COVID Webinar Series (TRANSCRIPT): Robert Redfield, MD

KRIS REBILLOT: Dr. Redfield, welcome.

ROBERT REDFIELD, MD:  Thank you very much.  Yeah, resourcefulness.

KRIS:  We stand at 3.3 million cases of COVID-19 in this country, over 135,000 deaths. What do those statistics tell you?

REDFIELD: Well, I think it highlights that we’re still in the midst of it. I mean, significant transmission of this virus continuing to occur throughout our nation. Although, I think it’s important to realize we are in a different place than we were last March and April, when we were really focused on symptomatic disease. Clearly, we had a much higher mortality that was associated with the cases that we identified. Now we’re seeing, obviously, significant infection, but the age of infection has dropped by a decade-and-a-half if we look at it, and, clearly, the relationship between the number of cases diagnosed and actually having significant morbidity/mortality has shifted substantially, particularly because of the individuals getting infected. Although, we’re not out of the woods for this. I mean, I just… you know, we’re back again. I’ve just been informed that we have a number of nursing homes, once again, that have active cases that we’re trying to go and evaluate. So I think, you know, while we’ve made a lot of progress, we still have a ways to go in terms of getting this outbreak under control.

KRIS:  The CDC has put out guidance for school openings. There are school districts that say they’re going to stay online, they’re  not opening. Other schools are doing hybrid.  Some school boards of education of are encouraging some districts to open up full-time.  The New York Times article based on internal CDC documents warned that fully opening K-12 schools and universities would present the highest risk for the spread of infection.  What is the risk inherent in opening schools?

REDFIELD: Yeah, I think it’s important, particularly, as you look at the CDC documents that you referred to, one of the things that we have tried to do is inform people of minimal risk, mild risk, etc. So, for example, no risk was… or minimal risk is just everybody stayed at home, period. And so, obviously, if we go to, you know, opening schools five days a week, that’s going to be a hierarchical risk. Okay? It’s not to imply that the risk is a prohibitive risk. It’s just to allow people to understand how to do their own risk assessment.

I think it’s really important, and local school districts are going to have to make these decisions. I’ve said that our guidance that we’ve put out from CDC, the purpose of it is to facilitate the reopening of schools. I happen to balance the risk here. It’s not risk of school openings versus public health. It’s public health versus public health. And I’m of the point of view, and I weigh that equation as an individual that has 11 grandchildren, that the greater risk is actually to the nation to keep these schools closed. You know, a lot of kids get their mental health services, over 7 million, in school. A lot of people get food and nutrition in schools. Schools are really important in terms of mandatory reporting sexual and child abuse. Obviously, the socialization is important. And, obviously, for some kids, I think actually a majority of kids, their learning in a face-to-face school is the most effective method of teaching. That said, it has to be done safely, and it has to be done with the confidence of the teachers. It has to be done with the confidence of parents. And so I think each of the school districts will begin to wrestle with this.

I think it is important to try to be factual as we go through this. When we look at, right now, the mortality of this particular COVID virus, in the first almost 218,000 people we looked at February to July, there was 52 individuals under the age of 18. And if I recollect, about 35 were actually school age. Some of them were younger than school age. We’re looking critically at those individuals. And, you know, clearly, there’s an increase in comorbidities related to significant medical conditions that we already [...unintelligible...]. But I think that’s important because what that means, actually, is the risk per 100,000, so far, you know, into the outbreak, six months into it, is, in fact, that we’re looking at about .1 per 100,000. So another way to say that, it’s one in a million. Now, I’m not trying to belittle that, I’m just trying to make sure we look at it proportional. Because if you do the same thing for influenza deaths for school-age children over the last five years, they’re anywhere from five to 10 times greater. So I want people to understand the risk properly as they make that decision. And, obviously, influenza, we also benefit from having therapy and a vaccine. So I don’t want people to overestimate the risk of serious illness to individuals that are school age.

That said, there is a real risk to vulnerable individuals that are teachers, potentially, that may have comorbidities. And, obviously, there are some students that have a comorbidity.

So this is not something to do, you know, faster than you’re ready to do it. It’s not something to do if there’s not confidence, as I said, of the teachers who I am confident are really motivated by the best interest of the children. There is going to need to be accommodation for those teachers that have high risk. Some of our colleagues think it would be a great opportunity for younger teachers in the classroom to be mentored by older teachers by video that may have a risk and should be more separated. But I’m of the point of view that the public health interest of these children is served by getting these schools open and CDC…

KRIS:  So…

REDFIELD: …will, obviously, work with each school district to help them work through it. And, as I said, our guidance is not regulation. Our guidance is not in stone. Our guidance is not meant to be impractical, and we have to work with each district as they try to translate that guidance into a functional plan.

KRIS:  So from your vantage point, are there areas, are there counties in this country that you think are (a) ready to reopen like as something close to normal, or…

REDFIELD: I’m listening.

KRIS:  Okay, good. So are there places where you think that it would be safe to open normally or close to normal? What’s the data point that you think a school district should go, ‘Okay. Yes. We’re ready to consider this.’

REDFIELD: Yeah, I think it’s a very important question, and, you know, the reality is different districts are going to weight the information differently. I think there’s actually a majority of counties in this country that are in a position to reopen their schools based on the data we have now—case counts that present positive, the availability of testing, and the resilience of the health system that they have. Again, realizing we don’t see significant disease in the children. We, actually, also, don’t have really much evidence, and we have looked at that children are driving transmission. If we were to do the same analysis for flu, we would tell you that schools and children in schools are big drivers of the flu pandemic. Well, for this virus, it does not appear that the schools are driving it. So I, actually, think a majority of counties would meet the criteria, provided that the teachers have the confidence to reopen, the administrators have the confidence to reopen, and the parents.

We’re going to be coming out with some additional resources this week, I’m hopeful, that we’ve been working on for the last several weeks. One is sort of guidance to parents and caregivers to help their decision tree on sending their kid back to school. And the other one is for administrators and communities of K-12 to do the same, how to do this in a safe way, but really targeting the community and the administrators. Another one is really how to really take advantage of face coverings, because to me... and face coverings are the key. You know, if you really look at it, the data’s really clear, they work. You know, and we’re not defenseless against this virus. We actually have face coverings. And I do think the more confidence that the American public has that face coverings are not a symbol, but they’re actually a very important preventative intervention that can really block this virus. And, you know, we are getting more and more data, so I can be more and more aggressive in relating that. I have an editorial coming out today in JAMA. We have an MMWR that’s going to be coming out today on this. I think the bulk of evidence is reinforcing the face coverings. And we’re going to be trying to have one coming out to have schools, to really help them understand how to monitor for symptoms and what to do if they do get a case.

So we’re going to keep working with the schools, but the real reality is each school… and you’re going to see a wide range, and I’ve already heard a wide range in the news, and I think we should, you know, respect those local jurisdictions to make the decisions that they think are in the best interest. But I just want them to understand that… make sure they understand the relative risk. I think a lot of people... I think the Wall Street Journal had an editorial, I think, yesterday, that really looked and tried to get people to understand the relative risk of corona to students versus influence at the students. And I think once people start seeing it that, ‘Okay, I understand flu,’ and we’re not… we’re not not reopening schools because of flu, maybe the reality is the coronavirus we could really move towards reopening schools, but let’s make sure in the process we’re figuring out how to protect the vulnerable teachers and students.

And I have a grandson with cystic fibrosis. So, you know, I think it is important that we all really recognize that this isn’t just simple open schools. This is let’s get these schools open, let’s do it safely, let’s accommodate the people that are at risk, so that we don’t have negative consequences, particularly to those individuals that may have multiple medical conditions.

KRIS:  So we have gotten questions from teachers in the past who are concerned about the lack of PPE in the schools, socially distancing in the schools, making some modifications to the schools. All that costs money. And there are issues about, even if we want to do the right thing, we can’t afford to do the right thing. Do you have anything to say about the financial implications of getting these schools ready for both kids and for teachers?

REDFIELD: Yeah, I think it’s going to be important that we look through in the school exactly what one needs to do to operationalize the reopening of the schools. This is why I think it’s going to be a dialogue, you know, rather than a monologue. The most important thing is the use of face coverings in the presence of schools. And I think as that data comes out, I mean, that, I think, as you saw in the American Academy of Pediatrics recommend that distancing may be as limited as three feet. Okay, we’re going to argue that the key issue is wearing face coverings, as opposed to grounding yourself, like locked in stone, you know, that say the terms, people have heard a lot about six feet. When we talk about six feet, what we talk about is ‘How do I define if you’re exposed to somebody with COVID? If I have COVID and we’re together, how do I determine who was exposed and who wasn’t?’ And CDC has defined exposure as someone that’s within six feet of someone that’s infected for more than 15 minutes without a face covering. So I do think as we begin to work through this, I think we’re going to find, I think, some balance, in terms of how the recommendations.

Now, clearly, there’s been recommendations, depending on how you handle teachers, do you handle them... so some of them are virtual that have high risk, or do you handle some of them with some type of protective barrier? I think those are going to be decisions that each school is going to make. We’ve just tried to give options. And now, you know, as I say, I want to work with the schools as they do them.

I think that the cost to our nation in continuing to keep these schools closed is substantial, and I’m hopeful that resources that are necessary can be made available. That’s obviously not... it’s way above my pay grade.

But there has been another cost that we’ve seen, particularly in high schools. We’re seeing, sadly, far greater suicides now than we are deaths from COVID. We’re seeing far greater deaths from drug overdose that are above excess that we had as background than we are seeing the deaths from COVID. So this is why I keep coming back for the overall social being of individuals, is let’s all work together and find out how we can find common ground to get these schools open in a way that people are comfortable and their safe. And if there is a need for investment and resources, just like there is a need for some of the underprivileged children that are probably better served if they have certain comorbidities to do homeschooling, they need the access to be able to have the computer and the internet to do that.

So, I mean, the goal is to get all these kids back into education. I’d like to see the goal being face-to-face education, five days a week, as when we get there, then we’ve got there for those children that don’t have an underlying significant comorbidity that would preclude it. And, hopefully, the states and the federal government will work together to see that the resources to get these schools fully operational come to bear.

KRIS:  Are you going to be tracking data, as kids start going back to school? What’s the plan for tracking what happens as these schools reopen?

REDFIELD: Yeah, that’s important. That’s the fifth new working document that we’re preparing this week, is how to monitor and evaluate the effectiveness of the programs. Obviously, that’s done in partner with the local, tribal, territorial, and state health departments, but I think it’s critical to be able to monitor how different schools are doing. One of the advantages of having each school figure out its own path is we have a greater opportunity to learn what really works and what doesn’t work. And so, you know, it’s going to be a reiterative process, and, obviously, a strong partnership with our state, local, tribal, and territorial health departments to get that accomplished. We’re going to try to put guidance, as I said, this week together as a baseline for how we think schools should start monitoring and evaluating this, so they can share.

One great thing about, you know, schools and teachers is I think there is a tendency to want to teach and share best practices as we learn what type of interventions really don’t seem to be necessary, even though they may be quite intense in what they require. And then what type of lack of interventions seem to be problematic. I think that’s what we’re going to learn. But I do have a lot of confidence that this pathogen is poorly pathogenic in those of us under the age of 45.

And I do think… you know, there are consequences of the decisions that we’ve made. I mean, one of the ones that’s the most personal to me, I spent a lot of my life working in Africa, one of the consequences here in the United States is, I mean, 85% of kids now that are younger than five are behind on their pediatric vaccination. Vaccines are such an important medical tool. But even worse than that, if you go to Africa where our polio eradication program and our measles vaccine programs have really come to a halt because of COVID concerns and field workers are not out there. I now have 120 million children in Sub Saharan Africa that haven’t received the measles vaccine. And they’re very at risk to die from measles. And they’re very limited risk dying from COVID.

So I think as we look at these things, it is important that we don’t... as Secretary Azar would say, in some of his talks he would say, ‘It’s public health versus... it’s health versus health. It’s not health versus the economy.’ As we know, how many people would miss their mammograms or their colonoscopies or their preventative medicine for neoplastic disease

But we’re here to work side by side. We’re not here to be critical, because, as your questions are noted, there’s a lot we don’t know yet. I wish I knew this virus for 10 years. Then I can answer all these questions. But the truth is we just got introduced six months ago, and I’ve learned already the one thing I’m not going to do is predict how this virus is going to act, because I was pretty hopeful that we’d have a peaceful July and August, and… to get ready for October and November. And, obviously, it’s not going to be a peaceful July and August. And, yet, I do know we still have to get ready for November.

KRIS:  I want to talk about testing, because, obviously, that is going to be key as schools open up. What’s the status of testing?

REDFIELD: You know, again, very, very important. Obviously, fundamental is readily assessable with timely results testing. While one can think it’s remarkable that we’ve gone from, you know, 10,000 tests a day, to 50,000 tests a day, to the other day Admiral Giroir said we did over 800,000 tests in a day. So you can see that’s pushing 5 million tests a week. The reality is that the need for testing is obviously still there. And the need for timely results, as we’ve seen, as we’ve gone to expand what I call surveillance testing in nursing homes, that’s then caused a backlog in getting the results back. So now, in many jurisdictions, as you just pointed out, by the time you take the test results back, they’re no longer actionable, because we really do need to have them returned within 48 to 72 hours if we’re going to really use that from a public health point of view.

I can just tell you, we’re continuing to work to try to continue to expand that. Hopefully, there’s some additional strategies that are going to be operational very soon. One is the idea that in populations where the prevalence may be lower, say, less than 5% of the individuals that are positive, we could actually pool tests. So rather than do one test, one test, one test, one test, you put five samples together and do a single test, and that would then augment your testing capacity. And then if you do get a positive in that sample, you go back and figure out which one of the five people. So that pooling is being finalized as we speak… both at the collection level, where you can go into a household and actually collect the swabs from five different people and put them in a single media tube, or at the laboratory where you take five different samples that have been collected, and then you do one test.

There’s new technology continuing to come. There’s one that we now are in the process of deploying, and the goal is to deploy a point of care test to every nursing home in this country, hopefully, starting later this week, early next week. The first 3,000, 3,500 prioritized nursing homes will begin to get this new equipment, so that they can start doing their own testing of their residents and their workers. And we’d love to get to a point in time when they could also then get to the point where visitors could come back in and people... you  know, I’m an internist and infectious disease doctor and I’ve seen the... there’s just a decline in individuals when they’ve been deprived from interactions. So you’ve probably seen it and your teams probably know how important just maintaining human interaction is, particularly in individuals that are in long-term care facilities. And when you do remove that, there is a clinical consequence.

But, you know, where that magic number is, I think many of us believe we need to get to about 3 to 5 million tests a day to be where we need to be as a nation, so that everyone has readily access or timely results. And all I can say is we’re continuing to push forward. You know, two weeks ago, we were probably at 400,000. Now we’re at 800,000. Hopefully, within a couple of weeks, we’ll be, you know, north of a million, but that’s what we continue to do.

We do continue to encourage the universities and other groups that have access to do testing to help us. Some universities have really stepped up. [...unintelligible...] Massachusetts, for example, is really become the backbone of testing for all of the Boston area, because we do have some really remarkable capability in our research labs, but you’ve got to get the research community to sort of chime in to do that. We did, recently, the CDC gave over $10 billion out to the states, which is in some states, like California and Texas got almost a half-a-billion dollars that we gave. Congress appropriated the money for testing, contact tracing. But you can’t just turn it on overnight. Just because they got the money doesn’t mean they have all the structure to get it done.

But I think it’s a critical area we need to continue to improve it. I think we’ve made enormous progress from, you know, eight to 12 weeks ago, but that’s not to say that we should, you know, do a happy dance and say that we’ve got this done. We still need significant more testing capacity in this country.

KRIS:  How essential is testing to reopening schools, to reopening the communities?

REDFIELD: Yeah, I… you know, we did put guidance out on this, both for K through 12 and for our universities, higher learning. We don’t think that this is the backbone for that decision-making process, testing per se. And different institutions, particularly in higher learning, are looking at some different strategies, particularly if they attract people from all over the country, which includes some areas that may be having significant transmission right now. But we didn’t recommend routine testing at all for K through 12.

The challenge this virus gives us, so unlike flu, which basically causes symptomatic illness and you can use that symptomatic illness to monitor flu…. we actually do, we have a surveillance system which just monitors for flu-like illness. And this is how we monitor for flu. We don’t necessarily test everybody for flu. We just monitor influenza-like illness. This virus is problematic because a significant number of people don’t have symptoms, and that’s inversely related to age. So when you really are looking at a group of individuals under the age of 25, you know, it’s probably going to be somewhere between 50- and 80% of people that have this virus don’t have any symptoms. So the only way you begin to be able to detect that is if you set up broader surveillance programs. This is one of the reasons we recommended that all nursing homes should test everybody in the nursing home, because even elderly individuals, a significant percentage of them may also be asymptomatic or sub-symptomatic. And so to really find out who in the nursing home has COVID, who doesn’t, start from scratch. And then the introduction of the virus in nursing homes really is most frequently the healthcare workers that go into the nursing home. We recently did an analysis in one of the nursing homes in the country that had significant infections, more than 40, and looked at the virus in the nursing home residence, and actually sequenced it and showed that the virus at the nursing home residents all had a common ancestor. But when we looked at the over 20, 30 healthcare professionals that were infected in the same nursing home, the healthcare professionals all had viruses from multiple different ancestors and not the ancestor. So, in other words, people on the outside were getting infected. They’re coming into work. Rarely that infection then crossed over to the nursing home. But once it got into the nursing home residents, it spread within.

So, you know, we’re going to continue to try to work with... that’s why that $10 billion that I gave out to the states, that was actually for the states to develop comprehensive testing programs, which was not just limited to the state’s public health lab. It was ‘Come up with a testing strategy,’ which they had to write, for your whole state, which would include your schools, will include your nursing homes, will include your homeless populations, will include your prisons. And let’s see how you can use testing to get a better handle on the outbreak, recognizing that asymptomatic disease is going to be the biggest challenge we have.

KRIS:  I’ve gotten questions about people being concerned that kids are asymptomatically going to bring the virus home and other people in the family are going to get it. So if you could address that, the asymptomatic spread. And then once we do have tests up and running and we can identify asymptomatic spreaders, how do we deal with it?

REDFIELD: Well, I think we can, if I just come back for a second to remind that we’re not defenseless. I do believe that if we all wore face coverings… and when people ask what was different about Europe, say, Germany versus the United States? Well, when Germany locked down, 95% of the people locked down. When America locked down, we were lucky if we got half the population, and, particularly, we didn’t engage, as you know, early on in the southern states. Even if we looked at our mobility tracking, when we track mobility changes, you know, the northeast was all changing and they were starting to restrict their movements, and then when we looked at the south, it was like nothing happened, right? Now, you got to remember at that time, the South wasn’t seeing any disease either, so they were saying, ‘Hey, there’s no big deal.’ Of course, now, we have a really serious, significant problem with the south right now.

So I do think wearing a mask, washing your hands, maintaining social distancing. But the biggest thing about social distancing is the mask. So I don’t want people to get hung up on six feet. If we’re wearing a mask… these masks really do work. These face coverings, simple face coverings, really do work in interrupting this transmission. And I think the American public is getting closer to accepting face coverings. As I said, I have an editorial coming out today, really trying to just highlight now is the time we all need to do it. If we all wore face coverings for the next four, six, eight, 12 weeks across the nation, as far as… transmission would stop, okay? So I think it’s a powerful tool and that’s the tool that I want people to use, because the price that we’re paying, you know, not to have our kids educated, not to have our businesses open, is also not to have our children vaccinated, not to have preventative medical care given for screening for cancer. These are real prices that could be obfuscated if we just wore a mask. And so I think that’s what we’re really asking people to do.

Meanwhile, we’re trying to be able to set more and more surveillance systems up so we can get a better handle on where there’s disproportionate transmission. You know, we’ve monitored county by county by county by county across this United States, and it is important to emphasize that a majority of counties in the United States are not having significant transmission. We’re less than 200 counties of the more than 3,000 counties that, you know, we have our eyes on. And so in those areas, we need to see those communities be able to have more confidence in getting back to certain activities, like school.

So I think we’ll continue to… back to your questioner’s question, you know, I think we do have growing evidence. I do think her point of view, or his point of view, and those have said that we don’t have overwhelming evidence, I think it’s fully appropriate. We’re building evidence that really does not point to children as being a major transmission instrument for this virus, you know, whether it’s in our household context studies that we’ve done where the introduction is basically by adults… but critics to that can say, but children were largely corralled, so we haven’t seen them in the same setting. We’ll see them once they’re in the school setting. And so I don’t want to get ahead of the data.

But I do think that the biggest thing that I would ask from a social policy point of view, as we get to reopen schools and reopened many aspects of life, one aspect of business I don’t want reopened and I would like closed is those businesses that cause irresponsible behavior. So I’m a big advocate for closing bars. I don’t see why we’re opening bars that allow people to over-consume alcohol until the wee hours of the morning when I’m trying to get people to social distance. But that’s not to say the same thing for other retail that I think we can do.

But I do think it’s important that we recognize the importance of the face coverings that we have. It’s important that we get everyone to get engaged in this right now. And I think we would see progressively a significant decline in these cases as we continue to get people to really, really, really embrace the mask and hand-washing, not going to bars, and maintaining reasonable distance when they’re in crowded environments.

KRIS:  The politics around face masks and some of the polarization in the country, has that made your job harder?

REDFIELD: You know, I think it’s just so important to look at this as it’s not a political statement, it’s a public health statement. And the more we can collectively get behind it as a public health statement and recognize that this is sort of the responsible thing to do for all of us in this country, is to do our part by wearing a face covering. You know, I think the reality is, last February, we didn’t really understand the extent in early February that asymptomatic transmission played. I know once I... and some of that is because we actually had data. When the original 12 cases came in the United States between January 22^nd we diagnosed and the end of February, we evaluated, I think, over 860 contacts, and of those 860 contacts, I only identified two people that were infected. Both were spouses. So that sort of gave us a sense that this virus was not going like this. Because, you know, we looked at 800 people, over 800 people of the original… of the original 12 cases, and we only identified two, which were intimate spouses. It made you think that this virus may be acting more like the other coronaviruses, which were not that transmissible. And then, of course, the virus got introduced not directly from China, but then through Europe, and that virus seems to, obviously, be very transmissible. And as soon as we recognize that the asymptomatic transmission was there, it was when we realized that face coverings were going to be an important public health intervention.

I’m always reminded of my Jesuit education, that Aristotle was known for saying, you know, you can put anything on a blank slate and people will believe it. But try taking it off that slate… and in his day it took a lot of work. You had to sand down the tablet and then put something else on it. It’s really hard to get people to believe it. So initial messaging is so important. And I think, you know, we honestly didn’t have the scientific data to support it back in January and February. We didn’t appreciate the asymptomatic disease. As soon as we did, we became big advocates of face coverings. And I do think then after that there was a politicalization of it. Hopefully, now we’re together, and we can get united. This is part of my editorial in JAMA. Let’s get united behind the most important defense we have against this virus right now, and that’s face coverings, and let’s leave the politics behind.

KRIS:  What will be CDC’s role in the rollout once we have a vaccine or hopefully multiple vaccines?

REDFIELD: Very important. You know, one of the critical roles CDC plays in our nation, of course, is to help facilitate the embracement of vaccinations, the most powerful tool we have, and one of the greatest gifts modern medicine has given to mankind. Our role here directly in the COVID vaccine program is going to be really highly focused on distribution. When we get this vaccine, how do we get it to the American people? Obviously, our role is trying to understand the prioritization, how do we roll this out as we initially get the vaccine? We have what we call the Advisory Committee of Immunization Practices, which is a long-trusted committee that gives advice to me, as the director, on all vaccines—childhood vaccines, the human papilloma vaccine, hepatitis vaccine, use of, you know, either anthrax vaccine or Ebola vaccine. So they’ll give us their formal recommendations. It’s a great group of top people from out the nation, not in government, that give their best advice on how to use that vaccine. Our role will be, also, then, when that vaccine’s available, how do we actually get it to the American public? So we have systems. We have the only public vaccine distribution system in the country right now. We normally give out about 80 million doses of the different vaccines every year. We have the capability to accelerate that to up about 900 million doses. So that’s going to be our dominant role.

The second role we’ll have is in monitoring the evaluation the vaccine for side effects, toxicity, also monitoring the distribution of the vaccine to understand where the gaps are, to make sure the vaccine gets where it is, monitoring the cold chain of the vaccine to make sure the vaccine is handled properly across the nation. So that’s really our dominant role.

Once the decision is made that we have an efficacious, safe and efficacious vaccine ready for distribution... and we’re starting that role now because it takes a long time. You know, we’re, obviously, concerned about making sure we can do better for groups that are under-vaccinated historically, particularly rural America. We’re trying to make sure African-American and Hispanic/Latino populations that are under vaccinated, how do we make sure we can do that? We’re also trying to build some distribution systems that we used in the 2009-2010 flu pandemic, where there was some reluctance by public health people back then about the role of pharmacy vaccination. I think we now know it’s one of the most important distribution mechanisms we have. So how can we really accelerate pharmacies as a key distribution mechanism for a vaccine, particularly in rural America? And then, finally ,how we can gap-fill with probably mobile immunization centers that will go through different communities that are underrepresented, particularly in rural America.

Part of that, what I really want to get done this September, and looking for help for everybody, is to get the American public to embrace the flu vaccine. You know, normally, we’re around 50% of the American public, actually slightly less, 47% of the American public takes the flu vaccine. Well, I need the American public to rethink their vaccine thought process, so that they have the ability to vaccinate with confidence, the flu vaccine. If I can vaccinate people with the flu vaccine, they’re less likely to need to go to the hospital. If they’re less likely to go to the hospital, then there’s going to be more hospital capability for people with COVID virus in the fall. And I really am concerned that if we do have a significant flu epidemic at the same time we have COVID, a number of the health systems will be stretched.

And the real driver of mortality... and it’s important for your group, in particular, the mortality… the most important predictor of mortality, I would say, is the health system getting overwhelmed. So when you look at the difference in New York, where they had about an 8% mortality, and we have other places that have maybe a half-percent mortality, same virus, right? But when the doctors and the nurses and the respiratory therapist all get stretched, and they can start to miss things. This is why we’re surging healthcare professionals right now, you know, to Texas and Florida. And we’re doing it early because we’re not waiting for the health teams to get so fatigued that we see accelerated mortality. We want to get these fresh healthcare professionals in there to relieve the overwhelmed healthcare professionals.

So the flu vaccine program, to me, is important, getting everyone to embrace it with confidence. We’re going to have probably at least 30 million more doses of flu vaccine than we normally have. I’m really hoping the American public embraces it, because one thing the flu vaccine can do is it can prevent children from dying. You know, I’ve mentioned to you that there’s far more mortality for children from flu than there will be from COVID. But it also can help have an impact on the disease seriousness that those of us that are elderly, like myself, we get flu, if we’re vaccinated, we’re going to be more likely not to end up in the hospital, and not to end up on a respirator, and not to end up in a funeral.

KRIS:  So regarding the COVID-19 vaccine, the speed of the work that’s happening is great. But given the feed and the need for a vaccine for COVID-19, (a) do you have any safety concerns, like how will the CDC be tracking that? And then there was a recent poll that showed that half to three-quarters of Americans intend to get vaccinated, but even half to three-quarters is not going to get us to what we need for so-called herd immunity. So what do you say to people who go, ‘I don’t know, I don’t trust these vaccines, I don’t want to be your guinea pig,’ what do you say to those folks?

REDFIELD: Well, I think it’s important. That’s why I talked about this whole idea of, you know, moving away from vaccine hesitancy to vaccinate with confidence. But, you know, it’s a real issue. As you know, I have school districts... I have little pockets in this country where less than 30% of the kids have gotten measles vaccine because their parents don’t want them to have it. And you saw what happened with our measles outbreak. I still got more people not getting flu vaccine in this country than do get flu vaccine. So trying to build that confidence in vaccine’s importance, and try to counter really a very effective group that’s trying to make people really hesitate, and actually some people beyond hesitate for vaccines.

I can say that when we say we’re accelerating this, first, the CDC is going to play a big role in monitoring all the side effects and toxicities of this vaccine, as is done, and we’re making sure we’re, you know, doing that for the whole vaccine program. But I don’t want people to misunderstand what we’re accelerating, you know, when you said project warp speed. So what’s going fast? Are we skipping steps? We’re not skipping any scientific integrity steps, and we’re not going to be skipping safety. But what we are doing that’s different is normally in... you know, when we have a product, we do a phase 1 study, and if it turns out to work, and everyone analyzes the data, it’s debated, then they design a phase 2 study. And then that’s done, and if it works and does what they want, they analyze data. Then they design a phase 3 study, and then if that phase 3 study shows efficacy, it’s possible that they will do a second phase 3 study, so they have at least two efficacy studies. And then the FDA will say, ‘Hey, the drug works and it’s safe.’ And then the company will begin to build manufacturing capability to make the vaccine for distribution. And that process can take five to seven years, right? What’s done here is the phase 1-2 studies were blended, you know, to get initial safety and immunogenicity data. And then certain companies, with US support, some without, are going into a phase 3 study. At the time the phase 3 study starts, and we have about three of them starting this month, the US government is making the decision, at risk, to buy 100 million doses of that vaccine. So we’re not going to wait until the phase 3 study Is done, and whether we find that it works or not. We’re going to go ahead and buy the vaccine now, so you can start making 100 million doses now. And if the vaccine works and we find that out when the study is over in November, we have 100 million doses ready to go. If the vaccine doesn’t work, then we have a lot of souvenirs, you know, in terms of the vials of doses. And, right now, there’re multiple vaccines that the US government has decided to move into that pathway, so it’s not like putting all the eggs in one vaccine. So there’re multiple vaccines that the US government is basically gone into contractual relationships to buy 100 million doses of that vaccine, deliverable upon the time that the FDA says the vaccine is safe and immunogenic and ready for human use. So it’s not like safety’s being discarded.

The other thing, though, that was important is, you know, debating about where do you want to use this vaccine first? And this is something that, obviously, CDC will be very involved in, the ACIP will be very involved in. But it’s very hard if I say I want to use it in individuals that have certain medical conditions that are, say, over the age of 65, if those people weren’t in the original trials, because I don’t know how the vaccine works in individuals. Is it as immunogenic, or is there an immunological senility, and so we don’t get the response? Are there side effects that we see in certain people, so certain comorbidities that we don’t see? So, really, these trials had to be really redesigned, in that those individuals have to be in the trials, in this phase 3 trial, because if they’re not in this trial, it’s going to be impossible, I think, to recommend. So those trials are being designed and such that non-traditional individuals… normally, when I used to do vaccine trials, developing new vaccines in my life, we didn’t enroll people over the age of 45 because the immune system also ages. We never enrolled people that had, you know, diabetes or significant disease. So now these studies are being designed in a way to be inclusive of the population that we hope the vaccine will be available for. Same thing with pregnancy. You know, we rarely would enroll pregnant women into vaccine trials. But if we’re planning to offer vaccines to pregnant women, they really do have to be enrolled in this phase 3 trial.

So, you know, I think some people will continue to worry, but I can tell you that there’s absolutely none of us on this group, and there’s a number of very, you know, strong physicians that are on this warp speed board, none of us are going to compromise safety. And what we are willing to compromise is money.

KRIS:  I am heartened that older adults are being included in trials because I know older adults tend sometimes not to respond to vaccinations as well as younger people. Will you be looking at different types of vaccines as far as which one works for which population?

REDFIELD: Yeah, I think it’s really important. Right now, you know, there are multiple vaccines that are moving forward. The final number… you know, I don’t know what the final number will be between now and September, but it’s going to be more than five, or it’s going to be at least five, you know, and probably will be… and my guess would be it will probably be less than eight. But your point is an important one, because the platform of these viruses, vaccines are quite different. So we have the old-fashioned protein approach with different adjutants, which I kind of like. It’s been around a long time. I understand it. We have the new platform of giving messenger RNA, so that RNA goes into your body and then your body makes the protein. So there’s several of those. And then we have the platform that we’ve used in the last decade or two, where we give a viral vector that carries the information for the protein into the body and then provides that, so the body makes the protein. And then you have a replicating vector virus. So we have multiple platforms, and some of them you can guess are going to be intrinsically safer for the elderly. And some of them will have a propensity that I could compensate the senility issue by different adjutants than I could use, like the solid protein vaccines, which I happen to be more of a fan of just because they’re simpler. I understand them. We’ve used them for 30 years and we know how.

But that’s why none of us can be definitive right now in terms of… people ask me, ‘Well, how are you going to prioritize the vaccine?’ I don’t know what vaccine I’m prioritizing. I need to know how does that vaccine perform in the different populations. So if we have a great vaccine that was available now, the first one, we have 100 million doses, but we find out that the elderly don’t develop an effective immune response to it, well, then we’re probably not going to prioritize that in the elderly. On the other hand, there may be, you know, vaccines that are uniquely preferential for individuals that are older.

And so I can tell you that’s a big issue because, you know, if we could protect people from death… to me, I would be very, very content if I could just prevent people from serious illness, ICU, no ventilators, and death. I mean, even if we had to have a bad cold for a week, as long as nobody died, and they have to go on a ventilator, you know, and get this virus behind us for that individual potentially for a long time, because now they’re immune. You know, even if these viral vaccines don’t prevent infection, but what they do is make it if you get infected, you don’t get sick, you know, and you don’t have to go to the hospital. To me, you could argue that’s the best of both worlds, that you get immunity from the virus infecting your body and the vaccine protects you from getting sick. A lot of vaccines actually work that way. But it’s too premature.

The one thing I can say, as someone that’s been in vaccine development since, you know, probably 1981, a variety of vaccines over my life, I’ve never seen anything move faster. It’s refreshing. Again, I don’t want to say this in a negative way, but sometimes government doesn’t move the fastest. You know, I usually look for the private sector to really be able to move. But I will tell you, in this instance, I’ve never seen the government move faster. And my hope is that between now and January, we’re going to have a successful vaccine, so we can begin to protect the American public from COVID and get this COVID virus behind us. You know, it’s clear that this, you know, first experience is really going to still leave over 75% of the American public susceptible to this virus. So we do need the biological countermeasure. Otherwise, we’re going to have to go through two or three years of wrestling with this virus, and I just would like to get it behind us.

KRIS:  You talked about the flu vaccine, whether people are going to get it or not. Is there a game plan for the fall?

REDFIELD: Yes, there is. And I think you said it right, you hope and pray for the best, but you’ve got to prepare for the worst. And I’ve said this publicly, you know, that I’m concerned that the fall and the winter are going to be quite difficult, is the words I use frequently. It’s been misquoted that I use different words. I didn’t use different words. I said ‘quite difficult.’ Okay? It’s going to be difficult. And it’s going to be difficult because of the potential of having two tough respiratory viruses at the same time. One of the things I talked about preparing, and I’ve already started, is trying to convince… beginning to work on our programs to get more people to want to get vaccinated against flu. The other thing we did to prepare was if more people did get vaccinated against flu, I need to make sure we don’t run out of flu vaccine. You know, the private sector makes, you know, usually, in the past, about 160 million doses of flu vaccine, because only half the American public take it. So the private sector makes what the market uses. This year were… we’ve got them, so they’re probably going to have close to 189 million, 190 million doses. So we’re going to have some more doses. I’ve purchased additional doses. Usually, we purchase 500,000 doses for adults. We have a great program to give free vaccine to children, but we don’t have a program to give free vaccine to adults that are uninsured. Normally we have about 500,000 doses that we give to states to help provide vaccines on uninsured adults. I purchased an extra 7.1 million doses, and now I’m purchasing another 2.2 million doses. So we’ll have, you know, almost 10 million doses for me to give to the states to make sure adults that are uninsured can get access to the flu vaccine. So all of that prep work is done. Meanwhile, we’re working to try to work with leaders in the African American and Hispanic community to help us understand what can we do better to get higher acceptance. And I mentioned to you, we’re really looking at our rural immunization distribution.

So that, to me, is really important because if we can get flu vaccines really taken up, it’s going to… as we go back to the school discussion, it’s going to minimize the number of children that are going to die next year from flu and this fall from flu. And as I mentioned, we lose far more children from flu every year than we’ve lost from COVID.

So that’s really important. And the other is getting the public health system ready. I mentioned to you we dispersed… actually, CDC, if you add the testing money, we’ve given them $12 billion to the states in the last three months to start preparing their critical public health infrastructure to be ready. Obviously, there’s a lot of focus… that’s not in my lane, but others are really preparing the hospitals that have a flexibility programs, so that they can surge their own capacity that they need.

We, obviously…. again, not my lane, but the US government has really beefed up its stockpile. We have almost 60,000 ventilators now that we continue to stock. You know, so they’re building, building, building capacity to be prepared in case we get seriously overwhelmed. And, you know, I will say, so far, in the fall… in the spring, we didn’t have patients in this country denied a ventilator. We had some health systems really stretched, though, as you know. We opened a lot of satellite facilities and convention centers in different states. So all of that system is being prepared.

You know, and… but I think the most important thing, truthfully, it sounds simple, that we can do is get the attitude about the importance of vaccination tilted towards vaccination. And between now and then, get the American public so sensitized to their own personal responsibility and duty to do their part, which is to wear a face mask, wash your hands. That’s going to help for flu, and that’s sure going to help for COVID virus. And, you know, maintain the social distancing. You know, don’t go into big, crowded places that you don’t need to be in. And if you ever are, please make sure you wear a mask and wash your hands. And make sure that if you are in those gatherings, before you go home to somebody that might be more vulnerable, make sure you’ve washed your hands and you wear a mask whenever you’re around those individuals. Because you, in fact, may have been asymptomatically infected and you don’t even know it.

KRIS:  I didn’t think I was going to ask this question, but when you mentioned Florida, and then you just mentioned crowds, what did you think that Disney World opening up?

REDFIELD: You know, I think I’m going to stay in the line that I’d been in, that… to recognize that we try to give information… you know, it depends exactly how they decide to do it. You know, if they stay really committed to mandatory masking, which my understanding they are, if they’re really smart about how they’re distributing concession material, which I was told they are, if they really have significant crowd control, I mean, I think that there’s a possibility that they can show that there’s a path, and to do and do this safely. So, you know, I’m not necessarily going to recommend that they do it, but I was not going to recommend that they don’t do it. I am going to try to give them technical advice. And if they do do it… same thing I’m trying to do with the airlines right now. I mean, everyone knows I’m very disappointed in American Airlines, which made the decision to fill their middle seats. You know, I just flew the other day on Southwest, and I was very appreciative that they’re continuing to leave the middle seats empty because they think that’s an important thing that they do. All the airlines, including American, are using mandatory mask, and I’m very thankful for that. But I do think if you’re on a six-hour plane, you know, ride with three people in a row, in economy class, you know, I’d prefer to see the airlines maintain of the middle seats open for right now. And so… but it’s really not for me… I can just give them the general guidance. They have to make the decisions for their own industry. And, ultimately, the American public will make that judgment, you know, whether they… what airlines they fly, or whether to choose to go to Disneyland or not.

But I think there’s ways for these businesses to operate safely, just like I said with the schools, I believe can operate safely, but I think there has to be some attention to exactly how they do that. You know, I’ve mentioned this several times, I’m anxious to work with the school districts to help them get their schools open. When they see hurdles that they aren’t quite sure how they can get to a place where they have confidence, how to work with them and see if we can find the strategy that they have confidence. Because these are not things that can be mandated. I mean, because, ultimately, the parents have to have confidence and the teachers have to have confidence. If you don’t have parents and teachers with confidence, you’re not going to have schools.

KRIS:   Is there information on the CDC site if parents and teachers and school administrators are concerned, where do they go to get your best guidance on where we are now and how to proceed?

REDFIELD: Yeah, I think the CDC… www.CDC.gov/coronavirus is our best site. And then there’s a search… there’s a search thing. You can put in your question and pretty much, in general, you’re going to get to where our information is. But people can also call. We have hotlines. We get lots of calls, and we have people that actually answer the phone, and help direct you or help make sure you find the information. And we also appreciate people doing that, because sometimes they ask questions that we don’t have information, and then somebody else asks the same question. And then we… that’s how we decide what information we need to get up there, when we hear the questions are coming in and we don’t have guidance on it or information or considerations or resources. That’s what really drives… you know, we have over 2,000 guidelines… guidance documents out there right now and consideration documents and decision tree documents. A lot of those were generated because someone took the time to call in and ask a question. So I would encourage your folks to also consider that, calling the CDC a hotline. I should know it by heart, but maybe I’ll have my assistant follow up with you and let you know that number. It’s a simple number, but I, obviously, don’t remember right now. But it helps us and it helps them make sure that they get the information that they need.

KRIS:  I want to sincerely thank you for taking the time to be here.

REDFIELD: Well, thank you very much, and thank all your listeners. And I hope if you do have questions or things that you think that would be useful for us to provide more information, please take advantage of that hotline that we have, so that can keep making sure we’re providing useful information to the American public.

KRIS.  Thank you.