Thanks for asking Dr. Jha the questions that my circle of elderly friends want answered. To me, it’s clear that the Feds, FDA and states avoid explaining what "data" they have defined that will be required to determine if a second booster will be authorized by the ponderous FDA system. Waiting to see what Israel determines from how their elderly fare does not seem to be acceptable proactive scientific analysis to me. By that time, a lot of compromised older folks will probably find their booster potency has waned or worst disappeared. This is frustrating to those folks who want to be proactive with their healthcare and feel that the rest of the healthcare system is done with Covid.
I know people who are doing work-arounds to get a second booster shot by claiming they have not gotten an earlier shot. They are using a false name, made-up DOB, claiming they’ve forgotten their vaccination cards and have no insurance. They pay cash to a busy and distracted pharmacy staff. These are proactive people who believe the medical system has made a decision that they are expendable. Care becomes a do-it-yourself sense of preservation. They do not want to be remembered as the folks who fell through the federal cracks in the system.
I understand your points. There is such a thing as over-boosting. But I think for very high risk groups, we have not seen evidence of that. So...proceed with caution.
I'll speak with the Israelis who work on this this week and see what they say.
Thank you so much for this and the direction you took this interview. Thank you to Dr. Jha who used his knowledge to explain public health and where we are in terms we can understand. It is still tricky to navigate and I read the comments of this community and I still hurt for all as this Pandemic has been life changing. That being said my hope is that we realize even more how important community is and that we must help others.
Yeah I think there's still a group of people who are not worried enough about the welfare of others. Like...I really don't mind throwing a mask on at the grocery store. It's really not an imposition, right?!
Thank you for asking him the hard questions. Here are my concerns about his answers: 1) Masking in health care settings is tied to transmission levels which are completely unreliable--I applaud California for continuing masking in healthcare settings, 2) ACIP just declined to offer a second COVID booster to at risk people, 3) Paxlovid requires a healthcare provider willing to prescribe it--my PCP isn't a fan. I just read an interview with Dr. Fauci in the Globe where he ties deaths to lack of boosters and lack of Paxlovid--but the people can't just access these treatments/vaccines. So, as you noted, your readership tend to be concerned and more cautious and Jha's responses unfortunately don't inspire a lot of confidence that healthcare settings will be safe, that at risk individuals can access vaccines or Paxlovid, and as the narrative is that "it's over" it's creating a situation where at risk/concerned/cautious people are more and more isolated. I listened to the Osterholm podcast this week and he admitted that the less at risk are going to move on, as they should. It leaves a situation where we have two realities and difficulty with how to co-exist. As Osterholm said, the 400 dead each day are people who were loved. Jha just doesn't project that same level of empathy.
I always find it maddening that Paxlovid is over-prescribed with the worried well but then you hear of stories of it being denied to people who need it!
Agreed. Our toolbox for out patients is pretty empty— one effective oral antiviral with lots of drug interactions that many prescribers won’t use and vaccines that wane quickly. I’ve been told to “ move on”- and I’d love to, but I’m still concerned and cautious and feeling stigmatized for wearing a mask and exhausted of assessing risk. Risk assessment is getting harder with no data. Why not give interferon an EUA? Is an oral remdesivir coming? Next generation vaccines are not on the horizon. Personally, it’s disheartening and frustrating.
One additional question: You asked Dr. Jha whether masks should be required in healthcare facilities forever?He responded that he leans a lot on CDC Guides, and that the CDC's focus is where you have high levels of transmission, asking people to wear a mask in healthcare facilities makes a lot of sense. He added that in places with very little transmission, saying it's not required also makes a lot of sense. Here's my concern:
A year ago, the CDC changed its map metrics from transmission levels to community levels. But, if you compare the same map side by side, the community map looks green and yellow (medium-low risk). But, the same map depicting transmission shows red and orange (high and substantial risk) across the U.S. And, since the CDC made the map metric change 160,000 people have died of Covid. So, which map is most accurate as a guide for mask usage? How can the 2 maps be so different? Dr. Jha also acknowledges 368 or 400 still die per day from Covid, and that it's still too high and concerning to him. That leads me to believe there is still high virus transmission out there and that masks are still a good idea - yet, I'm usually one of the only people still wearing one when I go out in public. And right now, with these case numbers, going to a maskless medical or dental provider would give me hives.
I think wastewater is the more reliable metric in terms of community infection burden. Deaths and all-cause mortality are the other extreme.
I think masking in hospitals is a no-brainer. Also would be nice in some crowded public indoor spaces. But even in San Francisco (where I am visiting), I feel like most people are not masking indoors. And this is a cautious town. So...hard to imagine anything will change for now. But if there are surges, I really hope people would be willing to mask up again in more places.
I hope the CDC shares that view on wastewater surveillance as well. It's seems reliable and convenient since most communities are served by wastewater collection systems.
I'm also interested in what happens with NY ending it's requirement that masks be worn in healthcare settings, letting them set their own masking rules. Will be hoping MA doesn't follow their lead.
I see that most people aren't masking indoors anymore. I'm not sure that's a good thing? BNO News Feed reported 267,100 new Covid cases this past week. If Sars-CoV2 mutates the more it's transmitted, and the best way to stop Covid from mutating is to stop transmission, masking indoors seems to add a safe layer of protection in addition to vaccines. These case numbers still demonstrate a need for vaccines that are better at preventing transmission and to prevent immune escape of emerging variants - I saw in the interview they're working to improve ventilation, but did Dr. Jha give any indication what's in development for preventing transmission, new vaccines, antivirals, antibody therapy, etc.? If you have time to reply, thank you! But if not, maybe you could do a follow-up in an upcoming Inside Medicine. Much respect and appreciation of your points of view.
Sadly, I don’t think they will ever mask again. My state went red— with current metrics— in December/ January and few masked. No one is following the status except the concerned. Masks are going or gone in many outpatient settings and in hospitals they are variable. Patients are exposed to unmasked visitors. We track other iatrogenic infections, why not COVID? I agree it’s a no brainer, but the CDC ties it to case counts. So Jha’s reassurance isn’t reassuring for me. Case counts are unreliable now, as most cases aren’t reported and will only become less reliable after May.
Well done. The following exchange covers what I am asked about the most (by far):
“Faust: James writes: as of today, there's no guidance regarding whether older and high-risk people who received the bivalent booster in September/October are eligible for an additional boost this April and May. Is this decision going to wait until fall of 2023? How do people who need to be up-to-date more than once a year stay up-to-date?
Jha: We've always been guided by evidence on this, and the FDA makes this decision when they see evidence that an additional shot protects people against serious illness and death, then they make a recommendation. …”
In short, there are no current guidelines or recommendations for James and others who are understandably concerned.
"When danger is growing exponentially, everything looks fine until it doesn't."
Megan McArdle, Washington Post, March 10, 2020
This quote is a reminder that there are situations where decisions are necessary before the ideal amount of quality data is available. Using the best available data, sound analytical thinking, and risk-benefit analysis, recommendations could exist with the caveat they will be reassessed as more reliable information becomes available.
Yes one area where Ashish and I do not agree is on how long booster effects last. My belief is they are highly effective for the at-risk but only briefly. My lens would be to boost the high risk more often, and the standard risk substantially less often. (3:1 not even 2:1)
Do you know if Israel or any country has data on the usefulness for an April/May booster? I am comfortable waiting until September for a vaccine+flu shot but the messaging here in the U.S. is sorely lacking.
I do not know but I am working with one of the major groups there and I'll ask them this week. What I can say is that the 4th dose (pre-bivalent) worked well but faded quickly. I do not yet know on bivalent. I'll see what we've learned and reveal what I am permitted to!
Thank you Dr Faust for your valiant try at getting helpful answers from Jha. However, again, you (and the public) received vague responses with nothing new.
Good line of questioning, and a good interview. I appreciate the time and thought that you put into these.
My husband and I are 59 and 63 respectively, fully vaxxed/boosted, and continue to mask in all indoor settings outside of our home. We will continue to select outdoor seating in restaurants, travel by car vs flying wherever possible, and have Paxlovid pre-plans established with our providers. A good stash of tests has a home in our closet. For the foreseeable future, this is the plan.
I really, really hope we see studies and data flow outward about bivalent boosters and wastewater monitoring and other surveillance continues to be done. That vulnerable groups do not get forgotten as many of them feel they are. I wish for a pharmaceutical industry that would be proactive and do things in the public interest, like work on treatments that would help high risk groups, as Evushield and monoclonal antibodies are not useful anymore with new variants.
Most of all, though, I wish everyone saw this as a critical community goal, that being, to keep *all* people safe, and lived accordingly.
You're an excellent interviewer :) This jumped out: I've read studies that report vaccines reduce long covid by about 15%. I haven't seen studies that find being vaccinated reduces long Covid by 50%, 80% and 90%. Is this across all age groups? For the immunocompromised? Are you familiar with the studies Dr. Jha cites? (I would love to read them).
I must admit I have not followed the literature on that carefully. The main reason is that we have a massive, massive, massive "case definition" problem. One study says LC is X and another says Y and another says Z. So it's really hard to know. Probably there are ways to dig into this, but I just have not had time.
We won't know when there is high transmission level because we have very little reliable data Even Johns Hopkins tracker is shutting down I believe in part because data is no longer available so in the end our CDC took a page from Donald Trumps playbook "too many cases make me look bad"
Dr Jha lovely fellow and skilled talking head Replace CDC director or maybe just resurrect her original approach to the job
I think wastewater is a reasonable way to track this all. It's not as easy to wrap the mind around as case counts, but if you think of wastewater as something like temperature, then it makes sense. Eventually, we'll have a sense of what numbers mean what. However, the implications are different. High levels in a college town vs a retirement community has vastly different implications.
thank you for your reply & it brings up the dilemma exactly I'm over 65 and I live in a college town that many many retired from first careers but still active working people live in When everyone in town was acknowledging the reality of Covid, everyone was safer. Now are those of us who live among or with non hi-risk people supposed to sell up and shuffle off?
It seems like we are being asked to self-segregate because public health is not willing to say a word. Worst public health messaging ever.
Act Up worked when public health failed to get people to pay attention to those dying of HIV/AIDs. Same kind of indifference when it's only them, not you as it was then.
Thanks for asking Dr. Jha the questions that my circle of elderly friends want answered. To me, it’s clear that the Feds, FDA and states avoid explaining what "data" they have defined that will be required to determine if a second booster will be authorized by the ponderous FDA system. Waiting to see what Israel determines from how their elderly fare does not seem to be acceptable proactive scientific analysis to me. By that time, a lot of compromised older folks will probably find their booster potency has waned or worst disappeared. This is frustrating to those folks who want to be proactive with their healthcare and feel that the rest of the healthcare system is done with Covid.
I know people who are doing work-arounds to get a second booster shot by claiming they have not gotten an earlier shot. They are using a false name, made-up DOB, claiming they’ve forgotten their vaccination cards and have no insurance. They pay cash to a busy and distracted pharmacy staff. These are proactive people who believe the medical system has made a decision that they are expendable. Care becomes a do-it-yourself sense of preservation. They do not want to be remembered as the folks who fell through the federal cracks in the system.
I understand your points. There is such a thing as over-boosting. But I think for very high risk groups, we have not seen evidence of that. So...proceed with caution.
I'll speak with the Israelis who work on this this week and see what they say.
Thank you so much for this and the direction you took this interview. Thank you to Dr. Jha who used his knowledge to explain public health and where we are in terms we can understand. It is still tricky to navigate and I read the comments of this community and I still hurt for all as this Pandemic has been life changing. That being said my hope is that we realize even more how important community is and that we must help others.
Yeah I think there's still a group of people who are not worried enough about the welfare of others. Like...I really don't mind throwing a mask on at the grocery store. It's really not an imposition, right?!
Thank you for asking him the hard questions. Here are my concerns about his answers: 1) Masking in health care settings is tied to transmission levels which are completely unreliable--I applaud California for continuing masking in healthcare settings, 2) ACIP just declined to offer a second COVID booster to at risk people, 3) Paxlovid requires a healthcare provider willing to prescribe it--my PCP isn't a fan. I just read an interview with Dr. Fauci in the Globe where he ties deaths to lack of boosters and lack of Paxlovid--but the people can't just access these treatments/vaccines. So, as you noted, your readership tend to be concerned and more cautious and Jha's responses unfortunately don't inspire a lot of confidence that healthcare settings will be safe, that at risk individuals can access vaccines or Paxlovid, and as the narrative is that "it's over" it's creating a situation where at risk/concerned/cautious people are more and more isolated. I listened to the Osterholm podcast this week and he admitted that the less at risk are going to move on, as they should. It leaves a situation where we have two realities and difficulty with how to co-exist. As Osterholm said, the 400 dead each day are people who were loved. Jha just doesn't project that same level of empathy.
I always find it maddening that Paxlovid is over-prescribed with the worried well but then you hear of stories of it being denied to people who need it!
Agreed. Our toolbox for out patients is pretty empty— one effective oral antiviral with lots of drug interactions that many prescribers won’t use and vaccines that wane quickly. I’ve been told to “ move on”- and I’d love to, but I’m still concerned and cautious and feeling stigmatized for wearing a mask and exhausted of assessing risk. Risk assessment is getting harder with no data. Why not give interferon an EUA? Is an oral remdesivir coming? Next generation vaccines are not on the horizon. Personally, it’s disheartening and frustrating.
Agree with the sentiments expressed here wholeheartedly.
One additional question: You asked Dr. Jha whether masks should be required in healthcare facilities forever?He responded that he leans a lot on CDC Guides, and that the CDC's focus is where you have high levels of transmission, asking people to wear a mask in healthcare facilities makes a lot of sense. He added that in places with very little transmission, saying it's not required also makes a lot of sense. Here's my concern:
A year ago, the CDC changed its map metrics from transmission levels to community levels. But, if you compare the same map side by side, the community map looks green and yellow (medium-low risk). But, the same map depicting transmission shows red and orange (high and substantial risk) across the U.S. And, since the CDC made the map metric change 160,000 people have died of Covid. So, which map is most accurate as a guide for mask usage? How can the 2 maps be so different? Dr. Jha also acknowledges 368 or 400 still die per day from Covid, and that it's still too high and concerning to him. That leads me to believe there is still high virus transmission out there and that masks are still a good idea - yet, I'm usually one of the only people still wearing one when I go out in public. And right now, with these case numbers, going to a maskless medical or dental provider would give me hives.
I think wastewater is the more reliable metric in terms of community infection burden. Deaths and all-cause mortality are the other extreme.
I think masking in hospitals is a no-brainer. Also would be nice in some crowded public indoor spaces. But even in San Francisco (where I am visiting), I feel like most people are not masking indoors. And this is a cautious town. So...hard to imagine anything will change for now. But if there are surges, I really hope people would be willing to mask up again in more places.
I hope the CDC shares that view on wastewater surveillance as well. It's seems reliable and convenient since most communities are served by wastewater collection systems.
I'm also interested in what happens with NY ending it's requirement that masks be worn in healthcare settings, letting them set their own masking rules. Will be hoping MA doesn't follow their lead.
I see that most people aren't masking indoors anymore. I'm not sure that's a good thing? BNO News Feed reported 267,100 new Covid cases this past week. If Sars-CoV2 mutates the more it's transmitted, and the best way to stop Covid from mutating is to stop transmission, masking indoors seems to add a safe layer of protection in addition to vaccines. These case numbers still demonstrate a need for vaccines that are better at preventing transmission and to prevent immune escape of emerging variants - I saw in the interview they're working to improve ventilation, but did Dr. Jha give any indication what's in development for preventing transmission, new vaccines, antivirals, antibody therapy, etc.? If you have time to reply, thank you! But if not, maybe you could do a follow-up in an upcoming Inside Medicine. Much respect and appreciation of your points of view.
Sadly, I don’t think they will ever mask again. My state went red— with current metrics— in December/ January and few masked. No one is following the status except the concerned. Masks are going or gone in many outpatient settings and in hospitals they are variable. Patients are exposed to unmasked visitors. We track other iatrogenic infections, why not COVID? I agree it’s a no brainer, but the CDC ties it to case counts. So Jha’s reassurance isn’t reassuring for me. Case counts are unreliable now, as most cases aren’t reported and will only become less reliable after May.
Well done. The following exchange covers what I am asked about the most (by far):
“Faust: James writes: as of today, there's no guidance regarding whether older and high-risk people who received the bivalent booster in September/October are eligible for an additional boost this April and May. Is this decision going to wait until fall of 2023? How do people who need to be up-to-date more than once a year stay up-to-date?
Jha: We've always been guided by evidence on this, and the FDA makes this decision when they see evidence that an additional shot protects people against serious illness and death, then they make a recommendation. …”
In short, there are no current guidelines or recommendations for James and others who are understandably concerned.
"When danger is growing exponentially, everything looks fine until it doesn't."
Megan McArdle, Washington Post, March 10, 2020
This quote is a reminder that there are situations where decisions are necessary before the ideal amount of quality data is available. Using the best available data, sound analytical thinking, and risk-benefit analysis, recommendations could exist with the caveat they will be reassessed as more reliable information becomes available.
Yes one area where Ashish and I do not agree is on how long booster effects last. My belief is they are highly effective for the at-risk but only briefly. My lens would be to boost the high risk more often, and the standard risk substantially less often. (3:1 not even 2:1)
Thank you Jeremy. This was very helpful.
Do you know if Israel or any country has data on the usefulness for an April/May booster? I am comfortable waiting until September for a vaccine+flu shot but the messaging here in the U.S. is sorely lacking.
I do not know but I am working with one of the major groups there and I'll ask them this week. What I can say is that the 4th dose (pre-bivalent) worked well but faded quickly. I do not yet know on bivalent. I'll see what we've learned and reveal what I am permitted to!
Thank you Dr Faust for your valiant try at getting helpful answers from Jha. However, again, you (and the public) received vague responses with nothing new.
Good line of questioning, and a good interview. I appreciate the time and thought that you put into these.
My husband and I are 59 and 63 respectively, fully vaxxed/boosted, and continue to mask in all indoor settings outside of our home. We will continue to select outdoor seating in restaurants, travel by car vs flying wherever possible, and have Paxlovid pre-plans established with our providers. A good stash of tests has a home in our closet. For the foreseeable future, this is the plan.
I really, really hope we see studies and data flow outward about bivalent boosters and wastewater monitoring and other surveillance continues to be done. That vulnerable groups do not get forgotten as many of them feel they are. I wish for a pharmaceutical industry that would be proactive and do things in the public interest, like work on treatments that would help high risk groups, as Evushield and monoclonal antibodies are not useful anymore with new variants.
Most of all, though, I wish everyone saw this as a critical community goal, that being, to keep *all* people safe, and lived accordingly.
You're an excellent interviewer :) This jumped out: I've read studies that report vaccines reduce long covid by about 15%. I haven't seen studies that find being vaccinated reduces long Covid by 50%, 80% and 90%. Is this across all age groups? For the immunocompromised? Are you familiar with the studies Dr. Jha cites? (I would love to read them).
I must admit I have not followed the literature on that carefully. The main reason is that we have a massive, massive, massive "case definition" problem. One study says LC is X and another says Y and another says Z. So it's really hard to know. Probably there are ways to dig into this, but I just have not had time.
Oh and Thank you for your kind words
but thanks for asking the questions anyway
We won't know when there is high transmission level because we have very little reliable data Even Johns Hopkins tracker is shutting down I believe in part because data is no longer available so in the end our CDC took a page from Donald Trumps playbook "too many cases make me look bad"
Dr Jha lovely fellow and skilled talking head Replace CDC director or maybe just resurrect her original approach to the job
I think wastewater is a reasonable way to track this all. It's not as easy to wrap the mind around as case counts, but if you think of wastewater as something like temperature, then it makes sense. Eventually, we'll have a sense of what numbers mean what. However, the implications are different. High levels in a college town vs a retirement community has vastly different implications.
thank you for your reply & it brings up the dilemma exactly I'm over 65 and I live in a college town that many many retired from first careers but still active working people live in When everyone in town was acknowledging the reality of Covid, everyone was safer. Now are those of us who live among or with non hi-risk people supposed to sell up and shuffle off?
It seems like we are being asked to self-segregate because public health is not willing to say a word. Worst public health messaging ever.
Act Up worked when public health failed to get people to pay attention to those dying of HIV/AIDs. Same kind of indifference when it's only them, not you as it was then.