Your Top 10 Questions for Biden’s COVID Coordinator (with Dr. Ashish Jha)

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You asked, we answered! Andy asks Dr. Ashish Jha, current White House Coronavirus Response Coordinator, the top 10 questions submitted by listeners, including our overall risk levels, what’s next for vaccines, how to diagnose long COVID, and minute by minute timing of the approval process for young kids. He explains who’s still dying from COVID, predicts when waves will hit different parts of the U.S., and breaks down the best therapeutics.

Keep up with Andy on Twitter @ASlavitt.

Follow Dr. Ashish Jha on Twitter @AshishKJha46.

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Andy Slavitt, Dr. Ashish Jha

Andy Slavitt  00:18

Welcome to IN THE BUBBLE. This is your host, Andy Slavitt. It’s Wednesday, May 11th. Ashish Jha is on the show today. Ashish has been on a couple times before but not in his official capacity as White House COVID Response Coordinator in the Biden White House, Ashish have been there for about a month. If you’ve listened to show before he’s been on a couple of times, it’s been great guest very honest, very straightforward. We were all very happy when he was selected to go in to this job had been out to the West Wing to meet with him when he joined, help him on board a little bit, not that he needed it. But at least I know where the men’s room is. And now he does, too. He has been engaged pretty deeply. And we’d set to do for this show was go crowdsource your questions, the top 10 questions you have right now about policy about where we’re going about the pandemic. He is the center of it all. He actually was kind enough to also tweet out send into your questions, because I think he will use this as a home base place where he’s going to share everything he knows he does his best to answer questions, then we go to everything from what’s going to be next with the vaccines to vaccine for kids zero to five, to focus on long COVID to what’s going on with packs COVID to what’s going on with Congress funding to how can we tell about risk areas to the court case that stopped the masked mandate. So we go at it pretty hard. I try to be pretty efficient, because it’s the middle of his day. It’s also your day, I don’t want to take too much of your time, either. So we’ll get to that in a minute. I thought I’d just spend a minute responding to some of the feedback on the Deborah Birx episode, which played Monday, if you haven’t heard it, and you want to listen to a really intense interview about what went on in the Trump years and her view of things and my pressing her on it. You should if you don’t want to hear that kind of thing.

Andy Slavitt  02:09

Because you heard it enough. That’s understandable, too. We got plenty of episodes for you. But it was a fascinating interview. And I thought I’d respond to some of the feedback I got, you know, there was some criticism that we got, which was, hey, why have her on in the first place? Why help her with a rehabilitation tour or sell books or however you want to put it? Very fair question. You know, I think my view is, I want history to record, not just what her book has to say. But as much as I can do a good job as I can do to press her on areas that have when I think it’s worth doing worth making sure we listen to I don’t think quite honestly, she’s selling a lot of books to her audience on the show. But if people wanted to buy her book, of course, they could do that. But that’s I don’t think she got quite the rehabilitation tour she was looking for. And I think it looks just like when we had on Facebook and the middle of all of the things going on and misinformation and disinformation of which they own a part of, it’s important to be able to target these guests. And hopefully I do my part and ask good questions. But we’ll get to that as well. You know, I think the next sort of question is exactly that. You know, when she’s on? How did she do? And how did I do? Look, I think it started with this, I think she’s a complex person. I think there are a couple of dimensions to her that are worth people knowing about namely, that for decades before she joined the Trump administration White House, she was a very serious aids researcher in Africa, a very serious scientist is not a very political person. So I think that that is important to bring out. And then you know, in terms of how she did on the podcast, what she has to say about herself, look, I wrote about her pretty extensively in my book Preventable, I don’t think she escapes responsibility, or should escape responsibility. She was actually there when things were going down. And there were some pretty insane moments.

Andy Slavitt  04:07

Now you can ask the question, hey, should she have quit in protest over things she disagreed with she you know, she’s claims that she didn’t agree with a lot that was going on, should she have quit? That’s a good thing for you to judge for yourself. You know, my own view on that is I couldn’t work for the guy to begin with. So I probably would have quit and found myself more effective at acting on the outside, I have a hard time working for people whose values they don’t support. But I would also say that her point is probably got a lot of merit, too which is life wouldn’t have gotten better for the country if she’d have quit, and witnessed Scott Atlas, the trapeze artists that she was replaced by who was worse and telling Trump what he needed to know. Did she lend him credibility? I think so. And, you know, are there things that she did that I think were mistakes? Yes. I think she was naive to what Trump was trying to do. I think she gave herself more credit than she probably deserves for influencing him? I think Trump was influenced by gut instinct; she claims. He listened to her data for five and a half weeks, I think he was listening to Wall Street tanking and the NBA being closed. And I think he was doing that as minimal time as possible. And he and Jared Kushner, who she counted as a supporter would say constantly, a refrain that’s in my book, that they got to, quote unquote, recapture things back from the doctors. They even refer to her as a school nurse, kind of very pejoratively. But you know, at some level, you admire the fact. Or you could admire the fact that she, you know, stuck in there and tried to influence things, knowing that she was making no friends and just made no friends. Certainly in the anti-Trump crowd, she certainly made no friends in the Trump crowd. So, you know, I think she was driven by clearly by something else in the interview, and she does come across as defensive. She has clearly a tough persona and a temper you can see that showing through or in moments, even when she was trying not to have it show through. How did I do as an interviewer?

Andy Slavitt  06:08

I think I did some things. Well, I think I could have done some things better. And I certainly welcome feedback and criticism about that. It’s not my intent to let people quote unquote, off the hook. I did press her in areas where I wanted to create some moments where she would be forced to say, yeah, either I didn’t tell the truth, or I said something that I judged to be very naive, like the Trump is very scientifically motivated, and driven. And you know, that sort of some of those moments, I think, speak for themselves. There are a couple of other moments where I wish I would have pressed her harder. For example, I think she oddly deflects blame for people not getting vaccinated, away from where it belongs, which is that we’ve got people who are not engaged and supportive of science and that she was part of the contribution to that and says, no, in fact, people didn’t get vaccinated not because they didn’t want the vaccine, but because they didn’t have a good communication strategy, communicating with them about the vaccine, just as sort of a weird place to pick. But look, part of these interviews is just letting you decide what you believe what you like, and what you don’t like, and not going to bring you guests that you agree with 100% of the time, or we will never hear and understand what’s going on. So anyway, that’s just my thinking, welcome your feedback. You know, I do plan to continue to have the most interesting guests that can shine a light on what’s going on and help us understand things. And completely understandable if occasionally see, you know, that’s not the show for me, I don’t want to listen to it. But if you haven’t, I think you’ll enjoy it. Now, let’s bring you a nice job. Before I do that, I should tell you that this network that we’re on, called Lemonada, has an interesting show that’s out now. It’s called burnout. And you might want to play it, it’s only four parts. The idea behind the show is just sort of this kind of nationwide focus on people hating their jobs, why they hate their jobs, why they’re quitting. And it’s a really complex set of issues relative to kind of where we are, at this moment of time with people are just sort of saying, Hey, I’m burned out. That’s kind of thing that like you’d ever hear. You know, I when I grew up, you never hear your parents saying, but it’s happening more and more. The hos is a guy called Connor Franta. He’s a mental health advocate. He’s a YouTuber, and it’s out now. So you might want to check it out. You can get it wherever you get any other podcast. Now putting all that behind us. Let’s get to the main event of the day. Let’s hear from Ashish Jha, as he answers your questions, rapid fire directly from the White House.

Andy Slavitt  08:54

Thank you, Ashish Jha for coming back to in the bubble now in your official capacity in the White House.

Dr. Ashish Jha 

Thank you, Andy Slavitt, for having me back in the bubble. And I’m excited to be back.

Andy Slavitt 

Love it. Well, this will be a fun conversation. I thought we’d cut it up this way. Maybe give you a couple minutes to just tell us about what the current state of affairs are right now in the country. With respect to COVID, and what we’re going through, then, as you know, and with your help, we crowd sourced questions from the internet. And we’ve slimmed it down to the kind of the 10 key questions that people have asked him. We’ll sort of go there. How’s that sound?

Dr. Ashish Jha 

That sounds like a great plan. Let’s do it.

Andy Slavitt 

So tell us what’s the current state of affairs with regard to COVID in the US right now?

Dr. Ashish Jha 

Yeah, good question. Let’s start off with where we are. On one hand, you know, look, infections are up right. They’ve been rising for about six weeks. Mostly initially, starting in the northeast New York, Massachusetts, New England states coming out of the Mid Atlantic, and they’ve been rising pretty steadily for six weeks driven largely by BA2, and one of the sub variants of BA2, BA2.12.1, which is now predominant around the Northeast. And so infections are up a lot, probably about three to four-fold compared to where they were around March 20 22nd. When they bottomed out. What’s interesting about that, Andy is that if you look at hospitalizations, they’re up, but not as much as one would have expected compared to prior surges. And death numbers have barely budged. I mean, they’re just up a little bit six weeks into this surge. That’s very surprising. And that’s also very unusual. Typically, as you know, in this pandemic, whenever cases start rising, we see deaths increase, and about 21-22 days later. Here, we’re about six weeks out, and we’re seeing just a slight uptick on deaths. I think it’s because the place where we’ve seen this surge is really well vaccinated and boosted, we’ve been doing a lot on getting therapeutics out. And that combination is keeping lids, you know, the lid on deaths, it doesn’t mean that as this virus now this new variant spreads across the rest of the country, we’re seeing more cases in the Midwest more cases into the south, that split between cases and deaths may not hold. And that’s what I worry about going into the weeks ahead, that we’re gonna see more cases in places that are less well tested, doing less testing, certainly are less well boosted. And it’s just going to be it’s going to be a tougher road in the weeks and months ahead. I worry.

Andy Slavitt 

You know, this feels like the first wave we’ve gone through where there has been probably a large amount of at home testing, government provided for you at home tests. So it feels a little harder to get a bead on the magnitude of this wave. Is it a wave? Is it a bump? You know, the numbers aren’t huge. And Lloyd and then the other hand, the multiple of untested positive cases could be higher? How do you get a sense for how the shape of this curve? Is it steeper than it appears? There seems to be a lot of people who many of us know who are reporting getting COVID. And with that, can you tell whether we’re on the front end? Still? Are we peeking? Are we in the back end? How much longer do you see this way of going for

Dr. Ashish Jha  12:23

Good questions. So no doubt that we are missing a lot of the infections we would have caught in prior waves, because of home tests, which as you know, I’ve been a huge fan of and you’ve been a huge fan of. And they’re really useful, and they’re great to have. And they have become quite plentiful, both from the government and you cannot worry, you can go out and buy your own through your private insurance or just by paying out of pocket. But they have become quite plentiful. And I think that means that there are different estimates of what proportion of cases were missing. John Brownstein has some really nice work on this and suggests that maybe if these home tests were not ubiquitous, we would see maybe twice or two and a half times as many cases. If that’s true, let’s assume that that’s right, and certainly seems quite reasonable. That means that the split between cases and deaths is even more dramatic, that this is actually a larger wave than we have seen. And yet, we have not seen the level of you know, severe illness, ICU care deaths, that we would have in a in a wave of this size before. One of the ways that I track it because cases I’ve become less reliable is obviously looking at wastewater data and wastewater data is easier to track in some places than others we’ve been we’re doing a lot of collection of wastewater, and it places like Massachusetts makes it super easy to track. Other places, again, New York State and others, you can see it and other parts of the country, there are places that don’t have a lot of wastewater data. So we’re, you know, we’re not as, let’s say, a little bit more blind than I’d like for us to be. And in terms of figuring out where we are on this wave. What’s interesting is Massachusetts looked like it peaked and was starting to come down and then it started climbing back up again. My guess is that the initial wave will just be BA2, plain old BA2 of Omicron. And then the more recent uptick, again, has been the sub variant BA2.12.1. And none of these are huge waves nothing like what we saw in January with the initial Omicron wave. But my sense is even in New England, we have not totally turned the corner in New York State upstate New York, which saw some of the biggest increases in cases a few weeks ago. It does look like that wave has crested and it’s coming down. More broadly. Andy I expect over the next month, much of Northeast a crest and start heading down if they haven’t already.

Andy Slavitt  14:54

And are we seeing anything which would tell us that Florida the West and Midwest are going to see a big wave after that, or are we also peeking in what we’ve seen there as well?

Dr. Ashish Jha 

I suspect that we have some ways to go in other places and two things are driving that. One is that because you have less immunity, you’re going to see, I think, more spread in many places that the South has another feature. And we’ve seen this in each of the last two summers, as we’ve seen a surge of infections in the South. That’s because we know how this virus spreads, right, it likes to spread most efficiently. When large numbers people gather indoors. And in the South, as it gets hotter, people will spend more time indoors. So I think the southern United States remains vulnerable to a BA two or a BA two dot 12.1 surge. And those places also have a lot less testing, or many places have a lot less testing. And so it’ll spread further and longer, before it becomes apparent. So I don’t think that this surge has crested or, or is anywhere near done. In many other parts of the country, I think you’re gonna see declining infections in the northeast, first, my hope is in the next few weeks, but maybe a couple of months away from that kind of turning around in other parts of the country.

Andy Slavitt  16:43

Okay, pretty good synopsis I think we’ll, at some point, maybe hopefully, we go through these questions. You give people a sense for what these different sub lineages imply as people are used to Omicron they just got used to the Greek letters. And now we got a whole bunch of numbers and decimals coming at them. But what can we go to the top 10 questions? And I’ll try to summarize for you that people have, and the number one question I would just sort of describe as people trying to understand their own personal risk, you know, in 2020, people’s personal risk was quite a bit higher, the tools were quite a bit lower. You know, 2021, we went through two things happening at the same time, both people getting vaccinated, as well as new, particular new waves coming in. And both of those things caused the vaccines to behave differently, et cetera. So maybe you start the simplest way to start this question about personal risk is described the people that are still dying from COVID-19. Every day, we’re still seeing a much lower number, but a few 100 people a day, dying from COVID-19, who are they, who’s most at risk of dying?

Dr. Ashish Jha 

Yeah. There are, in my mind, sort of two, three groups of people who are still at substantial risk of dying. I mean, one is obviously unvaccinated people that is a relatively smaller number, thankfully, than it has been, but still, a proportion of Americans were not vaccinated at all. And so, in my mind, if you’re over 50, and unvaccinated and especially if you’ve not had a prior infection, you remain at substantial risk, and throw in comorbidities being obese. Having an immunocompromised state, those people are all at very high risk. The second group is people who are vaccinated but not fully boosted. That group, specially people over 65-70. The problem is that with Omicron, two doses may provide some amount of protection against severe illness, but it does not provide almost any protection against infection. And once you get into more advanced age, what starts happening for people is a bad infection. Even if the infection primarily would not kill you can lead to a cascade of events that can get you into a lot of trouble. I often, I think about back in January was the last time I was on the hospital wards. I saw fully vaccinated, unboosted people coming in quite critically ill they had a breakthrough infection. They got they had fevers for three days, they went into kidney failure, their underlying kidney disease combined with a breakthrough infection that for a younger or a healthier person would not have been a big deal. Got them into a lot of trouble and got them quite sick. That’s a group that I think remains very, very vulnerable. Once you get people who are much more immunocompromised, and those are smaller numbers. People who have not gotten let’s say, […] that’s one of the kind of protection medicines that you can get. Almost at any age, obviously, if they get if they get COVID. They’re still at risk. But that’s I think a relatively small number of people when I look at who’s dying is primarily unvaccinated or unboosted people And when I think about unboosted, it’s usually people who are who have otherwise had a lot of risk factors.

Andy Slavitt  20:05

Okay? So unvaccinated people may be of any age, although clearly a bias is older and sicker than people who are vaccinated but not boosted that are older or have high risk factors. Exactly. And then is there anybody who is vaccinated and recently boosted? Who would also be at risk? Is there anybody that you worry about there?

Dr. Ashish Jha 

Yeah, I mean, look, the way to think about boosting is boosting will protect you to some degree against symptomatic infection, but obviously not 100% by any stretch. Second, is if you think about people who are high risk people who are older, and I really think about people in their 70s, and 80s. And again, this is really based on years and years of clinical practice, I’ll tell you people in their 80s, often, a pretty common run of the mill viral infection, will get them into a lot of trouble will get them sick. And so even if being boosted turns COVID into a run of the mill viral infection, you’re still at potentially high risk of having complications. So once you get older, and those people are still at risk.

Andy Slavitt 

So if you live with older parents, or you’re around older parents or grandparents in their 80s, even if you’ve been vaccinated or boosted, it sounds like we obviously don’t want them to get this. Let me go to question number two. Question number two, it’s probably one of the gaping holes still in our coverage strategy. And when people have a lot of passion around and it’s kids who are under five years old, where vaccines not yet approved, we had Rob Kayleigh on the podcast last week talking about this. And you know, I think, big picture, we talked about the fact that we’ve now been going for about 18 months since the first people got vaccinated. A vaccine that took, you know, nine to 10 months to develop this taken quite a bit longer than that to find the right dose for kids under five. I think at this point, parents are basically aware that the storyline is that you know, it’ll be June, before a vaccine is approved and ready for kids here to five. I think people just have questions, a variety of questions about why that is. And, you know, what’s, what about, is there anything about the Moderna application that would cause it to take longer than some of the other applications that have come in? Are you concerned that there’s a lack of urgency on FDA’s part? Can you look at every day on the calendar and go, yes, every one of these days matters, and people are working at either assessing the data? Or is there any way to accelerate that process? That’s probably a question you get commonly and one that I certainly do as well.

Dr. Ashish Jha  22:51

I get it asked a lot. And here’s how both how I think about it. And what I understand. And I’ve spent a lot of time. I’ve talked to Rob about this certainly. And Rob kill if and

Andy Slavitt 

He texted me when you guys were at dinner. So I know you guys are spending time.

Dr. Ashish Jha 

That’s right. And, you know, and look, I think one point to start off with is it’s very important in the position I am in now to give FDA the space that it needs to do this and what I am doing sitting here at the White House, is watching the process and making sure that it really looks like it’s moving expeditiously. And I will tell you that there is no shortage of urgency at the FDA on getting a vaccine authorized for kids under five. I feel it from talking to their leadership. And I know that they feel the urgency that a lot of parents are feeling. So the challenge is, you know, how quickly can you do this? And how quickly can you do this in a way that can continue to ensure safety and effectiveness of these vaccines for parents. The one thing I remind people is that for Pfizer, when Pfizer looked at, let’s say 5/11, they had a lot of data on kids 12 to 16. And when they were looking at adolescents, they had data on 16- and 17-year-olds and millions of kids who had gotten vaccinated ready. And they could use that as a way to assess what was happening with the age group they were looking at. Moderna has not filed an emergency use authorization for kids before. And so what FDA is trying to do is look at the zero to six in this broader context of all the data on Moderna and kids. And that inherently takes a little bit longer. They are you know; my sense is that all the data are coming in about now today is you know, may 9 And they’re still working through the submission. I think all the data are in but it’s going to happen either today or tomorrow. And it’s going to take a few weeks for the FDA scientists to do this. And by the way, there is a reason why FDA is considered the global gold Standard for this. In many other countries, what regulators do is they just take the word of the company, the pharmaceutical companies submitting, FDA does its own analysis, you know, this entity, they will go into the data, they will look at the data and they will manipulate the data and analyze the data and make sure that what the company is saying holds up through independent analysis. That is really, really important, it inherently takes a little bit longer. So, I am, I am also anxious to see this get authorized, I think it will happen as soon as it meets FDA standards. You know, obviously, none of us can foretell exactly what the outcome will be. But I’m pretty confident people are moving quickly.

Andy Slavitt 

Yeah, no, look, I recognized the position that you’re in, and you’re, you’re right in the White House can control the FDA processes. The thing that I think is that people are feeling acutely and including you I’m sure is that even the travel mask mandate disappeared, before we had finished kind of the who is eligible to be vaccinated. And of course, once kids get vaccinated, it’s gonna take a while for the fact that you know, for them to get their second and in case of Pfizer, their third dose. Yeah. I guess what I would just ask you is from the pushing and prodding you can do from the White House. If there’s a chance to move up the VERBPAC meeting from June, to earlier, a week earlier a day earlier, two weeks earlier? Will you guys push the FDA to you know, as soon as they’re done with their data to go instead of what I think people worry about is, well, we’ve got a calendar VERBPAC meeting in June, let’s use that as a milestone. And let’s just get it done by that and everything will be fine.

Dr. Ashish Jha  26:50

Yeah, that’s not I mean, I will tell you, that’s not the tone, or the tenor of the conversations we’re having right? The conversations we’re having, are obviously giving FDA the time it needs to do this well, and to do it correctly. But at the same time, if they can get done earlier than the VERBPAC date, I think there is every interest in moving this as quickly as possible. There’s no sense here that we’re gonna kind of walk our way through this process. And we’ll get there when we get there. There is the sense of urgency that a lot of parents are feeling I think that has been conveyed very effectively, to FDA leadership certainly has been conveyed very effectively to me. I’ve also had a conveyed by my own kind of friends and family who’ve got kids under five who do not waste a day to remind me that every day I’m on this job, and the kids are not authorized, they think I’m failing in my job. So I think we all feel it, and we want to get there quickly.

Andy Slavitt 

There’s a lot of care in that. And let’s just as long as we just talked about masks to sort of get your sense of the reaction in the strategy. Regarding masking, I’ve heard you say that, you know, we’re at a point now, where there’s gonna have to be local decisions about requiring masks. Can you just reflect a little bit on the, you know, the travel decision, which you guys made to remind people was to ask for 15 more days before making an assessment or keep the mandate in place, a court case that I think we reviewed, and, and my characteristic of the court case was a completely ridiculous decision by what appears to be a bias judge, the Justice Department, it sounds like is challenging this, I guess I want to make sure I understand a couple of things. One is preserving the CDCs ability, should the situation worsen to not have to rely on localities? In other words, to keep their legal authority hold. How do you feel about that? And then secondly, your overall sort of philosophy and what we should be saying to people about masking in an environment where we’re starting to see cases grow?

Dr. Ashish Jha  28:53

Yeah, good questions. So let’s talk about the transportation mas mandate and how that played out. You characterize it exactly right. The CDC had asked for a 15-day extension to the mask mandate to do a further assessment of what the impact of rising cases was on hospitalizations and deaths. And during that 15-day period, a federal judge in Florida, stepped in and vacated the order. And we felt and again, I’m not a lawyer, obviously. But the lawyers at the CDC, HHS or DOJ felt very strongly that this was a bad decision that the judge had gotten it wrong. And that and so that was one thing. And the second thing, which of course, is crucial, is we need the CDC to be able to have the authority in the middle of a crisis, to be able to do things that protect people on public transportation, and broad consensus among legal scholars among lawyers here lawyers outside that the CDC has that authority. under the Public Health Act, and therefore, preserving that authority was critical. So that’s why the DOJ immediately filed a notice or an intent to appeal. That appeal is moving forward.

Andy Slavitt  30:12

Are you being you worried that if you lose the appeal, that that will take a major piece of the arsenal away from CDC?

Dr. Ashish Jha 

Yeah, look, obviously, none of us want to lose that appeal. I think the again, the assessment by the legal team and both the DOJ and at HHS, is that this is a very strong case. The CDC is clearly within its authority. This was a clear authority; the CDC has given to it by Congress. And so a lot of confidence that we’re going to win this. Obviously, if somehow the court case goes against the CDC, then the other way to go is to go back to Congress. But at least in my mind, speaking to the legal team here, within DOJ elsewhere, my sense is a lot of confidence that we will win this case on appeal,

Andy Slavitt  31:05

but it’s good. And in the meantime, where we are with masking policy, you know, I just flew to Texas from California back, I actually flew the day after the case, really, in which about I’d say 75% of people wore masks, I think my wife and I were the only people to wear masks on this flight. Yesterday, it feels like the nuance of you to the required so you wear a mask or it’s not required so you don’t that there’s very hard to establish a sort of middle ground in this country, which is that maybe you should on a voluntary basis just be in other words, just because the government or a restaurant or an airline doesn’t tell you have to doesn’t mean that it’s not going to be in your best interest. And you know, you just went through some people that still are pretty high risk, and everybody that lives with people who are in those categories is at risk. And from a policy standpoint, you sit there and say, God, I wish there was something in between of mandate, and to kind of nobody’s wearing a mask. And how do you find that?

Dr. Ashish Jha  32:01

Yeah, no, it’s a very good question. And I absolutely like the problem with masking is, it’s really strange how politicized masking as an act has become, in a way that I don’t know that all the other tools we have in a public health response to a respiratory virus induced pandemic, not clear that those others have been politicized to quite the same degree. And so, you know, masks evoke this kind of very strong reaction in some people, I have seen math’s as like, a good thing they work, they’re not the end all be all. They’re not a panacea. But they’re also not useless. And they also don’t like. And so I do wish we could have the kind of conversation in our country where, in the middle of a surge, you could have public health people saying, Hey, folks should wear a mask. And you know, and 80 90% of people would do it. And then when the surge ends, and the cases are better public health, people come out and say, probably not as necessary, right now, obviously, if you’re high risk, you can continue doing it. And people would put their masks away. And it would not be a big deal either way, that is not where we are. I would like to figure out if we can get there, I would like to figure out if we can get to a point where masks are a tool. They don’t symbolize anything more than that. And we use them when we need to, and we put them away when they’re less important. And I don’t know, I’m hopeful that maybe we can, if we turn down the heat on masking a little bit and focus on just talking about them as one of the many things that we can do to keep people safe.

Andy Slavitt  34:08

Question four, which is what to expect in the fall from a vaccine booster regimen in this notion that has been talked about publicly of a new vaccine, a new type of vaccine that is either Omicron specific, or that’s what people will call as a bi-Vaillant. It’s something that has some part Omicron some part of the of the kind of current vaccine, and, you know, Pfizer and Moderna and seeing the praises of the mRNA platform. I’ve talked about how within 90 days, we have the ability to create a new vaccine. You know, Thanksgiving was the time we first started seeing a lot of cases of Omicron. We’ve had the data I assume for a while and it’s been closer to six months to 90 days, and people still haven’t heard and so there’s a lot of rumors floating around, but it feels like it There’s either slowness or an unwillingness to share the straight story. So what is it that you can say about what we’ve learned about, about a new type of vaccine in the fall?

Dr. Ashish Jha 

Yeah, I’ll share everything I know about this. This is not that it’s no secret, at least not no secret that I’m aware of. So vaccines were developed very quickly, the Omicron specific variant, vaccines were developed pretty quickly. Those are being tested, they’ve been tested in animal models, they’ve been being tested in humans, and people. The other thing is, we are testing a several different types of bio valence vaccines, vaccines that mix together, the original wild type and beta, or wild type and Omicron. And they’re in the clinical trials right now. Just like the original vaccine, you know, developing the vaccine, you can do very, very quickly, testing it in people, making sure that you’re following them seeing what happens to them, are they getting infected? Are they getting severe illness, that just takes time you got to recruit people, you got to enroll them. That is still ongoing. My best guess, and this has guests, you know, as an educated guess, based on everything I know is that in the next few weeks, we’re going to see a lot more data coming out on these bi-Vaillant vaccines, as well as maybe just a pure Omicron specific vaccine. And we will see where the data ended up. Again, based on the little bit that is out there. My expectation is that we’re going to see bi-Vaillant vaccines end up outperforming either an Omicron specific or the original vaccine. can’t promise that that’s the case. But that’s my expectation based on kind of what’s out there. We will see, and then FDA is going to make a decision.

Andy Slavitt  36:48

Is the assessment against the kinds of things we were talking about earlier deaths and hospitalization? Or is there a chance with a better vaccine, that we could actually be preventing infection again, with these vaccines, which I think we’ve sort of all but given up on with the current vaccine,

Dr. Ashish Jha 

I’m hoping to see real reductions in in symptomatic infections, we may not get there. We may not get there, but my hope is we’re gonna see reductions in symptomatic infections with these new generation vaccines not perfect. Not, you know, we may never get that 95% that we saw with the original clinical trials. But my hope is that we’ll see reductions in symptomatic infections. Obviously, seeing reductions in hospitalizations or deaths. Extremely important, that also just takes longer to accumulate, you need bigger sample sizes. So that’s also something that can kind of slow down how quickly a clinical trial can get. But that has got to be one of the things that I think we’ve got to at least look for and hope for.

Andy Slavitt 

Okay, let me go to keep you efficient. Moving along. Let me go to question five. I think, five is it though? I think we’ve done. Question five. Yes. Just the odds and ends question on vaccines. We’re down to two highly recommended vaccines with the news on Johnson and Johnson gets two parts of that question. One is with only two vaccines. are we feeling the need to add some more to the arsenal? Are we looking at […] approval or others? And then, of course, people who have been taking J&J, do you have any particular advice for people who’ve just had the J&J regimen?

Dr. Ashish Jha  38:23

Yeah. Let me start with J&J. And then we’ll talk about so first of all, I have said, from really the early days of seeing the J&J data, and I will repeat this, I think, J&J is a very good vaccine. It’s a very high-quality vaccine, which elicits a very strong cellular immunity response. That’s quite robust. And I think for people who’ve had to J&J or people who’ve had J&J as a booster, to their mRNA platform, I think those people have a have a very good degree of protection. So why did CDC and FDA then come out and restrict its use? It’s because of TTS, right? This thrombotic thrombocytopenic syndrome that you’ve seen where you get low platelets, and a clot, the bad three and a million, pretty rare, one in 2 million end up leading to deaths, again, very rare, but obviously a terrible outcome. And so what CDC and FDA have said is look, even though these are incredibly rare side effects, we have alternatives in Moderna and Pfizer that don’t have that rare side effect. And that’s why they’re strongly recommending that people basically move to that and only take J&J if they really can’t or won’t take the mRNA vaccines. You know, in terms of whether Madrona and Pfizer are enough. I know that FDA is I think one of the VERBPAC meetings is focused on Novavax. There are going to be other protein-based vaccines that are going to come My hope is over time we will have a broader arsenal of vaccines, again, Moderna and Pfizer have done very well by us in terms of like if most Americans have gotten one of those two and have you known, you know, obviously I have and I’m not questioning their ability to carry us through. But I do think it’d be better for our country if we can get more than just those two into the arsenal. So I know FDA is looking into that.

Andy Slavitt  40:12

The next question that people have, I think, probably high level of concern, and I know it’s one of yours as well, as long COVID. You know, I think most of us feel like we could kind of assess the risk of a bad viral infection. If it were going to be the acute phase only, we can make adjustments to our life to say I do or don’t I, based on my own health status or my age, know, how would want to behave in order to avoid getting COVID. But long COVID is a different calculus. And then the one hand, I’m think people don’t want to over Wait, the odds of getting lung COVID If it’s promoted if they’ve been vaccinated. On the other hand, there have been people have gotten long COVID, including my son will say the same thing. Do whatever you can to avoid getting this thing because it’s not fun. It’s not pretty. It’s kind of scary. You took a little bit about what, from a policy standpoint, you think the priorities are, and the effort is to tackling this one?

Dr. Ashish Jha 

You know, long COVID, obviously, is a really complicated issue, because I think there’s a lot of fear around how often it happens, you see numbers out there of like, 30 50%. I think that’s clearly not quite right in terms of thinking about how many people are really disabled by this in a significant way. But that said, what that means, unfortunately, is other people minimize long COVID and say, oh, it’s all an exaggeration, lots of people have symptoms after a viral infection. The truth is that there is a minority of people who are really debilitated by COVID. And its impact. So what we first need to do, I think, is really understand this disease a lot better. And what I mean by that is a couple of things. My sense is we’re looking at this and studying long COVID for the last nine months or so, is that it is probably a mix of different conditions. For some people, it may very well represent a viral reservoir that continues to cause intermittent infection for other people is clearly immunologic. And they probably need to be treated very, very differently, they need to be understood differently, need to characterize and clinically differently. So given this kind of mix of different conditions that underlie what we think about as post COVID syndrome, so long COVID, one of the first things we need to do is just I think clinically understand what’s going on in different groups of people and bucket them in different ways. So then we can try to really study both the natural history of the disease and potential treatments. So here are a few of the things that I’ve been thinking about, obviously, we need to build cohort studies. And that is starting to happen. As you know, there was a presidential memorandum on lung COVID, just actually, as I was coming in about a month ago, to really push the federal government to take this much more comprehensive approach. So cohort studies, I think we need to start trying out new therapies. I am interested in questions like, does getting Paxlovid reduce your likelihood of long COVID. Because if you have much shorter duration of viremia is that going to make a difference? Maybe you’re less likely to get a viral reservoir, maybe you’re less likely to have an untoward immunologic response.

Andy Slavitt 

And Paxlovid, to clarify, for folks who are putting it together is the antiviral oral medication. And you keep the NIH been at the table in talking about this. People have long COVID, you can’t talk about it enough. I agree to recognize the issue that they have. Let me move on. It’s hard to do every one of these issues justice, but I want to get to as many as we have here. Just a quick one on how to communicate effectively with the public around community transmission. People are concerned about the fact that, that they feel like they have less awareness of whether or not their seat spikes in their community, in part because what we talked about earlier with the testing, in part because this the CDC is now putting more waiting are lagging indicators, like hospitalizations, and in part because the wastewater data has been sort of a little bit imperfect. People that feel like they don’t know as much and they’re not seeing as many briefings. And so for people who want to adjust accordingly, what’s your thinking? Or what’s the best advice on how to keep track of community transmission?

Dr. Ashish Jha  44:35

Yeah, this is hard. So this is really now I mean, in terms of how to track what’s happening. This is very, very variable by state in terms of going through your own State Department’s Public Health website. Some states are now updating once a week. Many other states do continue to update every day. You know, the CDC it is true that the community transmission levels to the CCLs got change aims to incorporate not just infections, but also hospitalizations and hospital capacity. case numbers are still there. And you can still find it on the CDC website. What I try to do whenever I think about what’s happening, where I live or elsewhere is I try to triangulate between what the CDC data showing what the state’s showing of wastewater is becoming more and more available in most more communities. And that combination does make it make it easier. But it’s, it’s tough for people, because what you’re asking people to do is go to multiple different sites, and try to put this whole picture together. That’s complicated. And I do wish that there was some simple, easy way to get a snapshot of exactly what’s happening in your community. And that has not been easy.

Andy Slavitt 

Packs loaded in the antivirals. You know, we now have more, a lot more than at first that maybe you could just speak to two things that we’re learning or hearing about when we hear about Paxlovid. Which, by the way, by all accounts seems to be doing a terrific job. The questions people have are, number one, there appear to be reports that decreasing reports of bounce back, people who after the route of Paxlovid, the virus comes back. And then secondly, the criteria for qualifying for Paxlovid people are a little bit confused whether or not they have to be at high risk, not at high risk, whether that’s loosened a little bit. All right,

Dr. Ashish Jha  46:28

All right, so let’s talk about Paxlovid. The data from clinical trials were really compelling 90% reduction in hospitalizations, and no deaths in the in the pecs COVID group. So really compelling, antiviral, and it’s gonna get started early in the first five days of onset of symptoms are testing positive. In terms of who’s eligible, sorry about that first, then we’ll talk about bounce backs, or will fire a load rebound, as we often talk about it. In terms of who’s eligible in my mind, again, if you look at the EUA, from the FDA, it says anybody who is at increased risk of progression to severe disease, that actually leaves a lot of room and the FDA is EUA, the emergency use authorization points to a CDC guidance on who’s at increased risk. And if you go to that, the list is very, very long. And you can argue anybody over the age of 50, anybody who’s got a variety of chronic diseases overweight. So what I have said to both clinicians and patients, is that we should be largely pretty permissive that, that gives you a broad range of Americans, you know, maybe the 20-year-old who’s healthy, who’s got mild symptoms, and nothing else. Not eligible and probably doesn’t, was isn’t going to benefit much from tax audit. But if you’re, you know, in any kind of a higher risk group, which a lot of Americans are, I think the ability, I think you should seriously have a conversation with your provider about getting Paxlovid or go to a test retreat site. But I think we should be much more generous about using Paxlovid I think can make a really big difference in reducing complications and hospitalizations and deaths.

Andy Slavitt  48:05

Got it and bounce back concerns.

Dr. Ashish Jha 

Yeah, viral load rebound. Yeah. So as you suggested in clinical trials, about 2% of people on Paxlovid had a viral load rebound, basically, they got better their viral loads improved, and then they bounced back. By the way, it was almost the same in the placebo group, it tells you is probably more about the natural history of the virus than it is about Paxlovid per se. There is talk that it’s happening more often in clinical practice. I don’t know. My take is these days, about 10 to 15,000. People are getting vaccinated every day. If it was 2%, it still be 200 to 300 people every day. And social media amplifies every one of those cases. And so one wouldn’t be surprised if like, you know, my cousin had it. Well, my friend had it. And they could have been part of that. Or it could be more often. But here’s the key part. So far, all of the data says if you do have that viral load rebound, you’re not at increased risk of ending up in the hospital, you will end up getting sicker. So the key point is Paxil COVID. reduces your risk of having a bad outcome by at least 90%. And that holds no matter what the rebound levels are.

Andy Slavitt 

Well, look, I know we got to wrap up in a second. So I want to just jam the last couple of questions in a lot of the things we talked about, the Paxlovid the new vaccines, the boosters require Congress to act as we know. Yes. And as we sit here today, can you give us an update on how you feel that’s going?

Dr. Ashish Jha 

Yeah, you know, Congress, I think there’s a lot of understanding within a lot of members of Congress, and I’ve had really productive conversations with both Democrats and Republicans, that they understand that we are not at a point in the pandemic where we can completely kind of walk away from therapeutics, vaccines, testing, that, in fact, we need to continue plugging away on those things. And the question is, can you get to enough votes among Democrats and Republicans in both the House and Senate to get there, we have sent up a very pared down 22 and a half billion-dollar request. It has a modest sum for global, it’s mostly focused on domestic. It has money for more  Paxlovid, has money for the next generation of vaccines for testing. It’s hard to know. I mean, this was something that was sent up in March, and it was an emergency authorization then emergency requests, then, here we are in May, Congress still has not acted. I you know, Andy, I’ve been in DC for a month, which allows me to use the and honestly like, maybe I’m still being naive about this. But I just don’t see Congress walking away from the American people and saying, you know, this fall in winter, good luck, you’re going to be on your own. We won’t have any of these treatments, vaccines or tests, and Congress has to act now. I think there is a bit of a misunderstanding among some members of Congress, that maybe we can fund this in November. If we want vaccines for November, we got to actually purchase them in the next few weeks. I am optimistic this will happen. But it’s always hard to predict with Congress what exactly they’re going to do.

Andy Slavitt 

Well, they’re back now we’ve got only weeks. Speaking of which I think we’ve run up against your time limit. Today, there’s more we could have asked you. But I think we got to the most important ones. And you know, I want to save stuff for the next time because you’re such a popular guest. And that, you know, we’ll just save a little bit for the end. But feel free to close with anything you like. And it may be you know; I think what give people a sense for what to expect ahead. I think people are anticipating as another bad winter wave. Is that what you see? Are we really going to need to kind of go pull out all the stops on nursing home vaccinations and the new boost that people need to be ready for this. What you’d like to leave us with, Ashish?

Dr. Ashish Jha 

I would want to leave us with two sets of thoughts that seem at once contradictory, but they are in fact not. One is that this pandemic isn’t over. I mean, if you look at the viral evolution, and I know we were talking about those BA2, BA1, BA.12.1. By the way, I don’t make up these numbers. These are literally, but it’s confusing. But here’s the big picture, this virus is evolving relatively rapidly. It is finding ways to try to evade our immune systems and to create and that is what’s driving the viral evolution right now. And that is going to continue. And on one hand, you look at that and you think, Boy, this is difficult, this is scary. It can it can cause concern. And it’s a reminder, this pandemic isn’t over. And there’s still a lot of potential of this virus to do a lot of harm. That’s one set of thoughts. The second set of thoughts is, we are in such good place in this pandemic. We’ve got fabulous vaccines, which we’re going to be updating with new generation once. We’ve got great treatments and many more coming. Testing capacity capability is so much better than it’s been in the tire pandemic. And we’ve got a relatively good wall of immunity in the population that we’ve got to keep working on and building on. So do I expect a winter surge, we might get one if we don’t act, but if we look, we get new vaccines. We run a really smart vaccination campaign in the fall and winter, that gets high risk people vaccinated. We have plenty of testing on hand so that we can get tests out to the community. We have plenty of therapeutics on hand so that when people do have breakthrough infections, they’re gonna get taken care of and not end up in the hospital. We get through the fall and winter in good shape are hospitals in good shape, death numbers low. It’s totally up to us at this point. There is no excuse for falling prey to this virus anymore. We can do it. But we got to collectively, the administration, Congress, governors, if we all pull together, we can manage our way through this.

Andy Slavitt  53:55

Ashish Jha, you’re so kind and generous to spend all the time in the middle of your day and all you got going on. And let us hear from you some more. I think the public is I know that our audience is glad you’re there in the White House. And I think when I just keep hearing you push on these kinds of critical issues and so grateful that you are I’ll let you go.

Dr. Ashish Jha  54:13

Andy, thank you so much, and I look forward to coming back.

Andy Slavitt

Okay, that felt like a marathon and a sprint at the same time. I really appreciated Ashish patiently answering every question when he clearly had people in the White House, beckoning him to get on to other calls. And he just remained focused and tried to give us the best answers that he could. And of course, he’s always available to us, he and I get a chance to communicate regularly. So a lot of the information that I pass on to you, is well sourced and documented with people like Ashish. So we have our next Friday conversation coming up in two days on Friday, and I’m super excited for this one. And the focus of our conversation this Friday is what to do if you’re upset about a lot of the things that have been going on that quite frankly, politically have been hurting women, like the most recent Supreme Court leaked brief, the Roe v. Wade, it’s disappearing. And if it feels like things are kind of going backwards on a number of fronts, policy wise, whether that’s the anti-vaccine movement taking hold, whether it’s Roe, whether it’s guns, you know, whether it’s the rights of trans kids, what the hell should you do about it? And this is a show about action. And we’ve talked with two great guests, Erin Loos Cutraro and professor, Jennifer Lawless, who is the author or co-author of six books, including women on the run gender, media and political campaigns in a polarized era. This is gonna be really interesting conversation we’re gonna get into how should we react to a lot of things we see that we don’t like, particularly as it’s affecting women, kids, families, rights, etc. okay, that’s Friday. And then on Monday, actually we’re gonna be in New York, for the Webby Awards. You might know that this podcast was named the top health and wellness podcast, gotta hope we’re bringing you wellness and health. So it’ll be interesting. We’ll report on that. But also Monday, a new slate of shows also continues to kick off. We tell you what to expect over the next few weeks. John King from CNN, he’s the guy that does the weather political map guy, very funny guy, Rick Bright, who used to run BARDA, which was one of the premier agencies that was out in front around the vaccine. And then he got sideways with Donald Trump and unlike Deborah Birx, was very vocal about it, was demoted. […] become a great scientist as well, as an outside critic, very interesting, Beto O’Rourke, who you might know is running for governor of I think the state is called Texas. Michael Mina, who has been on the show a number of times, along with Patrice Harris, who is the former head of the AMA. Michael is going to update us on some of the new innovations around at home testing, some cool things there. And Larry Summers, the former head of the National Economic Council, former Treasury Secretary, the guy who’s been out in front and in predicting inflation, all those people and many more are going to be coming up on in the bubble in the next few weeks. Look forward to that. And hope you have a great couple days. We’ll talk to you with our Friday conversation.


Thanks for listening to IN THE BUBBLE. We’re a production of Lemonada Media. Kathryn Barnes, Jackie Harris and Kyle Shiely produced our show, and they’re great. Our mix is by Noah Smith and James Barber, and they’re great, too. Steve Nelson is the vice president of the weekly content, and he’s okay, too. And of course, the ultimate bosses, Jessica Cordova Kramer and Stephanie Wittels Wachs, they executive produced the show, we love them dearly. Our theme was composed by Dan Molad and Oliver Hill, with additional music by Ivan Kuraev. You can find out more about our show on social media at @LemonadaMedia where you’ll also get the transcript of the show. And you can find me at @ASlavitt on Twitter. If you like what you heard today, why don’t you tell your friends to listen as well, and get them to write a review. Thanks so much, talk to you next time.


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