In the Bubble with Andy Slavitt: Our Shot

What 11 Top Scientists Expect in 2022

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For this special end-of-the-year episode, Andy asked 11 of the top doctors, scientists, and thinkers to look ahead to 2022. They offer up their thoughts on the coming Omicron wave, what scientific breakthroughs they’re most excited about in the year to come, how much they expect we’ll have to modify our behavior in 2022, what the Biden administration should be focusing on in the coming year, and simply put, if 2022 will be better or worse than 2021. Plus, a conversation with CVS Health’s Tom Moriarty about fighting COVID in the new year and other health care advances we have to look forward to in 2022.

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Dr. Tony Fauci, Natalie Dean, Paul Offit, Dr. Mike Osterholm, Eric Topol, Dr. Lisa Fitzpatrick, Dr. Farzad Mostashari, Katelyn Jetelina, Andy Slavitt, Leana Wen, Peter Hotez, Dr. Bob Wachter, Tom Moriarty, David Agus, Dr. Celine Gounder

Andy Slavitt 

Welcome IN THE BUBBLE, last episode of the year, is your host, Andy Slavitt. Thinking back a year ago, what was going on a year ago, a year ago, we were beginning a pretty severe winter wave here in the United States. And we were also just getting the first vaccines into people’s arms. Now, we were all kind of thinking that that would be, hopefully our last holiday with COVID. Very, very much on our mind, and that vaccines could pretend the end of our worry over the pandemic. I even had an episode at the end of last year, with a number of people ranging from Anthony Fauci to Larry Brilliant to others, and said, what do we think 2021 will look like to play a little bit of that for you right here.

Eric Topol 

My prediction for 2021 It’ll come in like a lion, and go out like a lamb. From hellish to pre-pandemic-ish.

Leana Wen 

The first few months are going to be unbelievably difficult. But by the end of the year, we are going to have hope and positive change, and we’ll be approximating a new normal.

Dr. Tony Fauci 

By the time we get to the middle and end of the summer, we’ll have that proportion of the population vaccinated that we can really start thinking about returning to some form of normality.

Andy Slavitt

Now, what you just heard, that was representative from those couple voices, you just heard, everybody thought that we would start out bad in 2021 and get progressively better, and that by the end of 2021, we would be in really good shape. That’s not where we are. Newsflash, everybody was wrong. Everybody was wrong. So we’re gonna do it again, today, and we’re gonna ask a similar group of people to tell us what 2022 is going to look like. And you have reason to be skeptical. Because last year, Lena do so well. In fact, we didn’t really predict what was going to happen. I at the last year ago, was predicting that I was going to be spending the next year in California. I was wrong about that too. Lana and I were just getting up and moving a year ago, and it was about just after Christmas, that I got a call from the White House, disrupting my plans. Now, like history repeating itself, I talked to the White House again today. And I will assure you that this time, I was more effective in saying that I was not going to go back as much as I am loving and supporting of everybody’s work.

Andy Slavitt 

But we got a challenging situation with Omicron. And that’s what this episode is really going to start with. We have 11 of I think your favorite, smartest scientists. Dr. Paul Offit, Natalie Dean, Dr. Leana Wen, Dr. Peter Hotez Dr. David Agus, Caitlyn Jetelina, Dr. Celine Gounder, Dr. Lisa Fitzpatrick, Dr. Bob Wacher. Mike Osterholm and Dr. Farzad Mostashari. These are names that we all probably know by now, because they are some of the smartest leading scientists and voices they have all been out of the bubble before they’ve all been really many places. Some have advised in continue to advise policymakers, some are frequently on TV, many write books and write things. And I asked him each to respond to five questions. And they are the five I think toughest and most important questions that are on your mind. So we’ll dig into this with folks right now. And I hope it brings you the information you need to get through another concerning, challenging period. And then at the end, I will wrap up with my own views. Okay. Here goes. Question one. First question we asked. This group of scientists and physicians is to describe what we’re likely to see of Omicron in the US. When would a wave start? What’s the rate of spread and severity likely to be? And how long will it last? And we’re going to begin with Dr. Mike Osterholm. Who’s the director of CIDRAP. I don’t remember what that stands for, but it’s just called CIDRAP. It’s University of Minnesota. And then everyone else will introduce themselves and then we’re gonna go do the other questions. They’re gonna enter in the exam. same order, Michael, what say of you?

Dr. Mike Osterholm 

I believe that the Omicron wave has already started in the United States, the rate of spread will be remarkable. With it peaking likely sometime in early to late January. At that point, I believe case numbers would drop off precipitously is unclear how long will last, it’s very likely that Omicron could become the dominant variant, eliminating Delta as an important variant in the United States.

David Agus 

Hi, this is David Agus. Omicron in the United States is just beginning, it’s clearly in most states in the country, and going up at pretty significant rates on a daily basis. If we look at what happened in the United Kingdom, which has a higher rate of vaccination, than we do and a higher rate of booster shots, the doubling time enable it to be 40% of cases or so in several weeks, I think we’re going to see that here in the United States, where we start to see peaks in the first to second week of January, and hopefully we see declines by the end of January, beginning of February. The real question is, is the illness associated with Omicron significantly less or equal to what we’ve seen with other strains of the virus. And the transfer is we just don’t know yet. There’s some initial data at South Africa that certainly looks very encouraging in that regard. But there are some differences between prior COVID exposure in South Africa and here in the United States. And reporting is not 100% accurate. So we have to wait until we get data by the end of the week from the United Kingdom and Denmark.

Dr. Celine Gounder  06:37

This is Dr. Celine Gounder. I’m an infectious disease specialist and epidemiologist at the NYU Grossman School of Medicine, and Bellevue Hospital. And I’m the host of the Epidemic podcast, assuming we follow the same pattern as what we’ve seen in South Africa, that will entail a rapid spike in cases and then also a pretty steep decline thereafter, with a wave lasting maybe two months or so. So we’re looking at maybe an Omicron wave rising in December following towards the end of January or into February, with most of the Omicron cases in January, Omicron does seem to be even more infectious than the Delta variant and I think it’s important to understand that even if it turns out to be less virulent, so may be causing less severe disease in an individual who gets infected, if more people are infected, even with a less virulent strain, at a population level that can be just as deadly with just as many hospitalizations and deaths. With respect to severity. We’re still trying to sort this out. This really needs to be stratified by demographics. So for example, by age, and then also by immune status, you have some people who have never been infected, never vaccinated. You have some people who’ve been infected, and that was a remote infection early in the pandemic, or that was a recent infection. You have some people who’ve gotten one dose of vaccine, two doses of vaccine, three doses of vaccine. And then you have some people who have a combination of immunity from prior infection as well as vaccination. And we really need to look at how virulent Omicron is in each of those populations by immune status as well as by age. And we don’t entirely understand how it plays out in all of those groups. Among relatively younger people who have some immunity from prior infection or vaccination, it seems to be a milder illness. But we don’t have a definitive answer on how virulent Omicron is.

Paul Offit  08:46

Hi, this is Paul Offit. So Omicron is the fourth variant to come into this country, it appears to be more contagious. I think in all likelihood, what we’ll see is that in people who’ve either been naturally infected or vaccinated or both, at most, what they’ll experience is mild illness. For people who’ve been neither naturally infected nor vaccinated, there is certainly an increased risk that this would cause severe disease, meaning the kind of disease that causes them to seek medical attention, or go to the hospital or go to the ICU.

Leana Wen

This is Leana Wen we are at an uncertain time right now; we could very well be facing a twindemic of Delta and Omicron here in the US. Already there are parts of the country that are overwhelmed once again, with hospitals being at capacity or over capacity. And so there’s very little room for what happens next with Omicron. And I think that it’s difficult to prognosticate exactly what’s going to happen. But we have to remember that we’ve been here before, before holiday gatherings when the weather is colder, when people are going indoors. And we really cannot afford to have this happen again, especially because this time even more so than with any of our previous times, we have so many more tools than we did before. And that is the great tragedy of it all that we have vaccines, we have masking. And we have testing, which is something that we need to employ a lot more of, if we are going to figure out as we need to how to live with COVID-19.

Katelyn Jetelina  10:22

Hello, this is Katelyn Jetelina, epidemiologist at the University of Texas Health Science Center and founder and author of Your Local Epidemiologist, the Omicron wave has already started in the US we are seeing it exponentially increase as time moves on. Currently, the doubling rate is about two to three days, which is far faster than we’ve  seen with Delta other variants. And how long will the wave last? We have no idea. And we don’t know because South Africa’s wave hasn’t peaked yet, I think they will be the first data and to really see how wide this wave is going to be. Previous waves took about two months. But given the high RT, given the high rate of transmission, this wave will probably be a whole lot less than and then two months at least, that’s what I’m hoping

Dr. Farzad Mostashari

This is Dr. Farzad Mostashari. With my predictions for 2022. I think we’re likely to see with Omicron, a very, very rapid increase in cases and a somewhat less rapid increase in hospitalizations and following unfortunately, deaths. But a very sharp spike up in probably a pretty quick peek in maybe February, although it’ll spike in different communities in different times. And then coming down pretty quickly after that. But I think it’ll really rip through a lot of, in particular, the non-vaccinated populations in the US. I hope that some of the preliminary data we have on it not having a higher in fact, potentially lower-case fatality rate to hold, in which case, it might actually end up being over the long run something of a blessing in disguise delta to delta, essentially suppressing worse, more lethal variants. Because it is so incredibly catchy.

Natalie Dean  12:46

This is Natalie Dean from Emory University; the Omicron variant has a clear capacity for explosive outbreaks. So when we think about when a wave could start, I think it could start very quickly. We know the viruses here and circulating. And so depending on when a first introduction occurred to different regions, I mean, different regions will have different timing when an outbreak really starts to take off. But I think it’s clear that things can change very quickly. And that’s why we’re watching the UK to see what’s happening there. That will be particularly important for seeing what happens with respect to severity. We don’t know what the virus will look like in a population where there’s a fair amount of vaccination, although the UK benefits from even higher vaccination, particularly among the vulnerable than we do in the US. So we’ll have to see as for how long it lasts. I mean, there’s some things we still don’t understand about Delta, about how Delta waves increase and decrease. And so I don’t want to speculate on what we’ll see with Omicron there.

Peter Hotez 

This is Dr. Peter Hotez. Well, I was hoping we’d be in a better position than what it looks like. The hope was from South Africa, it wouldn’t be reproduced in Europe or the US. But unfortunately, seeing what’s happening in the United Kingdom right now. I think we have to assume that we’ll see something similar. So this was true of Alpha, this was true of Delta. It’ll be true of Omicron. Historically, it’s been about a four to six weeks delay. And so I think we can expect another Omicron surge, it seems to be out pacing delta in the UK. I don’t know if that’ll happen or happen right away. So I think we’ll see a twin epidemic, at least for a few weeks, and this will all then presumably start up in January. And one of the things that I’m worried about, Andy is the fact that this will be a time when many of our health care providers have waning immunity, even after their third immunization based on some data we’ve seen in Germany, so I’m worried and fearful that we’re going to have to think about the possibility a lot of healthcare providers are going to become ill with symptomatic COVID. And I think we need to think about a fourth immunization.

Dr. Lisa Fitzpatrick 

Hi, this is Dr. Lisa Fitzpatrick, you’ve heard me before on IN THE BUBBLE talking to people as Dr. Lisa on the street. I think the wave has already started. The problem is we are always so behind. So by the time we recognize these variants, they’ve already been circulating for a long time. So we found out about this because the South Africans sequence the virus and we don’t have this capacity everywhere. So the more we look for it, the more we’ll find it. So I suspect there’s way more Omicron out there. Van we know about what gives me hope about that, though, is that we have not seen a drastic increase in hospitalizations, are deaths, sure some of the hospitals are filling up. But these are mostly unvaccinated people still would suggest to me that Omicron is not more virulent. Even though it’s seems to be more transmissible, it doesn’t seem to be making people sicker, or killing people, which is the great news.

Dr. Bob Wachter  16:30

Hi, this is Bob Wachter, Chair of the Department of Medicine at UCSF and ex interim host of IN THE BUBBLE. Obviously, it’s hard to know for sure, but the spread is so fast. And the doubling time is so short that it looks like we’ll begin to see the impact of Omicron in the US in late December. But the full brunt of it won’t come until mid to late January. There are some early indications that it may lead to a big rise in infections and then peak and fall. It’s really twice as likely to infect people as Delta, which is what it’s looking like right now. Many people will catch it in January and February. And it might burn itself out as it strikes most vulnerable people we’re beginning to see some evidence of that in South Africa. The trick, of course, is parsing different types of vulnerability. unvaccinated, uninfected people and there aren’t that many of them left are the most vulnerable, the least vulnerable will be those who are fully boosted and or fully immunized. And I’ve also been infected previously, folks who have gotten quote, fully vaccinated and quote with two shots of Pfizer, Moderna, or one shot of J&J. There’s somewhere in between vaccinated and not vaccinated or protected, not protected, and they are increasingly vulnerable. The question, of course, will be how severe the illness is, and it’s looking like it may be somewhat less severe than Delta, but maybe not enough to make up for the very large rise in cases.

Andy Slavitt  18:22

Alright, question two, same group, same order, what will be the big scientific developments of 2022. Consider vaccines, boosters, therapies, etc. Start again, with Mike Osterholm.


Dr. Mike Osterholm 

In my mind, the most important scientific development of 2022 that we must have been improvement on vaccines, and particularly in terms of long term and durable immunity. studies addressing that and pan coronaviruses, vaccines in general, will be a very important part of this next year’s research agenda.

David Agus 

Well, the first is going to be the introduction of the Pfizer drug. So it’s not a perfect drug and that its bioavailability is challenged. But the data today really looking couraging and that you’re seeing a 90% reduction in serious illness and hospitalization and people who take it within five days of symptom onset. And that’s a pretty dramatic result that will make everybody shoulders come down in the country, because we’re going to be able to effectively block hospitalization and that’s what we’re worried about. Hospitals fill up, care begins to decline significantly, and the outcome is worse among COVID-19 patients. And also obviously other diseases, cancer, heart disease, etc, are ignored. And so I think the big advance will be that secondarily, we are obviously have plenty of vaccines at the present time. And the question is going to be the booster campaign at that point. And that I think remains to be seen.

Dr. Celine Gounder 

I am hopeful that we’ll make headway in 2020 To on developing a pan […] virus or pan beta Coronavirus vaccine that would protect us against all of the SARS-CoV-2 variants currently in circulation, or that might arise emerge in the future, as well as other beta corona viruses like SARS, and MERS, and others that might also emerge in the future.

Paul Offit  20:22

I think the biggest scientific accomplishment would be a vaccine that is given by the intra nasal route, because that kind of vaccine would be much better able to prevent mildly symptomatic disease over a longer period of time and therefore decrease shedding to a much greater extent than vaccines that are given as a shot can do.

Leana Wen 

Vaccines are undoubtedly the biggest scientific development of 2021. I believe that for 2022, we will see a combination of the following that will allow us to better live with a pandemic. First we need to have vaccines available even for younger children. Children of my kids age, ages one and four, really need to get vaccinated to so that their families can return to some element of pre-pandemic normal. In addition, therapies, especially oral treatments will be important for us to learn to live with this Coronavirus to reduce the risk of it being something that’s existential to something that we can manage. And finally, testing. We know that vaccinated individuals, even people who have had boosters can still get infected with COVID, the risk of doing so is much lower, however, to really be sure, adding testing as an additional level of protection, additional layer of protection needs to be essential.

Katelyn Jetelina

You know, I think there’s going to be a ton of discussion, a scientific discussion over the need for an Omicron specific variant vaccine. And I’m not convinced yet that we’re going to need one, that doesn’t mean others are not. And so I really look forward to that scientific discussion. I hope that more therapies come out, we just got some really great news about the Pfizer anti-viral. And so I’m hoping more will come out, because we could really use all the help we can get right now with this. Winter season and early spring.

Dr. Farzad Mostashari  22:16

In terms of big scientific developments, my hope is that we will be able to scale up production of the small molecule pills. So the Pfizer drug that is shown to be almost 90% effective at preventing hospitalizations and deaths. that’s those are the kinds of things that I think can make a huge difference to really reducing the impact that the virus will have on society and on preventing hospitals from being overwhelmed, which is the big, big, big fear that I have.

Natalie Dean 

There are several things that we’re watching for we’re excited about the potential for Pan Coronavirus vaccine, the potential for inter nasal vaccines, those may take some time to develop. In the meantime though, I’m most interested in variant specific boosters like an Omicron specific booster, what that process will look like, how quickly those can be turned out. And then whether they provide some sort of real advantage over a traditional booster. We know that with a traditional booster, what we’re seeing is some potential for a broader form of immunity, better immunity than a second dose. So both in quantity, but also in really the quality of protection. And so whether there would could be a further advantage if you had a variant specific booster. The other scientific developments I’m interested in really relate to understanding what combinations of vaccines work best. We have now, different combinations different original doses, and then different boosters, different timing between these different doses. And so you know, from Moderna, they’re using half dose booster then they use for the primary series. And so really sort of narrowing in on what combinations of things work best. I think there’ll be a lot of insights there that that we can use moving forward.

Peter Hotez  24:24

Well, I have a natural conflict of interest. We’re accelerating our recombinant protein COVID vaccine for global health. And we have some optimism that it’ll be released for emergency use authorization in India fairly soon. And when that happens, the Indian government has made a commitment to do advanced purchase of 300 million doses. So our Texas Children’s Center for vaccine development which is co-headed by myself and my science partner for the last 20 years Dr. Maria Elena Bottazzi are quite excited that this could be one of the major vaccines used to vaccinate the sun Southern Hemisphere, the low- and middle-income countries in Sub Saharan Africa, Southeast Asia and Latin America. And this could be the vaccine that really helps close the gap. We’ve also, this is done through biological II in India. But we’ve also licensed technology to the big vaccine producers in Indonesia, Bangladesh, and now a new one in Botswana. So we’re hoping to really make a difference.

Dr. Lisa Fitzpatrick

Well, I think the scientific developments of 2020 and 2021 have been pretty remarkable, with now new drugs to treat COVID-19. And vaccines, I mean, vaccines for COVID-19. This is the medical breakthrough of probably the century the fact that we were able to produce these vaccines so quickly, when none of us thought this could be done. Like that’s a big deal. And I don’t know that 2022. We’ll see anything quite as drastic,

Dr. Bob Wachter  26:00

I think the rollout of the new Pfizer, antiviral will be a very big deal, particularly if it doesn’t lose any efficacy in the face of Omicron. And it’s looking that way right now. If we can really take high risk people who are infected and lower their chance of hospitalization and death by 90% safely, that’ll change the dynamics of the pandemic, it will really should lower the risk of severe illness. And at that point, we will need to really follow hospitalizations and deaths more than we follow cases. But we’re not there yet. And the drug is not out and approved, and there’s going to be supply constrained in the short term. And giving people that medication is not trivial. We’re going to need better access to testing, to doctors, pharmacies, and to the medication which is going to be in short supply for the first several months. None of those things are assured. But that’s the thing I am most excited about, at least for the first half of 2022.

Andy Slavitt

All right, we’re back with question three. Question three, is how do you expect you and your families behavior to be modified? If at all? In 2022? In what do you recommend for others? Start again with Mike Osterholm.

Dr. Mike Osterholm 

If in fact Omicron moves through the population quickly, as I suspect it will, I think the primary modification, our families behaviors will be that associated with the next month and a half. At that point, it’s very likely that should Omicron pass through our communities and develop what that best will be a low-level endemic rate of transmission. I think many of our behaviors will go back to that of pre-Omicron and particularly pre-COVID. In general. That also means that we will continue to remain vaccinated.

David Agus 

You know, 2022 is going to be an era of where we’re invading each other’s personal information. You know, right now, I, myself and my children, we are getting together with friends who have been vaccinated and who have had boosters. So asking people, have you been vaccinated? Have you had a booster critical? The role of the antigen test at our Thanksgiving dinner this year, we did antigen tests on all of the family that came right before they came in the house. So we were able to have some degree of certainty that there was low risk to these exposures. And I think more and more, we’re gonna have antigen testing as part of our routine for get togethers here in the United States.

Dr. Celine Gounder  28:36

I think much of how our behavior may be modified over 2022 will depend on how much community transmission we see, in the coming months, whether Omicron comes to dominate over Delta or not. And that’s not entirely clear at this time, if Omicron turns out to cause only very mild disease, like the sniffles like a common cold among people who are fully vaccinated and boosted. And if those breakthrough infections among the fully vaccinated and boosted are also shown not to be very transmissible onward to others, we may well relax some of our behaviors. But I think some of those factors remain to be seen. I think there are two reasons to wear masks and to use some of these other mitigation measures, one of which is to protect ourselves and then the other is to protect others against us. Should we be perhaps unbeknownst to us carrying the virus? And so I think it’s really important to determine whether the Omicron variant is virulent or only causes mild disease in individuals but also, if you are double vaxxed and boosted and you have an Omicron breakthrough infection, how likely are you to spread that onward to others?

Paul Offit 

Well, certainly our family’s behaviors already been modified. We’re much more likely to go into a room with many people and knowing that they’re all vaccinated, wouldn’t wear a mask. But for the most part, whenever we’re in a large group of people, and we’re not sure that everyone’s vaccinated, we continue to wear a mask.

Leana Wen  30:11

Well, my family is still a mixed vaccination status family, and that my husband and I are fully vaccinated and boosted. But we have two young children who are still not at the age where they are eligible for vaccines. And until they are able to be vaccinated, my husband and I are still living with a lot of caution, not for concern for ourselves, but for concern for our unvaccinated children. So we are very much looking forward to having vaccines available for younger kids. So that we will be able to resume many elements of pre pandemic normal, including traveling, including gathering indoors, really without much worry with other individuals. Right now, we are able to gather with others, but we wouldn’t make sure that we’re tested in advance, we’re still being quite limited when it comes to our travel, because we don’t want to have to quarantine afterwards before seeing our own children. And those are the behaviors that we’re very much looking forward to not having to do anymore, once our children are able to be vaccinated.

Katelyn Jetelina 

So I think this is important to answer with some context, you know, my husband and I are fully vaccinated, which includes getting the booster shot, the challenges right now for my little family is that our girls aren’t I have a two-and-a-half-year-old and a 14-month-old. And so you know, our behaviors are going to be continued to be modified until they can get fully vaccinated, which is hopefully early spring. And so what that means is, they’re still going to childcare, but all their teachers are fully vaccinated, their teachers are still wearing masks inside. We try and be as careful as possible, you don’t go to crowded indoor areas with my girls, like, you know, we don’t go to indoor trampoline parks, for example. But we certainly go to the grocery store still. And do you know a little more of the moderate risk activities. But I think once they’re fully vaccinated, and we can start going back to normal, especially if we can get transmission down in the United States and I have not overwhelmed our hospital systems. But I think that really is to be determined.

Dr. Farzad Mostashari  32:21

I think in terms of our behavior, how that changes, basically, with virus variant that is this catchy herd immunity, fails, it’s no longer a realistic option. So I mean, another way to put it is, it’s really you share your concern, shifts away from society to yourself. My recommendation for others is obviously get vaccinated. If you’re not vaccinated, you know you really are, you’re gonna get it. And you know, better hope that that you’re not one of those who gets a severe case, the population that I’m most worried about in this scenario, are the at risk and immunocompromised. And I think where they are in residential facilities like skilled nursing facilities, we absolutely have to get them boosted as soon as possible. And it’s just unacceptable the slow rate. And you know, we messed that up once and up to 40%-50% of the deaths and early stages of this pandemic came from sniffs, we can’t repeat that. But those at risk in immunocompromised, the burden is really going to be on them, they are not going to be able to live normally for a long time, they are going to have to continue to social distance, to use strong masking. And hopefully we can get it to the point where if they do get infected, access to the effective drugs will be there for them.

Natalie Dean 

I’m not really sure what 2022 is going to look like. You know, I mean, I think when we last summer, we were feeling really good after all vaccines came out. But then we had delta and it really forced us to reevaluate some things about you know, what the future was going to look like. And I kind of feel like we’re at this same point where we have Omicron, and we’re really not sure what’s going to happen. But there is definitely you know, there’s a real capacity for things to go poorly, unfortunately. So when I think about me and my family’s behavior, we’re already reasonably cautious. I mean, we figure out what we prioritize in our life and that is spending time with family, spending time with close friends, but you know, we do that just sort of in one-on-one setting rather than going to a crowded restaurant or going to a crowded setting where we can, we spend time outdoors. But, you know, we’ve figured out what we prioritize and we’re willing to accept some risks. for that, but in general, I, you know, I’d expect things not to change too dramatically until I really until we really feel comfortable in our surroundings.

Peter Hotez 

It really depends on how this next big surge goes in January. And so for now trying to and home and with families surrounding myself, ourselves with individuals who are fully vaccinated. And I think that definition will change to three doses, we’ll see what happens about the need for potentially a fourth immunization and to be mindful and to continue to wear masks when we’re indoors.

Dr. Lisa Fitzpatrick 

We’ve been at this a long time. My concern is that people have just decided they’re going to learn to live with this. And it’s just a fact of life. So I don’t know that people will modify their behaviors. I think people have message fatigue. And when there’s a new variant, people just say, Okay, well, here comes another one. But I don’t know that there’ll be modifying their behaviors. In the case of my family, all of us are vaccinated, at least in my immediate family. So we don’t really have concerns because we’re mostly with each other. But we’re not in public or in places where we don’t know folks, we still mask and I think this is still my recommendation when you are around people. You don’t know You certainly don’t know their vaccination status. We should continue masking.

Dr. Bob Wachter  36:31

I expect to remain fairly careful, in part because I’m 64 years old and a little bit wimpy. And for me that involves things that really aren’t that big a deal. It mostly involves wearing a good mask, I’ve really switched to wearing at 90 fives when I wear a mask. This might change if Omicron proves to be much more mild than delta and it takes over as the leading virus. And or if the Pfizer or similar drugs make the possibility of severe illness much more remote, I might become a little bit more open to doing things. I’m still comfortable flying again with an N95. And whether I’ll eat indoors in a restaurant is totally predicated on the level of surge in a community, I will still do it in San Francisco, but probably will stop fairly soon if the cases go up and if Omicron enters our world and in a bigger way.

Andy Slavitt 

Question four what should be the top policy priorities for the Biden administration and other policymakers right now? Again, we’ll start with Mike Osterholm.

Dr. Mike Osterholm  38:03

The top priority for the Biden administration at this point must be determining how to respond to the Omicron variant, the transmission. What happens if we have a very large number of healthcare workers who become infected? And what is already a very limited and tight healthcare worker market. Will we allow them to continue to work if in fact, 10%-15% or even 30% of them are infected? But yet not seriously ill? I think this whole issue of how to respond to Omicron will be the most immediate and top priority.

David Agus 

I think is to continue the vaccine and the booster campaign. I think the transition of vaccines to physician’s offices is going to be critical. Physicians have interactions on a regular basis with patients and should be the advocates of vaccines, not the government to individual patients. So transitioning vaccines from pharmacies, large places into physician’s offices I think should be one of the keys. Number two is to increase testing and make sure that testing stays around throughout the year. That is antigen testing, make sure it’s available and inexpensive for individuals across the country. And obviously the new initiative to make it free as fantastic, as well as continue PCR testing. And the next is to make sure that the oral Pfizer drug has a broad approval label with the FDA and that this drug is available for anybody who has had initial exposure and I think the last one is to make sure that the AstraZeneca long-acting antibody is used in immune suppressed patients in this country. 3% to 4% of the people in this country are immune suppressed, for whatever reason, cancer, autoimmune disease, other drugs they’re on and they cannot respond to a vaccine. We have to get this to those individuals and will significantly lower their risk. And then I think that you know the vinyl is going To be just following to make sure and identify when we’re going to need a new booster shot.

Dr. Celine Gounder  40:04

I think one of the top priorities is around messaging and setting expectations that are attainable and realistic, but also appropriate with respect to public health, not just individual health. And I think that comes down to how do we understand and explain breakthrough infections. And this will very much depend on how virulent Omicron breakthrough infections turn out to be in different populations are the breakthrough infections we’re seeing among people who are double vaccinated and boosted? We’re seeing a lot of breakthrough infections among triple vaccinated people right now. Are these mild cases? Or are these people proceeding on to hospitalization and death and I think the public needs to understand that if it’s a mild breakthrough infection, that the vaccines are still working, because the primary purpose of the vaccines is really to prevent severe disease, hospitalization and death, if they continue to do so despite breakthrough infections. That does not mean the vaccines are not working. The public should be prepared for breakthrough infections, particularly with the emergence of Omicron.

Paul Offit 

I think the single top priority is to figure out a way to vaccinate the unvaccinated we cannot give up on this. I was working in the hospital, Children’s Hospital Philadelphia last week, and we admitted many children to our hospital with COVID. Virtually all were over five years of age, some had to go to the intensive care unit. And what all of those children had in common was that none of them were vaccinated, even though they could have been nor were their parents vaccinated, nor were their siblings vaccinated, we’re not going to boost our way out of this pandemic, we’re going to vaccinate our way out of this pandemic. And until we figure out a way to do that, we’re going to continue to suffer.

Leana Wen 

One thing that the Biden administration needs to focus a lot more on is testing. We’ve been saying this since the very beginning of the pandemic that this was in many ways our original sin. This was what the administration, the previous administration, the Trump administration did not do nearly enough of and in fact, they actively downplayed testing. Well, I wish that the Biden ministration would put as much effort into testing as they have around vaccination. They’ve done such a tremendous job with increasing vaccine supply with getting distribution out. But unfortunately, we have not seen them put the same effort. When it comes to testing, we need to get to the point where there is testing rapid testing at home testing available to all Americans, at least twice a week, so that it becomes the norm for kids to be tested before school, employees to be tested before work, for people prior to and during conferences and after get togethers to get tested for friends before getting together for dinner to get tested, we need to get to that level in order for us to truly manage COVID-19 risk, especially as we will be living with this for the foreseeable future.

Katelyn Jetelina  42:57

So if I were advising the Biden administration, you know, I really like how they’ve gotten on top of boosters. And a little bit of testing, I will say that I was very disappointed the Biden administration, the biggest reimbursement program was through insurance. And that’s really missing still the underinsured and uninsured, those that actually probably need access to free testing more so than the uninsured people in the United States. And so I’d really love to see a big push towards accessibility to rapid antigen testing for everyone for Health Equity purposes. I think that I would love to see also more […] into masking inside. You know, vaccines are fantastic, but it’s very clear, we’re not going to vaccinate ourselves out of this pandemic. Just you know, a 60% vaccination rate is just not good enough to do that. And so we really need to marry vaccines with other public health mitigation measures.

Dr. Farzad Mostashari  44:03

Top priorities, as I mentioned, skilled nursing facilities and ramping up production of the medications and boosters.

Natalie Dean 

So among the top priorities, rollout of rapid testing, making sure that is accessible, that just seems extremely important when you look to other countries and how things are going in other countries in terms of availability of, you know, the ubiquity of rapid testing. That’s definitely something that people could be more aware of and can be more accessible to folks and just sort of really integrated into our daily lives. Increasing vaccination coverage is an obvious one, I think increasing boosting and accessibility to boosting, using text messaging, really reaching out to folks, you know, partnering with community organizations and making sure that people are aware of the benefits of boosting and that made accessible to them. I think also clear communication in a situation where things are evolving so quickly, and there’s a lot of uncertainty. And so prioritizing communication with the public about what is the incoming evidence? You know, how are we making sense of that? And how does that affect our daily lives. So just more open, clear communication.

Peter Hotez 

I think getting our arms around the Omicron surge and getting some clarity on what’s going to be needed, especially around the need for fourth immunizations, how we’re going to handle the surge on hospitals and avoid a collapse on health systems. And finally, a more coherent plan to vaccinate the world. We have a plan at Texas Children’s Hospital, we’re going to be provided 300 million doses, it’s actually more right now than the Biden administration has given out. So it’s not that we’re so wonderful. We need the US government to come up with a more cogent plan for vaccinating the world.

Dr. Lisa Fitzpatrick  46:06

I’m not the person to answer this question, but I’ll tell you what I hope are their priorities. Number one, equal access to treatments and testing. So these new medications that have been approved to treat COVID-19, I hope this story doesn’t play out similar to monoclonal antibodies, where we saw disparities in access and awareness about the treatment. So when these medications are made available, I hope they are either covered by the US government or mandated to be covered by all health insurers, including the Medicaid program. But there also needs to be an awareness campaign to let people know these treatments are available, with respect to testing. This is to me this is our biggest failure throughout the pandemic. The fact that we don’t have convenient ready access to free rapid testing is a public health failure still, because this is how Coronavirus continues to spread people don’t have easy access to rapid testing. So if I had to prioritize the treatment access versus testing, testing would be number one, number two and number three in helping people understand how to access testing and why it’s so critical that people identify Coronavirus infection.

Dr. Bob Wachter 

The problem is that her lots of priorities, they have to try to do everything they can to get everyone possible boosted. They have to cement the legal position of mandates. Unfortunately, lots of organizations that were moving in the direction of mandates which clearly work have lost some of their courage. As the courts have been wishy washy on the legality of mandates, I’m hoping that we can use mandates that’s an important and in some ways, the most reliable tool to get people vaccinated and boosted. And maybe the hardest thing of all is we have to convince people that this thing isn’t over. And that a lot of people will die unnecessarily if we don’t continue to take the virus seriously. Obviously, pandemic fatigue is very real and very natural. But we’re still losing over 1000 Americans a day and Omicron could make that substantially worse. And so despite the fact that people are fatigued, it still is a killer. And we still have to do everything we can to try to stay as safe as we can while trying to get back to the things that give us joy and purpose in life.

Andy Slavitt  48:45

Question five, this is the hard one. Give me a one-word answer. 2022 better or worse than 2021? Starting again, with Dr. Mike Osterholm.

Dr. Mike Osterholm 

I think it’ll be better than 2021.

David Agus 

Better, better, better. Thank you very much.

Dr. Celine Gounder 

Better. I can’t imagine 2022 being worse than the dumpster fires of 2020 and 2021.

Paul Offit 

Better. Thank you.

Leana Wen 

Absolutely better. Alright, thanks

Katelyn Jetelina 

better. Alright, thanks, guys, bye.

Dr. Farzad Mostashari 

2022 is going to be better than 2021. I think most people are going to live mostly normally after this wave rips through and comes back down in Q1. That’s my hope. Thanks.

Natalie Dean 

I gotta say better because I’m an optimist. It does feel uncertain, but I have to help for better. Yeah. Okay, that’s all I have. Thank you.

Peter Hotez 

Hard to answer that in a single word. I think we clearly have far more technologies than we’ve ever had before. But we have a lot of challenges. So I’ll say better, but with a pretty big couple of asterix, so thanks so much for this opportunity, Andy and team and wishing all the best for the holidays. And it’s been a real honor to be working with you this year and throughout throughout the pandemic. Thank you

Dr. Lisa Fitzpatrick  50:18

Better. Definitely better.

Dr. Bob Wachter 

Worse than better. I’m sorry, that’s three words, but I think it will be worse for the next four to six months. And then the second half of 2022 may well be better. But I think all of us stink at predictions. When it comes to COVID. It’s just shown us its ability to throw all sorts of curveballs we can’t anticipate. So that is the problem.

Tom Moriarty 

I’m afraid it’s going to be worse.

Andy Slavitt 

Boy, that last voice familiar to us, kind of the party pooper of the bunch Tom Moriarty, CVS Health, I gotta tell you, like, I kind of admire Tom’s answer. Let’s say I agree with him, but I might admire it. And that I kind of sense listening to the others, that some of them really did want to say worse. They kind of bit their tongues, or seemed to bite their tongues and say better almost as if not to curse us. But I don’t know, I don’t think he curses. I think we everybody said last year, things will be better. And they were worse. So maybe if Tom says things ought to be, are gonna be worse, maybe they’re gonna be better. I don’t know. I really recently had one of our on-mic chats with Tom, and actually wanted to be able to let you listen into that. We discussed some of the new developments in the fight against COVID. Some of the things that people I think are trying to get to happen at the pharmacy level, the test the therapies and what that’s going to be all about. So let me read that. And then I want to wrap up with kind of my own view on the questions that we address today.

Andy Slavitt 

Okay, how are you doing, man?

Tom Moriarty  52:00

I’m good, how are you?

Andy Slavitt 

Good. Excellent. Well, let’s get into this. You obviously have so much to do with how we work ourselves through these various challenges that come our way. The latest challenge, of course, is called Omicron. And I’m curious if you could take me through your thinking about Omicron And how, you know, when it first hit you, what rates is through your head in terms of how do we have to respond as an organization.

Tom Moriarty 

And so obviously, a lot of time being spent on that, Andy, and it’s great to be with you again, what we’re focusing on is clearly how quickly the variant is spreading. Who came out talking about how it’s the fastest spreading variant that they’ve ever seen. It’s now in some 78 countries already. And if it’s not identified in the country, it probably is there already. They just haven’t identified it yet. For us, the biggest issue is, as I think for most folks, is the efficacy of the existing vaccine protocols. And you’ve seen Pfizer’s work and some work coming out of the UK that talked about the first two shots, maybe not being nearly as effective as you need it to be. And the importance of getting that booster.

Andy Slavitt 

I’m really glad you pointed that out. We have about 26%, about just shy of 50 million people who’ve had their third shot. And, you know, I think the hard thing to make sure people understand is exactly what you said, which is what you felt like you needed two shots a couple months ago really needs to be three shots. Now that we have Omicron. So when you think about the readiness that you’ve got to have, and the access to booster shots, etc. How are you feeling about the ability people who want to know like, Okay, I want to get a booster. Can I get one?

Tom Moriarty 

There’s plenty of supply. So supply is not an issue. Obviously with the amount of folks now who needs to be boosted, you do need to plan ahead. There clearly will be boosters available for you but plan ahead because we’re doing now, almost 2 million vaccinations a week within CBS and the role of Pharmacy here are not just CBS but all pharmacy I think is one of the underappreciated things coming out of the pandemic. And hopefully something will focus on from a public health perspective going forward. But there’s plenty of vaccines, plenty of availability, and you know, just need to schedule your shot and get it done.

Andy Slavitt  54:35

Yeah, I mean, I’ve been reading estimates that we could be seeing a million cases a day at peak. Look, the good news is my mind. We have the tools if we use them. We have vaccine boosters, we have rapid tests we have coming therapeutics, we have better surveillance, we have indoor air ventilation. But if we don’t use them if they sit on the shelf, then winter 2022 Feels a lot liquid or 2021. If we do use them, it could be profoundly different.

Tom Moriarty 

Oh, yeah, I mean, just look at the data this morning for Pfizer, the updated data on their antiviral, it’s close to 90% effective in preventing hospitalization and death, if taken at the right time. To your point, what that means is, you have to start taking it within three days, I think of your diagnosis, yeah, well, we need to make sure that these products are available, and available quickly for those who need it. And that they get tested and they start administering the product right away. There’s a lot of infrastructure associated with that, that, you know, is still being worked through by the administration and others at CDC. And our hope is obviously that the leverage pharmacy again, they should, and not go back to, you know, to the States into the counties and using, you know, 10 sites and that kind of thing. But these are all things we really have to plan for and get out there. Because when that Pfizer product gets approved, there’s going to be significant demand for it almost right away.

Andy Slavitt  56:06

Can you see the world where CVS sets up a kind of it, your testing facilities are where people get ready to rapid tests or get tests on site, and then can get some telemedicine access to get a prescription to say, the Pfizer drug so that like, you can have a one set process as soon as you get your positive test, you can you can get a script.

Tom Moriarty 

That’s exactly what we built out. So we’re ready to go in terms of, you know, coming through the drive thru for, you know, a rapid PCR, so not the swab, but a rapid PCR coming into a Mini Clinic, and then also doing the virtual visits, do the evaluation to make sure you’re meeting all the criteria established for and then get your drug right away. So we have the protocols built, we’re ready to go, we just need to work through with the administration to get on the approved list.

Andy Slavitt

So beyond Omicron, COVID, had major impacts across the healthcare system. It’s had a big impact on providers, physicians, it’s had a real impact on nurses is I think we’re seeing a lot of people leave the profession. And it’s interesting, we had your colleague Sree Chaguturu on the podcast, talking about, among other things, virtual care. And he said that, based on the data that he saw, about 38% of behavioral health visits went virtual in 2020. Do you see that as a permanent shift? And do you see other types of care being able to move to that model?

Tom Moriarty 

I do, Andy, and you know, once that I’ll give you his iqvia, which is that the data resource tracking company, I looked at a report that they put out last week and the year over year, progression of telehealth from 20′ to 21′. It’s up 17%, again, in 21′. So clearly, there has been a movement to this, and there’s been a consumer preference for it as well. It will drop down once, you know primary care practices and regular health centers reopened fully, it will drop down. But I think it’s going to be a staying power associated with that as we go forward. And it’s going to be an important element of extending care into communities, whether underserved or rural or elsewhere. That’s going to be an important component to solve for that.

Andy Slavitt  58:31

So do you think we’ll come out of COVID or come out of the emergency stage of COVID, If I’m more precise about it, with a kind of a new awakening and understanding of health disparities, social issues, mental health? It’s sort of de-institutionalized care, as you talked about?

Tom Moriarty 

Yeah, I think listen, clearly, the pandemic highlighted the social disparities and economic disparities, we have an access to health care. And I think we as a country have done a great job in addressing that. I mean, over 40% of the vaccinations that we’ve administered, we have done in underserved communities and been very focused on that.

Andy Slavitt 

Say that one more time, I think people have a tough time even believing that, just say that again.

Tom Moriarty 

So over 40% of all the vaccines we’ve administered for COVID have been in underserved areas as defined by the CDC. So we have had a real focus on that health equity portion of what we’re doing. And I do think that we’ll survive coming out of it. There’s an awareness and an awakening, that access to care is real. There’s real need in these underserved communities. And there are different solutions that we can bring it to them and models that we haven’t frankly models that others have to help solve for that issue.

Andy Slavitt 

Final question is, you know, if you’re giving people advice, who are listening on things to do to best protect themselves, their families, their communities, when it comes to both COVID and then the rest of the health care that they might need for the families. What would be your grounding advice?

Tom Moriarty  1:00:07

On COVID, we’re kind of going back to the future where we started, okay, mask, wash your hands social distance, get vaccinated get boosted, you have to do that. And then more broadly is don’t neglect or defer other health care needs because of COVID. There are ways to access care safely, to see your primary care doctor to see follow up on the specialist, oncology care and other things. We can’t have another year of deferred care, because the impacts not just to the individual’s but to the healthcare system overall, I think could be catastrophic. So don’t defer care. Take care of yourselves and find the care that you need.

Andy Slavitt

Okay, thank you, Tom. And thank you to everyone, Paul, Natalie, Lena, Peter, David, Katelyn, Celine, Lisa, Bob, Mike and Farzad, thank you all. And thank you all for all you do. I think he said you’re heard some harmonizing around a set of opinions. You know, it feels to me, like we are really hearing that we’re going to see a wave that is already underway, but likely because of the rate of spread, to come at us awfully fast. And I think the implication of that to me is twofold. One is very troubled about the state of the healthcare system and hospitals in the first part of the year, if this crash all happens at once, I think happening as it will, on the heels of the holidays happening if it will, at a time when people are tired of the pandemic and paying attention to it, will mean that we could be in for some tough times in January. But I think what we’re also hearing is things that grow very fast, are likely to come down very fast. And, you know, this thing could peak in the third week in January. And we could find ourselves, you know, hospitalizations peaking in February, and really starting to see things drop in different parts of the country and probably dropped quite quickly. So in a good case, in the bubble listeners, we could be coming into the February, March month with some really positive things vaccines for kids 0 to 5, the new Pfizer therapeutic, which I think will be in short supply, but more and more available, more rapid tests and possibly a high level of coverage from either vaccines and boosters, or even from people who are infected by Omicron, we can hope, we have to hope that it’s not as severe as people might think, or even that it’s less severe.

Andy Slavitt  1:02:52

And we could hope that, you know, that gives us more coverage. So I think that’s really what’s in store for us, good scientific developments, for sure. Which I think we’re going to need because people are tired of going through all of this. And I think we will all find the right balance; I’m assuming and hoping over the course of the year in our own kind of behaviors and modifications and so forth. I really hope that the Biden administration, when I think about priorities, continues to play it straight with folks, maximizes global vaccinations, and really focuses on getting rapid testing therapeutics out to the public. If we do all of those things, then my answer is yes, 2022 can be better than 2021. But like everybody else, let’s get through a day at a time. I really appreciate all of you being with me on the show all year. I really appreciate by Wachter for taking these duties on the mic in the first part of the year when I was in the White House. I really appreciate Kryssy Pease and Alex McOwen for making the show as great as they make it. And again, to all the people out there who are working to deliver a better result for people who are living through these really challenging times. So grateful and so glad we could be a part of your lives. I got a couple of more episodes over the course of the year that you’re going to hear and some great episodes to start the next year.

Andy Slavitt  1:04:27

Let me just tell you what those are. Before we get out of your hair, you’re gonna hear me on OUR AMERICA with Julian Castro, and you’re going to hear me on another show called I’M SORRY. And you’re going to see how sorry, I really am. You’re also going to get to hear some of my extended conversations with Sanjay Gupta and Ed Yong, the great journalist, so hopefully you’ll find that to be interesting. Then in January we come back with more podcast episodes of in the bubble Yes, we are making it in 2022, our first episode is going to be with David Agus. You heard on the show, and we’re going to have Jon Favreau up and coming on the show. I’ve been teaching John in the podcasting business so I think that’s gonna be good. I think he’s taking my tips. I think he’s gonna do quite well with that. Happy New Year. Love, Peace and Happiness to you and your family.


Thanks for listening to IN THE BUBBLE. Hope you rate us highly. We’re a production of Lemonada Media. Kryssy Pease and Alex McOwen produced the show. Our mix is by Ivan Kuraev and Veronica Rodriguez. Jessica Cordova Kramer and Stephanie Wittels Wachs are the executive producers of the show, we love them dearly. Our theme was composed by Dan Molad and Oliver Hill, and additional music by Ivan Kuraev. You can find out more about our show on social media at @LemonadaMedia. And you can find me at @ASlavitt on Twitter or at @AndySlavitt on Instagram. If you like what you heard today, please tell your friends and please stay safe, share some joy and we will definitely get through this together.

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