark of $266 million because they're looking at three million refugees in eastern Africa that have this problem of food insecurity. Well, if we can address that, we improve their security and that actually, guess what, improves trust and will help. It's not a magic bullet for misinformation, but it certainly will help, right? I think if we address some of those issues, again, give people what they need. Let's also, in the process as we're talking about global vaccine equity with respect to COVID-19, let's talk about global vaccine equity with the places where people in eastern Africa are dying from measles, right? The measles outbreaks that continues to hit DRC and places like Central African Republic, let's make sure we're not forgetting that part and give people what they need, what they've been asking us for. Let's actually listen to them and respond appropriately. That's pandemic preparedness as well, right? So, again, because we may not be able to meet some of the issues that are true supply-side shortfalls when it comes to COVID-19 vaccines, those discussions are happening with people that, again, will know this much better than any information I could give you. I do know about some of these other areas that we can address, and when we do that in concert, then again, that's how we build that trust. That's how we start battling misinformation when it comes to vaccines or medical misinformation in general. FASKIANOS: Great, thank you. A lot of questions. Next question from Maggie Chambers, who's a senior international business major at Howard University, "Recently the Quad countries committed to giving one billion doses to people around the world. How do you see this changing the tide of the spread of the virus and the return to normalcy?" STOKES: Thank you. And that is, again, when we talk about the distribution and the commitment of countries to make sure that we're doing allocation of vaccine doses, yes, absolutely, that solves one piece of that puzzle, that puzzle of supply side. But remember that sort of chain that I described for you. There are also of these other bottlenecks that we have to remember that we're not missing in the process of it. So how do we actually do the logistics of that? Who is going to be addressing cold chain storage, administration, and then, of course, all the other aspects of community engagement? So yes, absolutely as a solution to supply side, making sure that we're getting all the countries that have been able to have that amazing purchasing power of allocating vaccine doses to their own countries. I think that Kaiser Family Foundation has a wonderful article that sort of summarizes this where they say less than 20 percent of the global adult population is from the high-income countries, more than 50 percent of vaccine purchases have happened within these countries. If you include middle-income countries, that's more than 75 percent, right? So if we can address that sort of discrepancy by this, yes, that is a solution for the supply-side problems that we need to continuously engage with, especially in the United States. And for our other question that we had earlier in terms of vaccine diplomacy, that also addresses that issue. I would alert you to one issue though—normalcy. Careful with that term, what gets us back to normal. I want to take a moment for everyone here on this call, by the way, to recognize all of you what you have gone through in this last year. And if it's hard to hear what I'm saying, because again, when you keep hearing statistics or people speaking at you, it can be a little hard to take in the information. Why is that? Because, well, what everybody has gone through has been—and I use this in a very deliberate term as someone who is an emergency physician—that's trauma, which we are engaging in continuously. It’s a trauma response. I don't call it post-traumatic stress syndrome, because we have to get to a post period, right? But it is very real. You have to make room for that. You have to allow yourself some time to also disengage, to have doubts about what people are telling you, when to disregard what we're saying. Leave yourself and your brain some room to be able to process, come back to it, continue the conversation. And then when you do, it's not that we're getting back to normalcy. Right now what I want us to get to is a place where we're okay and then eventually somewhere better. That's where I want to get us to. I don't want to go back to normal because you know what, in a lot of places where I used to work, that wasn't such a great place anyways. So let's figure out how we do this. I think one of the most amazing things that could potentially come from this, we're not there yet, but if we continue engaging in these conversations, we'll get to somewhere that, again, when we look back on this, it would have been worth it, right? For all the death and despair that we've gone through, let's make it worth it. And I do believe that we will do this if we continue these conversations. FASKIANOS: Thank you. I'm going to take the next question from a raised hand. Tanisha Fazal. Q: Hi, thanks so much for taking the time today. I'm a political science professor at the University of Minnesota. You've been talking a lot about misinformation. I wanted to ask you about lack of information or data issues, especially when it comes to sub-Saharan Africa because of your background working there. One of the things that I've been trying to figure out, when you look at Our World In Data or other data sources, for example, is how much of what we're seeing in terms of the numbers is due to—particularly, again, in sub-Saharan Africa—is due to a lack of testing versus some of the predictions that you were hearing, maybe last summer that because of skewing younger, the COVID-19 pandemic wouldn't be as bad in Africa. So I was wondering if you could just speak a little bit to what your sense is of how severe the pandemic is in sub-Saharan Africa. Also because you were talking about other diseases and maybe they have just always overshadowed an illness like COVID. Thank you. STOKES: Tanisha, thank you so much for that question. I'm going to reference two people in particular who have been just phenomenal resources for getting information like this. One is in your actual neighborhood—Michael Osterholm, your team at CIDRAP. I follow that team relentlessly. I think they've been some of the most amazing public health practitioners in the public spaces, particularly in communicating information in a way that actually gives us the best immediate guidance for what's going to happen in the next few weeks. And by the way, if you did not listen to the live stream that happened from Michael Osterholm in CIDRAP yesterday, please do it. You can even disconnect from this if you don't have time. I would say go listen to that. If you listen to that, learn from it. It can save your life. Okay, one. The second person I follow when it comes to specifically epidemiologic methods in complex emergencies is Dr. Les Roberts over at Columbia University. It's actually his surveillance system in DRC that I was helping with back a few years ago. Now, how do we get the information if—you are absolutely correct, there is underreporting happening in central Africa and eastern Africa. There is underreporting that's happening, by the way, six blocks from where I am right now here in New York City. We have underestimated COVID-19 at every turn, and we are absolutely globally everywhere behind with testing. So that's everywhere. And, yes, of course, just like we have global vaccine inequities, we have global testing inequities when it comes to COVID-19. So if we know that there's a problem with testing because we just can't get tests there, we don't know how we can get that operationalized. What are some of the other ways we can do it? So Les Roberts describes this as a method called triangulation. If I cannot directly measure by a test, what is another way of looking at it, okay? Because when it comes to, for example, mass casualty incidents, mass death, over a period of time that can be pretty hard to hide, right? You can, and I have seen mass graves in eastern Congo, but again, in the places that we're looking at, right, it would be something that would be hard for us to ignore, especially over this period of time. So I do think that there is a component of this that is underreporting, but when we triangulate the information, we actually do see, well, again, still not seeing the high rate of death that, as we were saying, just as I was mentioning, those countries that were making those initial lists from the mortality analyses from Johns Hopkins, right? And that, I think, is again the multifactorial issues of younger populations, populations that have higher rates of exposure to different types of infectious diseases. There are other issues that are possible factors. I don't think it's appropriate to discuss this in a public setting, because I never want to participate inadvertently to misinformation by something being extrapolated. So I’m happy to talk more offline about these. But again, Jennifer Nuzzo and the team at Outbreak Observatory is pushing for, again, as people are pushing for global vaccine equity, they're pushing for global testing equity. I think both things should be pursued to be able to protect us overall. Again, though, we still do need to be aware of the numbers. Last thing I will actually say, by the way, speaking of Michael Osterholm and the team at CIDRAP, they did highlight something yesterday. They were they were talking about numbers because up until recently, we haven't seen the level of mortality, right, for the number of the reasons we just discussed in central and eastern Africa. But he did highlight some issues that potentially are going on in Tanzania potentially with variants and the dynamics of what populations are being affected, what ages and what people are being affected. That might change, right? We might actually see younger populations more affected. We need to be aware of that. And so just because what has happened in the past might not necessarily be what's true in the future for COVID-19, again, all the more reasons to have the discussions on vaccine equity. FASKIANOS: Thank you. So in the chat somebody wanted you to repeat the names. It’s Mike Osterholm and Les Roberts, those were the two. Jennifer Nuzzo is also, in addition to her post at Johns Hopkins, a fellow at CFR, which we're happy to have her part of the team. And so building on that, Kevin Lockett, who's a student at Ohio University, referenced Osterholm and [Mark] Olshaker talking about developing a universal coronavirus vaccine that would target the pieces of virus particle that all variants share, saying we require an effort on the level of the Manhattan Project. So his question is, “Given that this is a global issue and it's spread outside of national boundaries, how can legal mechanisms be used to incentivize countries together their respective resources to work collectively together toward producing a universal coronavirus vaccine?” STOKES: Thank you for the question. And I will once again highlight my biases and limitations—emergency physician. Yes, I do know health systems strengthening, but when we're talking about more specifically about not necessarily vaccine distribution administration, but development, innovation, right, when we talk about things like that, I defer to the experts on that. I will highlight a couple other people—Angela Rasmussen and Luciana Borio. In addition to the team at CIDRAP, these are the people that I look to. Also I will say Florian Krammer, who's here at Mount Sinai’s Icahn School of Medicine. These are the people that I look to when I need guidance, specifically there because, again, we need to know what our biases and limitations are. Now, if we try to translate and say, again, we resolve these issues of innovations, we do get something on the level of a global coronavirus vaccine. Again, a big assumption there, right? And how do we leverage in terms for addressing some of those issues from not just manufacturing but a legal standpoint? Again, please, I would highly encourage you to look at the WTO, who has portrayed some of the issues that have been voiced there in terms of how to address these issues. I will say this, even in the advent of the legal framework, let's say, for example, we do address issues that are arising, let's say about patents regarding the innovations, right? Please don't ever forget, again, operations. Remember, where is this excess manufacturing capacity that we're going to find? We need to make sure that we're highlighting those places. It's not just the ability for people to do it, they need to have the quality control to do it. A good example of what's happened with this is Merck, a fantastic pharmaceutical company that has stepped up when their own development they decided, “Look, our vaccine, does not seem to be meeting the efficacy numbers we want.” And so they're supporting other pharmaceutical companies to do production. That's a perfect example right there. So trying to take Merck, which continues to be this leading company in terms of not just innovation, but just ethics. Following that model, seeing how we can extrapolate from there, I think that is a good guidance for us. FASKIANOS: Fantastic. I'm going next to a written question from Kelsey Thompson, who's a student at Fletcher School at Tufts, “What have you seen being done regarding vaccination of displaced populations, refugees, and those in armed conflict zones? I've seen recent articles about state responsibility for vaccinating displaced populations within their borders but wasn't sure if there were greater international efforts supporting their vaccine and overall COVID-19 health care that you might be able to talk about.” STOKES: The most unfortunate aspect of this is I can answer this quite simply. It's not happening. I would rather us just be straightforward and honest about this. There's a lot of talk about it. There are a lot of papers that are going to be published; I'll have to read a lot of them. The operational relevance of this and the real world lives saved, again, there's a reason I brought up that. It was more than just a thought experiment. It's real problems that me and my colleagues actually have to talk about, among them Les Roberts and Craig Spencer. How do we actually get vaccines into arms of those people that are at risk? There are other conversations that then come up again. We want to make sure as we're having those conversations about COVID-19 vaccine equity that we're not in the process displacing some of those other really crucial interventions that would actually save immediate lives there. So notice in the entire time here, I haven't really talked about suppression of variance, right, as a primary reason for global vaccine equity. I focus on reducing excess deaths because, again, I think when we talk about suppressing variance, the irony in the conversation of equity is that sometimes it actually displaces issues of equity with respect to averting excess death, right? We're talking about suppression of variance because COVID-19 remains the number two cause of death now for high-income countries. But again, if we're having that conversation and not addressing the actual causes of mortality in the places that are low- and middle-income countries, specifically in places of humanitarian help or refugee and IDP populations, again, you have to do both, right? Both is necessary and definitely not one without the other, not one that actually is going to in the process take away from the things that they actually need right now to save their lives. And again, I will say it until I turn blue in the face, which might be a sign of COVID-19, no, please, please, please, look at the people who are doing those real-world interventions that will help right now—World Food Program. Looking at supporting initiatives from the WTO. These are things that are actually going to translate to those specific issues of mortality in the places where mortality is hitting the hardest, and not because of COVID-19, because that's just how it's been for a very long time. Again, we talk about a better future, right? What do we want to look like at the end of this? I would love it if at the end of everything we've been through with this pandemic that we actually come up with solutions. We commit ourselves to those things that we've been talking about for decades, if not for centuries, and actually find a way to actually have some real-world solutions. FASKIANOS: Thank you. Next question comes from Michael Raisinghani, who is from TWU, "Since we do not have longitudinal data on any of the COVID-19 vaccines, how do we know about the side effects? Is it realistic that we could win the battle against COVID-19 by 2025? And how do we proactively minimize the threat of the next superbug?” Well, you just said that you're not looking at the variants and the next one, specifically, but— STOKES: I mean, this is a great question, Irina. They're all interconnected. It's not that I'm trying to sort of disregard some of these discussions. They're all valid, right? But again, my focus is a reflection of my bias and limitations. I will say this. I get this question a lot when it comes to looking at the safety of vaccines. And I don't just mean from my patients or even from my fellow providers—my family and friends. You are in very good company with people that I hold dear to myself that have these questions all the time. And by the way, even after we have the conversation, we usually have to have it again next week and then the week after that. Do not be surprised. It's an iterative process, right? It's a process that requires, again, I call these conversations because truly we need to have them again and again to remind ourselves. So let's talk about vaccine safety, okay? Within the U.S. the three vaccines that are currently available to us are made by Pfizer, Moderna, and Johnson & Johnson, right? Well, how do we get to that point in the United States, in particular, of not just a distribution but administration of a vaccine? Again, I referenced the FDA. There's another body, the ACIP, that looks specifically at vaccine safety. The rigors of going through that are profound. To get a vaccine administered in the U.S., a COVID-19 vaccine, it's an enormous feat. It's what's one of the miracles truly of the amount of investment that's come from the pharmaceutical companies, from funders, from governments to get this going, right? I should also tell you, guess what, we could have probably done this with a lot of other diseases. But again, we just have not had that level of collaboration, right? But again, it happens absolutely with this very intense review process of safety. Now, so I can tell you right now that in terms of when we talk about long term, right, I have people that are asking me, “Well, how do we not know five, ten, twenty years from now we're not going to see some side effect?” Again, I’m always going to be straight. Anyone who tells me they can know what's going to happen in five, ten, twenty years clearly hasn't learned anything over the last year, which is, we need to be dynamic, and that we learn new things all the time. I will tell you this, in addition to the very rigorous safety review that the FDA does, we have now had hundreds of thousands of people that have been in the original vaccine trials for almost a year. Remember I talked about that process of triangulation, right? Well, I can't get a time machine and go twenty years from now to see what the vaccines are doing. Then what do I do? I triangulate that information. We have not seen anything other than we have had some severe allergic reactions, meaning anaphylaxis. Like all medications and drugs—and even by the way, sometimes foods do to us—it’s not exceptional to the vaccine at all. Nothing, no reports whatsoever. That's phenomenal, right? And so when I'm looking at how to triangulate information I have right now to be able to tell me what's going to happen later, that's a huge indicator. One. And two, we have, in addition to COVID-19 vaccines, a century of information on vaccine development in general that just shows just how safe they are, right? Truly it is one of the safest things we do in medicine. As an emergency physician, you should take that to heart because I can see all of the different ways in which some of the things we do in medicine that are very high risk. This is one of them that isn't, and it's one of the things that are actually going to save people's lives. I don't like using the term getting us to normal. It will get us to something better, though. So please, please, please, please, when you hear me, it’s absolutely safe and most likely long-term safe. It will save lives right now. FASKIANOS: Sonya, you obviously are on the frontlines of this. Thank you for all that you're doing. I'm in awe of doctors and nurses who have been just on the frontlines in the ER and intensive care units taking care of people. There's been a lot of talk about how people have postponed regular visits, children aren’t being vaccinated for other diseases because of the pandemic. Can you talk about what you're seeing in the ER and your concerns just on sort of what we thought were the normal things or that we knew about in everyday life and your concerns there? STOKES: Any emergency physician who would hear that question would be so thankful for it. Anyone on the front lines, because, yes, this was an issue. It remains an issue of people avoiding regular care for underlying medical illnesses that, by the way, put you at risk for COVID-19. For example, people not following up with their regular physicians for care for their hypertension, for their diabetes—this is a big problem. In the early days of the outbreak, the first wave in New York City, and I can have a very vivid memory of this exact day last year of what it was like in the emergency departments in New York City, it's something I will think about every day for the rest of my life. I could understand at that time people's apprehension of coming to the ER, especially in a pandemic, especially if you watch a movie like Outbreak back in the day. That was, I'm dating myself here, because that was a movie that came out when I was younger. That's again, these are things that people are looking around, again, they're looking for information so that they can know am I putting myself at greater risk by seeking care. And again, this is coming from a perspective that knows, that recognizes in the early days and was something I was concerned about even. The health-care systems have made enormous changes to address these issues, and it's something that I've been highly encouraging of my patients and the people I care most about in this world. Please do not forego care for these issues because in the end we might see, again, when we're looking at mortality and how we measure it, we might actually find, and the CDC has been tracking data on this, that we're going to hurt ourselves in the long term by doing that, that it will actually increase our mortality by doing that. For all of these issues, please make sure if you have access to a primary care physician or a specialist that you're supposed to see regularly, always stay in touch with that physician or that provider and also be highly cognizant of the fact that in the United States that is a privilege, having access to a health-care provider. So what we can also do to help support that is please let’s support initiatives in the United States that supports primary care, because I am very well aware that it is very difficult, even here in New York City, to talk about accessing any health-care provider outside of the emergency department. It's just not something that people have either because of a lack of health insurance or inadequate health insurance. These are things we really do need to address. Speaking of equity, we need to do that at home. We need to do a better job with it. FASKIANOS: Great. I’m going to take a written question from Joanne Michelle, who is a PhD student at the Mailman School of Public Health at Columbia University, “If you could talk about the role of the medical and public health colonial legacies in this discussion and address the myths or misinformation in many humanitarian settings. How do you manage that as you're on the frontlines to deal with those uncomfortable histories to getting people to take the vaccine?” STOKES: Again, I hope that we had some of these answers or at least more questions from this question earlier on, seeing the models of the people who are doing this best, okay, I mean, we should just be very open about some of our failures here. I'm very well aware, by the way, of having the ER doctor in New York City talking about global vaccine equity when I myself had access to a vaccine  and we have health-care providers in South Africa, right now, colleagues of mine on some of the WhatsApp groups that I run, who, again, have not had any access to any vaccine at all. These are health-care providers, right? So the best way I know how to do this is by making sure that we are first learning from the people who, quite frankly, are doing this a lot better than us. I think the best way to address any issues of historical or colonial issues is by recognizing our failures. I don't mean our failures abroad, I mean our failures at home and then taking a step back and asking the people who do this better globally, “How did you do that?” and having them front and center. Let's talk about how we would do that even within the U.S. By the way, if we look at the top-five states that are administering vaccines here in the U.S., New York City is not even making the top thirty, by the way, or New York State. It's Wisconsin. It's Nevada. It's New Mexico. I want to hear from those people. How did you do that? You need to tell us. So I want to actually take a step back, let's accept some of the ways in which we failed, and then let's learn from the people who seem to be getting it right. That's actually how we do it in a real way, in a real-world way that actually, as I said, averts excess deaths and saves lives, which more than anything is number one in the middle of a pandemic. FASKIANOS: Great. I'm going to take the next written question from Beatrice Guenther, who's an associate professor of French and international studies at Ohio State. No, not Ohio State, excuse me, Bowling Green State University in Ohio. Okay. And she wants to know, “What would be your top-three recommendations that you propose for pandemic preparedness?” Or maybe we could state it as what are the top-three recommendations that the task force, the Council on Foreign Relations task force, proposed for pandemic preparedness? Not that we want to think about the next one but— STOKES: I would say that there is a list of the recommendations from the report that are given equal weight. I wouldn't want to say what the top three—to speak on behalf of the membership, I think we all contributed our different perspectives. I will give my own perspective from the report that is in there. I highly encourage you to read it. Again, thank you to all the members of the report. So number one is actually creating dialogue. How do we do that nationally and globally, because that's actually how we do leadership, right? What is it that we're going to do in terms of addressing some of the issues where we have time and again seem to have failed in terms of just the communication? So when we have breakdowns in our chain of command and our lines of communication in public health, what are some of the ways that we can get around that? And then, again, please refer to some of the work from Tom Bollyky and looking at this from the Council on Foreign Relations on some of the different ways in which we can address this. Number two—investment in public health. I'm going to say also primary care, which I think is public health. We really do need to actually address how we invest, what are the means for that, and making that actually operationally relevant. Someone very recently told me that the difference between pandemic preparedness and response is about having responsive responders. We need to actually make sure the responders have a way in which the recommendations, the investment that we do in public health and primary care actually translates to those responders being able to use that—contact tracing, testing, making sure we have adequate surveillance. So that's number two. Number three is I would argue something that is actually a little excerpt that I gave at the end, which is I think we actually need to look at surveillance another way. I think that some of the different ways in the report that's trying to address that we want to with respect to the sovereignty of nations, we want to make sure that we are addressing sort of those shortfalls in public health. But I want to prepare for failure. That's what I want. As an emergency physician, it's great if we can restock the National Stockpile, have innovations in vaccine and treatment development, testing, contact tracing. I want all of it. I’m an ER doc. We know a good thing when we see it, and we never turn down a good thing. But what happens if we have those same limitations and parameters all over again, right, what do we do? I want to prepare for that. I would highly recommend and, again, my bias and limitations are pretty apparent here, but I would say we need to invest in how we do pandemic surveillance and response. I would integrate that into our hospital systems, specifically in emergency medicine. This is what we do all day long. I would invest in that globally. I would network us and make sure that your ER doctors, your responders are talking with each other. Because guess what, guys, how did we do this in the beginning? What were we hearing from about this pandemic? We were networking with each other pretty much as soon as the first wave hit here in New York City. And that's actually how we came about saving our patients’ lives and each other. Let's figure out how to actually make that systematic and scale that up is what I would recommend, because we have to prepare for failure again. I don't want to prepare for a future that may never come, all right. I want us to get to somewhere better, but also be prepared in case, in case we don't get there, in case this happens again. And then we will truly be able to get through this together as a community to something that is worthwhile. FASKIANOS: There's been a lot written about how we here at home have not been resourcing or providing adequate funds to the health-care industry. And so, as you know, as we have gone through this pandemic, we're now over the year mark. Do you feel as a health-care professional that there is the determination to start funding and better fund our health-care system? STOKES: I don't know this word determination. I know that there is a demand from us who are health-care practitioners. I know that there's this disparity with the amount of funding that seems to go into the health-care system in the United States, but doesn't seem to translate to actual equity, that our vulnerable patient populations remain even more vulnerable now. It's disturbing to me, in the middle of a pandemic, we're cutting resources to emergency departments. I don't know if there's determination because I don't know this word. I do know it's necessary. It's about our survival. I really hope this translates to something that we can work on together, not just in some distant future. Right now it would be great. FASKIANOS: In the present. On that we will end. Dr. Stokes, thank you very much for being with us today, and for all that you have done and are doing. We really appreciate your service. It is so critical to saving so many lives. So thank you very much. I encourage you all to follow Dr. Stokes at @sonyastoked. You can follow her on Twitter. We will send out additional resources to the groups, things that were referenced. Dr. Stokes does have a reading list, too, so you can get more. I hope you will do that. Again, on our website CFR.org, Think Global Health, which is a global health initiative being run by Tom Bollyky, who is a fellow at CFR, and, of course, ForeignAffairs.com, you can find additional resources. We encourage you to go there not only for this issue, but for many other issues in international relations and foreign affairs. So thank you, Sonya. Our last academic webinar of the semester will be Wednesday, April 7, at 1:00 p.m. Eastern Time with Susan Thornton, senior fellow at Yale University's Paul Tsai China Center. She will talk about the U.S. response to China's Belt and Road Initiative, which is the topic of another CFR-sponsored Independent Task Force report that we just released on Tuesday, yesterday. So, we will send out the link to that so you can read that in advance. So thank you all for being with us. Please do follow us @CFR_Academic on Twitter, and I mentioned the other Council resources. So thank you. (END)
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    Anita L. Barkin, co-chair of the COVID-19 task force at the American College Health Association, leads a discussion on the role of colleges in disseminating vaccines and provide rollout recommendations for campus communities. FASKIANOS: Thank you. Welcome to CFR's Higher Education Webinar. I'm Irina Faskianos, vice president for the National Program and Outreach at the Council on Foreign Relations. Today's meeting is on the record and the video and transcript will be available on our website, CFR.org/academic. As always, CFR takes no institutional positions on matters of policy. We're delighted to have Anita Barkin with us to talk about the planning for vaccine rollouts. We have shared her bio with you, but I will give you the highlights. Dr. Barkin is co-chair of the COVID-19 task force at the American College Health Association, known as ACHA for short, and a member of the board of directors for the Healthcare Georgia Foundation. Previously, she was a district nursing director of the North Central Health District. She oversaw operations of the district office, thirteen county clinics, and the Hope Center. She also served as director of Carnegie Mellon University Health Services for twenty-seven years. Dr. Barkin is a board-certified nurse practitioner and an ACHA fellow. Over the course of her career, she has held offices in local, regional, and national college health associations, and the Georgia Public Health Association. And she previously served as chair of the nursing session of GPHA and president of ACHA. She is a leader in pandemic planning for colleges and universities and this is the perfect audience to address today. So Dr. Barkin, thank you very much for being with us. Will you begin by talking about the role of colleges in disseminating vaccines on campuses and in their communities and provide your recommendations for campuses and what they're doing in their communities? BARKIN: Certainly, I want to, first of all, thank you for the opportunity to join you and your members this afternoon and discuss this very timely issue. And there are lots of questions that folks have out there regarding the vaccination rollout. If I may start by going through the PowerPoint presentation I gave as kind of a warm-up to our discussion. [To CFR operator] And so, yes, you can move to the next slide, please. So, we'll start with a short introduction, overview of the approved vaccines: what does the phase distribution plan look like? And then discuss some of the action plan items that we're recommending for institutions of higher education. Next slide. So currently, there are two vaccines approved under the Emergency Use Authorization, the EUA, and that is Pfizer's vaccine and Moderna. Now, if you look at them, the efficacy is about the same for both and even the dosing schedules are very similar. Pfizer is intended for use in sixteen years and older individuals and Moderna is eighteen years and older. They are, however, already starting trials to see what happens in younger folks. And so I think we'll see some information coming forth on the applicability for children and young adults, as well. There are some challenges with the Pfizer vaccine in terms of shipping and storage in that they–—that requires an ultra-cold freezer temperature of minus ninety-four degrees approximately, where Moderna is easier to store and ship and it's stable in a refrigerator for longer. And you can order less of it, fewer doses, and that's a big advantage for smaller organizations or smaller schools that really couldn't make use of 195 to 975 doses of Pfizer, in addition to the fact that the storage, as I said, storage capabilities are quite challenging with the Pfizer vaccine. Next slide. So two facts about COVID mRNA vaccines and those are—that is the technology that has been used to develop the Pfizer and Moderna vaccines is that the—and these are circulating, and so I thought it was important that we address these two particular issues. First of all, the vaccine cannot give you COVID-19. mRNA does not use live virus. It is a small fragment of the RNA that prompts the cell in the human body to make the protein. It does not affect or interact with cell DNA. It never enters the nucleus of the cell where the DNA genetic material's kept. Once the cell breaks down, it gets rid of the mRNA. And as soon as it's finished using the instructions to make the protein piece. So there's a lot of misinformation out there regarding how it works and its ability to interfere with cell DNA so I want to put those two myths to rest. Next slide. And there are more vaccines in the pipeline using different technologies. AstraZeneca, Janssen, Novavax are all in phase three clinical trials. And we need lots of vaccine in the pipeline. The limitations on the ability to manufacture enough vaccine to vaccinate the U.S. population quickly is really going to be dependent on having a variety of vaccines available to immunize the population. Next slide, please. So there are three questions that are yet to be answered. Does vaccination stop asymptomatic transmission? How long will the protection last once a person is vaccinated? And how will vaccines deal with various mutations that are making their way on the scene? Next slide. So especially relevant to the higher ed population are two phases of the ACIP recommendations. ACIP is the Advisory Council on Immunization Practice. And this phase structure was accepted by ACIP and rolled out. In phase 1A, the jumpstart phase, first group to be vaccinated says high-risk health workers and first responders. It is important to know, and ACHA certainly was interested in ACIP understanding and being very explicit in its intent to include healthcare workers on college campuses and first responders on college campuses. So if you have a health service and EMTs or paramedics, first responders on your college campus, they do fit into phase 1A of the distribution cycle, so they should be first in line. In phase two, you'll note that it says K-12 teachers and school staff and childcare workers. That has been interpreted to also include faculty and staff of colleges and universities. So “teacher” used in the broader sense of the word. And so we are seeing some places where faculty and staff are being vaccinated. And that is most commonly happening in schools that have—schools with health care professionals: medical schools, nursing schools, dental schools. But in, for example, in West Virginia, they have gone ahead and distributed vaccines to college campuses so that faculty are covered under phase two. So now that's jumping ahead of the phase-in recommendations of ACIP, but I do want you to know where this all falls in the conversation as it relates to higher education. Next slide. So the vaccine rollout plan from a federal standpoint was to—that the vaccine would be rolled out and managed at the state, tribal, territorial, and local level. And that states would be responsible for promoting confidence and uptake. The second set of partners that were engaged on a federal level were private corporate partners like CVS and Walmart. And some CVS and Walmart sites have received vaccines and many others haven't. And the major role that they anticipated CVS would play was especially in vaccination efforts for nursing homes and other conjugate settings, like prisons. Next slide. The federal plan has presented a number of challenges and missteps. There's been no unified nationwide government plan or strategy as a result of the decision to move this to the state level. There has been miscommunication and miscalculation on how many doses states would receive. States are already experiencing lack of human and financial resources to manage the rollout. And so many states are struggling, more so than some others, dependent on what their resources and human capabilities are. This is resulting in inconsistencies across the country in the prioritization of residents to receive the vaccine, how to alert people to sign up, promoting vaccine acceptance, and configuration of immunization sites. And I think you—just one example that I will give you is, for example, in Georgia, the governor decided to expand phase 1A to include individuals who are sixty-five and older. And that was a jump ahead of what had been planned by ACIP. Other states have not done that. So we're seeing a lot of inconsistency. As I told you, WV, you know, West Virginia has gone ahead and distributed to colleges and universities to immunize their faculty which fell into the second phase according to ACIP. So we're seeing a lot of inconsistency. The states are overwhelmed. Complicating the matter is a surge in cases, which is overwhelming the healthcare systems in states. So there's a shortage of personnel to even conduct these mass vaccination clinics. And I think also what we're seeing is a lack of funding for public health over the years has come home to rest. And the lack of funding in public health has resulted in strained resources in terms of the ability to conduct mass clinics and to inform the public about the benefits of vaccination and the safety of these vaccines. Next slide. So what can institutions of higher education do, given that there is all of this confusion about the distribution? It varies from state to state. How do we proceed? How do we become proactive in this situation so that when that vaccine becomes available to our populations, we have already worked to inform resistance to vaccination? Well, right now, our advice to institutions of higher education would be to immediately develop a comprehensive communication plan and health promotion strategy that increases vaccine acceptance and confidence in the community. And you need to do that while continuing to reinforce the need for ongoing public health strategies for mask wearing, social distancing, and hand hygiene. All of those strategies as mitigation strategies that were in place in the fall need to be continued and reinforced in the campus community, while also providing this information that will facilitate vaccine acceptance and confidence when the vaccine becomes available to you. And just some general principles about good communication. You want to communicate often and in a transparent manner. Anytime you receive updates on what's happening with the vaccine or your ability to access vaccine for your populations, you need to be communicating that and remain current. And also establish an advisory group that's comprised of diverse members of the campus community and student leaders. What messaging is going to resonate with the different populations that are on your campus? And who are those individuals on your campus who serve in leadership roles, who are respected sources of information and trust, who will be out there and willing to communicate their confidence in the vaccine and in reinforcing the public health messaging? Next slide. Of course, maintaining close contact with the appropriate public health authority to discuss planning and distribution of the vaccine is critical because these decisions, at least under the current strategy, and this may change with the new administration. The new administration may decide that they need to create and develop a national strategy for more consistency across the state lines. But right now, as it stands, it is critical that you be in touch with the local appropriate health authority, public health authority for the location near your campus. And you need to do some advocacy work upfront. Public health authorities need to understand the role that healthcare providers and first responders play on campuses. And I think many are aware of the important role of student health services on campuses, but some may not be. And understanding that they are providing patient care, they are at risk for exposure to the virus from their population, and that they need to be considered in the vaccination plan when that distribution occurs locally. The other thing that ACHA has done is to explain and advocate the importance of vaccinating college students before the end of the spring term, if at all possible. We have identified the end of the semester as a mass migration event. Students go back home, not only to different communities within the United States, but they are traveling internationally. And we're not sure what the travel requirements will be for international students. Their countries, their home countries, may develop travel requirements, and vaccination may be one of them. So if we can get our students vaccinated before the end of the spring term, right now, the way ACIP phased-in vaccination program is structured, college students would kind of be at the end of the line, unless they have a comorbidity or a pre-existing medical condition that pushes them further up as a high-risk individual. So we're trying to lobby for students to be vaccinated before the end of the spring term. And that advocacy at the local level will be critical because these decisions are being made at those local levels. Next slide. You need to start thinking right now about your institution's ability to serve as a distribution site for vaccination. This is a resource intensive activity. And certainly, colleges have experience with mass vaccination programs. Certainly, that experience comes with the meningitis outbreaks that we've experienced on college campuses where mass vaccination strategies were employed. But it takes a lot of resources to pull off a mass immunization strategy. And there are some particulars that come with mass immunization as it relates to the COVID vaccines because we need to think about social distancing, having people six feet apart, which typically we wouldn't have to worry about with other types of mass vaccination events. We need to worry about having the ability to react for an anaphylactic reaction, a severe allergic reaction, and rendering the appropriate care. You need to have your protective equipment, masks and gloves and gowns. And there's also paperwork that's involved because we will need to be informing the state of who has been vaccinated and then tracking who needs the second vaccination. So, there are certain specific criteria that would apply in a mass immunization event for COVID that will need to be taken into consideration. If after you assess your institution's ability to do so, a conversation with your local public health is important, right? ‘Hey, we believe we have the resources available to do this.’ And then they will expect you to fill out paperwork to apply to be a pod for a vaccination. We did—during H1N1, many campuses acted in this role as a pod for distribution. I know that at Carnegie Mellon, we vaccinated students, staff, faculty, and their family members during that event, and so it was a great help to our local public health in Allegheny County. But if your resources do not allow you to move forward with a mass immunization event on campus, it's important to have discussions with local public health and with a network of surrounding providers to see who can act as a referral source for vaccinating community members. The other option is to consider hiring a company to provide the on-campus experience vaccination. And then, of course, you need to continue to assess the effectiveness of your current mitigation strategies and adjust them accordingly. Next slide. These are a couple of resources available on the ACHA website. Our COVID resources are open to the general public so you don't have to be a member organization to access these resources. The first one is specific to mass vaccination guidance. The second document listed is a consideration for reopening in the spring and includes everything from how you—considerations for opening your health department, your mental health counseling services, and communication processes, and athletic considerations. So it's a broad umbrella in that document. So I will leave it there to kind of kick off the discussion and open it up for questions and answers. FASKIANOS: Terrific, thank you very much. That was really comprehensive. And I know we want to invite you all now to ask questions, to share what you're doing on your campuses. So if you want to click on the Participants icon at the bottom of your screen to raise your hand there. You can also click on—if you're on an e-tablet, on the More button in the upper right hand corner to raise your hand there. And we also have a Q&A box where you can type your question if you would prefer. And I see that our good colleague Mojubaolu Okome has her hand raised and if you could identify your institution to give us context, that would be terrific. And please remember to unmute yourself. Q: Thank you. My name is Mojubaolu Olufunke Okome and I teach political science at Brooklyn College, which is a commuter campus and an institution of modest means. So one of my concerns is that it does not seem as safe this—I mean, the presentation is wonderful, but it does not seem to be tailored to the needs of commuter campuses. And anyway, for the spring semester, we're still doing online education mostly. That's one thing. The other thing is if we have a—I know we have to focus on the U.S., but we have international students. And if there is no worldwide strategy on this vaccine, I mean vaccination, I fear that we're just going to be facing increased challenges because people are traveling back and forth. So I wonder the extent to which there's going to be a difference in strategy by the incoming administration on whether or not the U.S. should still do unilateral decision making and administration of whatever strategies there are, or multilateral. Then the other thing is, for poor institutions with commuter students, what kind of strategy is going to work, really? BARKIN: Okay, well, let's start with your first comment about commuter campuses and being online. So if students are online, there still is an opportunity to use social media platforms and your internet to educate your student population about the vaccines, vaccine safety, and strategies, public health strategies for keeping themselves as safe as possible. The other thing you might consider for a commuter campus is a drive-through clinic. So if you have large parking lots, students can sign up and drive through. Now, obviously, that's going to require you to develop some kind of a sign-up structure or engage public health and see if they can help you with the drive-through clinic. Because it is resource intense, and our public health departments are under a lot of strain. So how much assistance they're going to be able to provide institutions of higher education is really in question. And whether you can even secure the vaccine to conduct the mass immunization strategy, again, it involves a pretty significant conversation with your local public health. In regard to the challenges we face with international students, I'll give you one example of a challenge that came up with ACHA in the fall. The Chinese embassy had determined that they wanted to put testing requirements in for Chinese students who intended to return home for the winter recess. And the testing requirement was going to involve test results that were delivered within seventy-two hours of departure, which, in many locations around the country would have been extremely challenging. We heard from our partner institutions that have Chinese students who were struggling with this requirement. We did contact the Chinese embassy and we advocated for them to consider either forgoing or loosening up, changing that requirement to allow for more time. They really didn't change their strategy. But they did say that they were receiving a lot of concerns, not only from colleges and universities, but from Chinese students saying that they were having difficulty meeting the requirement or they were concerned they couldn't get the result in seventy-two hours. Now, fortunately, they did assure us that they would work with every student to help them through the process. But I think it certainly supports the point you're making. One issue is what if a student manages to get one shot of the vaccine here in the U.S.? What happens when they're due for the second shot and they're back home? Will they be able to access that same vaccine? These are questions that we certainly are thinking about, you obviously are thinking about, and it would require a national and international conversation. So I know that isn't an answer to your question, but I think that your concerns are well-placed. FASKIANOS: Thank you. Let's go next to Nicolle Taylor. Q: Hi, thank you so much for this opportunity, really appreciate your time. I serve as the chief business officer at Pepperdine University and work closely with Dr. Lucy Larson, who is our medical director. And I was wondering if you could just elaborate a little bit on the first responder description that you gave earlier as to where they fit in the phases. First responders, we have a public safety department on our campus. And so would all of those folks who are—I understand administration is probably separate than officers, but is there even a further differentiation to, EMT service versus dispatch or something like that? BARKIN: Yes. So, again, the decision ultimately rests with your local health authority. But the way we are interpreting the first responder is anyone on your campus who serves in a capacity that they would be first on the scene for a medical emergency or responding to a student injury, accident, illness. So we would include—if your security forces, your police department, are serving in that capacity and have that role, then we would include them in that phase 1A, according to our definition. However, again, I have to say that it largely will be dependent upon how your local health authorities interpret that. But you can certainly advocate for that. And I think the way you advocate is by giving them real examples of how your security staff, police department, EMTs function on your college campuses because public health, all public health folks, may not be aware of how medical services, emergency services are delivered on college campuses. So I see your role as an advocate and as an educator in that regard. Q: That really helps. I apologize, I appreciate that. Can I ask you a follow-up question with a different population? FASKIANOS: Sure, go ahead. Q: We have a very limited number of essential staff who are working on campus, whether that is in a facilities role or in something related like that. Would those folks fit into the phase two definition that you were describing when you talk about teachers and staff? And then I'll certainly yield the floor. Thank you. BARKIN: Yes, there is not—if you go to the ACIP guidance, they spell out kind of whom they include as essential personnel. I think that what we have heard from some public health sources is that there is a real interest and concern about getting our educational systems back up and running. And so to the extent that we can make, again, make a case for the importance of having specific staff, employees engaged in critical functions for the university, you certainly can advocate and make that case, even though you may receive one answer in California and someone in Georgia may receive another answer. It's certainly the advocacy and the explanation behind it is important. And so if you have those relationships established with your local public health, it's worth making sure that you continue to nurture them and stay in close contact with them. But I think there is an interest in that and it would fall under essential workers in the second phase. Q: Thank you. So Richard Arnold, who is a professor at Muskingum University in Ohio, wrote a question: "I live in Ohio was under the impression that college faculty did not fall under the teacher category. Does this vary by state or can you just clarify on that?” BARKIN: Again, it very well may vary by state. I can tell you here in Georgia, faculty have been told that they do fall under the teachers group. I can tell you that in West Virginia they have already started to vaccinate faculty. So it could very well be that Ohio makes a different decision. And that's part of the problem with the rollout. As I said, without a firm national strategy, you have lots of iterations on the theme. And the interpretation for this has been placed in the hands of the states. Now what I will say is this. And again, I'll use Georgia as an example, simply because I'm real familiar with the Georgia public health system. Governor Kemp made a decision to expand 1A to include sixty-five and older. So if you have faculty and staff who are sixty-five and older, you can certainly message to them, in Georgia, at least, 'Hey, this decision has been made by our governor and this is how you can get in line for an appointment for vaccination.' So I think the institution has to stay abreast of the decisions that are being made by the governor, by the state departments of public health, so that if there is an opportunity for folks to get vaccinated who, maybe it's not a faculty designation, per se, but it's some other designation, maybe anyone over the age of fifty-five with another health condition, you want to be putting that information out because the more folks that get vaccinated, the safer your community becomes. We know that. And so this does become an advocacy point. And I think it's more—it's been a struggle to get the vaccine out. And if you— there is information that I've looked at recently where they've actually ranked the states in terms of who's doing a better job of using the vaccine that has already been shipped to them. And there's great variation on that. So I would say that, yes, you need to be in communication with your Ohio officials and say, 'Hey, I've heard that, in other states, faculty are being included in that teaching category and beyond K-12. What's happening here?’ And that may be an advocacy point for you. FASKIANOS: Anita, is ACHA doing any kind of—do you have any plans to do a sort of a tracking project that would sort of collate what all the states are doing to be a resource for the colleges across the country and administrators? BARKIN: We have not developed any kind of toolkit that we are currently using for those decisions. When ACIP—and these decisions were just made recently. And the ACIP just firmed up that phase distribution process in December. And we were at the table and we were advocating for, as I said, anyone in college health and emergency medical services to be included. We also are looking at and making the case for schools, professional health schools, dental schools, medical schools, nursing schools, and saying to them, 'You know, if you vaccinate those individuals, they can help you with mass vaccination clinics.' And that was not spelled out in that phased distribution process. But now we're calling attention to it. And this is another advocacy point for folks on the call. If you have a dental school, if you have health professional schools, on your campuses, you can make that case to your public health authorities and say, 'Look if you help us get these folks vaccinated, they can provide—they will be a pool of human resource for you as you develop you mass vaccination clinics and as we get more vaccine in the pipeline to the public.' But lowering our resistance to vaccines will be critical. And there are populations that are more likely to resist vaccination than others. And we know that the African-American population holds a high degree of skepticism about these things based on historical events. And some—I saw a very good PSA done by Howard University that featured leadership, student leaders, diverse population, talking about why they're getting vaccinated, kind of in front of the camera, to try to build that confidence up in the community so that when that vaccine becomes available, people are ready and willing to accept it. FASKIANOS: Thank you. So I'm going to go next to Rey Koslowski, who has his hand raised and so if you can accept the unmute prompt. Thank you. Q: Hi, Rey Koslowski, I am a professor of political science at the University at Albany, part of the SUNY system. And we're actually going to have a—I guess, it's a drive-through mass vaccination beginning on our campus tomorrow. BARKIN: Great. Q: Yeah. And things have moved very quickly this week. And seeing messages from our United University Professions, our union, President Fred Kowal, saying basically, that when that definition of teacher was put out to say we want college professors as well. And what has happened is that the state put out its list and it's for professors or faculty who are teaching in-person classes. So that's the way it's working for us. Now, if you are teaching online, no, but for example, our campus, thirty percent of our classes will be in-person or hybrid this spring. But here is the thing that has happened—which, as I said, it went very quickly—but on Tuesday, the I guess it's phase 1A went to including people sixty-five and older with comorbidities. And there's a website where you can sign up, the New York State Department of Health, and friends of mine started trying to get in there. One got an appointment in March. And then, if you missed out and didn't get in, got booted out for whatever reason, you waited and another one got in April, and by Tuesday night, no more slots at our university, and they would get it at our university through the State Department of Health. I'm somewhat skeptical about your suggestion that we might be able to inoculate students because, as I understand it, as this 1A has redefined and opened up to sixty-five and older in so many states, we're up to about one hundred fifty million people who are eligible as this happens, and I don't think the production rate is getting anywhere near that to be able to handle that. My question for you is actually about, in a sense, triaging and thinking about those prioritizations. Could a negative antibody test be utilized in prioritizing? Because, again, the question's that somebody has been infected with the coronavirus, perhaps has been asymptomatic, do they have some immunity ready and perhaps shouldn't be prioritized? For example, again, with some students, if they have a negative antibody test, maybe that they haven't had COVID, for example? BARKIN: Right. Well, that's certainly an interesting thought. However, I can tell you that in discussions with—in presentations that I've heard from the FDA and the CDC, they've said that to do any kind of testing to determine who's qualified to get COVID, to get the vaccine, is not going to be practical or feasible. That it adds another layer of administration, resource, and expense. So while it's an interesting proposition, it's really not a feasible one. I share your concern about how much vaccine will be on the market by April, May, which we would commonly call the end of the spring term. But what we are saying is that the reason that college students should be prioritized is because that is a mass migration event. And that the advantage to vaccinating those students in terms of preventing infection and outbreaks in the communities to which they're returning and the countries they are returning to outweighs concerns about—or outweighs the idea that they're in the main healthy and their chances of sustaining serious consequences as a result of infection are not great. So we are making the argument that these people are highly mobile, they have the opportunity to spread disease, right? So it's a mass migration event. We should prioritize that. Now, whether we'll have enough vaccine on the market, who knows. Moderna has promised eighty million doses for 2021. Pfizer is far less than that. However, we are looking. AstraZeneca is pretty close to ending their clinical trial and may be considered for EUA as early as before the end of this month. I think that we need to get more vaccine in the pipeline, and it's going to take more than just Pfizer and Moderna to do that. So, yes, I hear your concerns. I wonder about the feasibility. But what we're saying is there's good reason to prioritize college students because of because of that migration. FASKIANOS: Thank you. I am going to go to Pearl Robinson next, who chatted her question. But, Pearl, do you just want to ask it? Pearl is at Tufts University. [Pause] Okay, I will read it, then. "As someone who personally benefits from the strategy outlined that seems to be promoting special treatment for privileged educational elite, who stands to lose from higher education's gain?" BARKIN: Okay, I'm not understanding the question. FASKIANOS: I guess it is, by putting the higher ed community first, there are going to be a lot of people in the community that are disadvantaged and are further back in the queue. BARKIN: Okay. Well, first of all— FASKIANOS: Pearl can jump in and clarify if she wants. BARKIN: Well, first of all, I don't know that we can call all members of the campus community privileged and elite. And I think that there is—but there is a good bit of concern about ensuring that there's equity in this distribution process. And so, I think that we're not asking for institutions of higher education to be placed above people, but that there be consideration for where you get the greatest mitigation effect from vaccinating different populations. We are—I would argue that it is going to be tough to penetrate underprivileged populations, populations of color, they—and that is part of the problem here is the, again, the messaging, the communication about safety, the outreach. There's a lot of work to be done to bring people to the table, especially communities where we know there is greater resistance historically to vaccinations, areas where folks are disadvantaged in a number of ways in terms of transportation and shelter. That is a big part of why they put essential workers in so early, because we know the folks who are essential workers, your grocery store employees, the folks who are serving us in fast food restaurants, there are a lot of minorities that are working in those capacities. Custodians, custodial staff. So, that was an attempt to ensure that we get people who are working in those types of situations covered. So it is a very difficult situation to maneuver. This is a complicated issue and nothing short of having a lot of vaccine and enough vaccine is going to remedy it. I can tell you even here—I am seeing a lot of frustration by people trying to—who now are qualified as sixty-five and older, trying to call in to get an appointment. Well, if I'm an economically disadvantaged sixty-five year old or older and I don't have transportation to a clinic that is an hour away, I may get the appointment, but I can't get there. Q: May I speak? BARKIN: Go ahead, I am sorry. Q: Oh, yes, I just had to unmute. I just wanted to—I thought it was important to raise this issue. So I teach at Tufts, and I am African American. Last spring, I heard that our university was trying to get this opportunity that you're talking about. And already, people were saying we're in a situation where this is a zero-sum game, limited amount of vaccines, the communities where the disease is in higher incidence, where you have a problem trying to persuade people to take it, quickly, the available vaccine is taken up. And so it's like the privileged people who know how to lobby and everything, they grab up what's available and then later on, somebody says, 'Well, that's too bad.' And then somebody else says, 'Black lives don't matter.' So I just wanted to put that on the table as we're thinking about this. BARKIN: Right, and if you– Q: And I will benefit from this policy. BARKIN: Well, I think if you—and you probably may very well be aware of this, but if you look at the CDC site under an ACIP site on how they made these determinations, the ethical considerations are outlined there. And many certainly speak to what you are pointing out. And it is a real, difficult, and complicated matter, especially when states are, at this point, not well enough resourced to address those issues. And we can say, 'Oh, yes, these populations should have access to vaccine and we should be able to educate them about the safety issues and certainly talk to them about public health strategies in addition to the vaccine.' But saying that and actually doing that are two different matters. It requires a lot of resources and our states have not been well resourced in that manner, nor has public health. I mean, public health in Georgia, we serve the folks who are those disadvantaged individuals that you are talking about. And for many of them, the transportation issues are overwhelming even to try to get to an appointment. How they access vaccines, how they can—whether it is online, some health departments have online forms. Well, you have to have a computer, you have to have adequate internet. And we haven't even addressed the issue of rural areas where internet capabilities are pretty compromised. So yes, I appreciate your comments and, as I said, the ethical considerations in that discussion is available online through the CDC. FASKIANOS: Thank you. I think we have time for one question. If you all are looking at the Q&A questions, there's some—Craig Klugman has put in there—people have shared what's going on in their communities. And Craig Klugman has cited an article, Inside Higher Ed, that talks about—I'm not going to click on it because I'll be taken out of this—but how faculty and staff outside healthcare fields become eligible for the vaccine, I believe. So I'm going to take the last question from Diana Newton, who is at Southern Methodist University in Dallas, Texas, who asks that you speak to the health risks to a campus community where the large majority are vaccinated, but a small minority refuse to receive the vaccine for a variety of reasons. And I wanted to tack on to that. I think in your presentation, you talked about asymptomatic. And what do we know really about if you get the vaccine and asymptomatic transmission? Because I think that there's not a lot of clarity around that. It may be there has not been enough—we do not know enough about it. So that would be great. BARKIN: We still do not know enough about that. I just was on a call with, as I said, with leadership in biologics at the FDA. And those three questions that I have in my PowerPoint were the three questions that they said keep them up at night. So they feel that the vaccine will handle the mutations, but they are not sure about the asymptomatic transmission. And when you talk about herd immunity, which is referencing the first part of this. What if we have students who get vaccinated and some who refuse to be vaccinated? What does it take to create a safe environment? I think that, without a doubt, we are going to be wearing masks and social distancing even after folks become vaccinated for some period of time until these questions are answered. What does it take on the herd immunity side? I've heard number percentages from sixty to eighty percent of the population, somewhere in that range, they feel that this rigorous surveillance, rigorous testing can stop. College campuses have set up these robust testing strategies which have been critical, I will tell you, in mitigating against outbreaks and identifying cases early on and containing those cases to a smaller number. And we are advocating for twice a week testing in terms of surveillance and certainly testing students upon arrival. But I think we are going to be in this cycle for a while until we get more experienced with a vaccine and the scientists can determine and our epidemiologists can determine how this is all playing out in terms of asymptomatic transmission and the effectiveness of the vaccine. How long we are protected. FASKIANOS: Well with that, Dr. Barkin, thank you very much for being with us and for your presentation. I have gotten a few questions about whether or not you would be willing for us to circulate it to the group because they would like to share it with their administrators on campus. So that's fantastic. And if there are any other resources you would like to share with me that we can disseminate to the group, we'd love to do that. BARKIN: Yeah. FASKIANOS: But it's really—thank you very much for this. This is obviously—it's changing quickly. BARKIN: [Laughs.] Yes, it is. FASKIANOS: And so we just keep on the news every day. And just as we discover more about this awful disease and how to deal with it. So we really appreciate it. And we hope that all of you will continue to follow us on @CFR_Academic on Twitter and go to CFR.org, ThinkGlobalHealth.org, and ForeignAffairs.com for resources on COVID-19 and much, much more on international affairs. So I hope you're all staying well, good luck with the beginning of your semester, beginning of 2021. And again, Dr. Barkin, thank you very much for being with us. BARKIN: Thank you. I enjoyed it and stay safe, everyone, out there. I'm happy to share the PowerPoint and any additional resources I think would be helpful. FASKIANOS: Thank you very much. (END)
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