Lifting the COVID-19 Public Health Emergency

Carlos del Rio: [00:00:05] I am Carlos Del Rio, President of IDSA. Welcome to this episode of Let's Talk ID podcast. Joining me today is Dr. Ashish Jha, the White House COVID-19 Response Coordinator. While serving in this position, he is on leave from Brown University School of Public Health, where he serves as the Dean. Welcome, Ashish.

Ashish Jha: [00:00:24] Carlos, thank you for having me here.

Carlos del Rio: [00:00:25] Well, thank you for dedicating time to be with us today. So let me ask you, you and I have talked a lot about your experience. What has it been like to be inside the White House and to be the COVID-19 coordinator?

Ashish Jha: [00:00:35] So what happened when the President came into office in January of 21, was he really put an all of government program together to try to fight this virus or fight this pandemic. And so as the coordinator, I and our team really think about an entire government-wide response. So obviously, we think about what is CDC and FDA and HHS is doing, but how COVID is affecting travel, how it's affecting what's happening at the border, how COVID is affecting really every part of government and every part of society, and thinking about making sure that we have a coordinated, effective response against this virus. As you might imagine, it's been an extraordinary experience. It's been a huge learning experience and obviously a huge privilege to serve in this role, to try to get our country into a better place, which I would argue we are in. I mean, I think we've clearly made just a lot of progress against this virus.

Carlos del Rio: [00:01:29] Absolutely. So was the job what you imagined when they offered it to you? And are there any surprises or things you wish you knew ahead of time?

Ashish Jha: [00:01:37] Yeah. You know, it's hard even to know what it is that I imagined it would be like working in the White House. I'd say, you know, there's been a lot of learning and I don't know if I'd call them surprises, but let me lay out a couple that I think have really struck me as important insights. One is the sheer breadth of the set of issues that the White House has to deal with, really every part of the functioning of the government. I'm sure COVID is one part of it and important part everything from policy issues on climate change to national security to what's happening more broadly with health, education; it's just all the big stuff ends up here and understanding that breadth of the US government and what it has to manage and what the President has to deal with and his team has to deal with, I think has been really striking and eye opening. The second thing that's a bit related that has been really interesting to me is, you know, I knew this, of course, conceptually, but we are a big and diverse country. And what that means, Carlos, is on almost every policy issue, there are a whole host of views, a whole host of interests. And what I have been really struck by is the senior officials inside the White House. And I think this is true for other government officials. Most of them are trying to get the answer right. They have to absorb all of that information, try to synthesize it, get everybody's perspective, and then try to come up with an answer that moves the policy forward. I've been both really pleasantly surprised at how dedicated people are to getting the answer right, but also how complicated a process that is in making sure that voices across the spectrum are being heard.

Carlos del Rio: [00:03:14] You know, clearly, I'm sure and I've talked to you, the hours are endless, right? I mean, this is worse than being an intern on call. You're essentially on call all the time. And it's not necessarily that you're doing this for the money. It's really service to the nation. So, first of all, thank you and thanks to everybody inside the White House for their service. So a big date is coming up on the calendar, we're all looking at May 11th. The public health emergency ends on May 11th. Can you tell us a little bit about what this means, what will happen? And I think, most importantly, what does it mean for a practicing ID clinician? How should we be prepared or should we not be prepared? What kinds of things can we be expected to happen and how can we help our patients?

Ashish Jha: [00:03:53] There are a lot things that will happen on May 11th and a lot of things that won't. And there's some confusion about this. Public health emergency primarily is a tool that the secretary of Health and Human Services has put in back in January of 2020. That Secretary Becerra, has kept in until May 11th. That has allowed the health care system to function during this emergency period. So policies like bed control and can you set up beds in parking lots or supervision rules. There are a lot of these things that are called kind of 11, 15 waivers. And what that did was it gave the health system a lot of flexibility. Now, we knew that the public health emergency would eventually have to come to an end. So we started going through all those rules and saying which ones are good that we want to keep. And we've spent a lot of time in the last six, eight months making sure that we actually have a policy for keeping it. So telehealth, a lot of really good things on telehealth, came out of the public health emergency. Most of them are going to stay. Pharmacy administration of vaccines. That was a prep act benefit that's going to continue. So there's a whole set of things that are going to be able to continue.

Ashish Jha: [00:04:59] My sense is most clinicians will not even notice on May 12th when they go to work, most things will remain the same. The one thing that people might notice that's important is that the free COVID tests that you can get through health insurance, that will go away. Not for everybody. Some people will keep it, but many insurance companies will take that away. So that's really the only thing that people will notice. And let me actually say what I think will not change products, EUA vaccines, EUA therapies, EUA tests, they will all remain. None of them are tied to this public health emergency declaration. They will remain free for a while. So on May 12th, the day after the public health emergency, one of your patients can walk into a Walgreens, get that Paxlovid prescription, pick it up for free and go home, whatever their insurance status. So there's a lot that will remain after the public health emergency ends. Most of what's changing are these kind of Medicare rules. And we've been working very, very closely with health systems to make sure that those changes are really seamless.

Carlos del Rio: [00:06:03] The other thing that changes and I tell people because people seem to not be aware, is the CDC ability to collect information.

Ashish Jha: [00:06:11] Yes.

Carlos del Rio: [00:06:11] It was very tied to the public health emergency. And what the public health emergencies being gone, essentially the CDC tracker that we all have used and that we look at information, states will no longer have the requirement of reporting data. So I think we're going to lose a lot of our ability to do surveillance.

Ashish Jha: [00:06:27] Yeah, So two things on that. Very good point. Okay. So let me actually clarify on that what will and won't change. So I think of CDC data kind of in three buckets. One is data from labs that will give us information about how many cases there are. That will largely go away because that's a public health emergency tool that we're not going to be able to continue. So we will have less data into kind of number of cases, number of tests happening in every state. Second source of data is hospitalizations and deaths - that will continue. That's a policy decision we made. We're going to continue collecting data on hospitals. So hospitalizations for COVID, we will continue having that at the local level for the foreseeable future. The third is wastewater. Wastewater has been this incredibly, I think, innovative way of doing surveillance, and we have garnered a lot of knowledge, actually a much better way of tracking infection in a community. Wastewater surveillance will not go away. That will also stay. So wastewater stays, hospitalization and death data stays, but cases and test numbers, those will go away after May 11th. And not everywhere, but in many places. And so we'll have to find other ways of making that up.

Carlos del Rio: [00:07:38] That's very helpful. Thank you. And one thing I also tell my patients is, you know, if you're in the US, you can still get from the government website, you can still get free COVID tests. And I say, go ahead and get a few because you'll get your four tests that you're eligible for and until May 11th, you're able to do that and you can keep them to be used later if you need to.

Ashish Jha: [00:07:56] Yes.

Carlos del Rio: [00:07:56] One of the questions that I frequently get from family, but also from colleagues who are overseas, is will the US continue to require proof of vaccination for non US citizens traveling to the US? Many countries have done away with that. Is that also going to go away on May 11th?

Ashish Jha: [00:08:12] We're examining a whole set of requirements that we have for vaccines across the federal government. Vaccine requirements for travelers is certainly one of them. And we are planning on coming out with a new statement on our position very soon. And I expect you're going to hear an announcement very soon on our decision of what will happen to these requirements after the patents.

Carlos del Rio: [00:08:33] It's good that it's being looked at carefully at each one of these situations. Speaking about vaccines, you know, recently FDA and then made updated recommendations for COVID vaccination and then CDC director endorsed them. It was really good to see sort of a simplified approach to the vaccines because, you know, we were all still seeing people in the hospital or in clinics who had never been vaccinated. And we try to get them the original vaccine, the monovalent vaccine, and it wasn't available. So now we have a much easier path and much easier answers. What to do? What do you think will happen going forward? I get this question now a lot, you know, in the fall will it be people over 65 now can get a bivalent booster again if they got one? You know, will we be given another one in the fall? Is it too soon to talk about that? I know your thoughts have been around an annual vaccine, but what do you see happening?

Ashish Jha: [00:09:17] So first of all, I agree with you, Carlos, that I think this recent simplification is great. And just to remind everybody, the simplification from FDA, CDC is, if you're over the age of five, you don't have to think about how many doses have I gotten, not gotten. The simple question that you should ask yourself is, have I gotten the bivalent vaccine? If you have not, you should go get it. And if you have, you're good. Of course, there's always one caveat. And the caveat is if you're over 65 or if you're immunocompromised and it's been at least four months since you got vaccinated or infected, getting a second bivalent is probably beneficial is a good idea and you should consider that. But really, we're at a point where people can just get that one bivalent and know that they're up to date if you're not in a high risk group. Now, to your question of what's going to happen, we don't know, obviously, what exactly is going to happen this fall and winter. It does feel like from a cadence point of view, that we were moving towards a once a year for most people, maybe more often for the highest risk. But this is obviously an FDA decision. And what I suspect is going to happen is that later part of this year, in June, July, they're going to look at the data and they're going to make a determination about whether they want to do a strain change for the vaccine, to update it for potentially circulating variants that are likely to be here in the fall. It's a bit like the flu model in that way. So that is what FDA may very well do. But we just don't know right now exactly what the cadence will be that FDA will come up with.

Carlos del Rio: [00:10:39] Yeah, I like this term. It's up to date. And again, what you said, if you have received a bivalent booster, you're up to date. My concern, obviously, I know your concern is that only 16% of the US population has received a bivalent booster and only 46% of those over the age of of 65 even gotten their first bivalent booster. So I think we got to do better in getting people their bivalent boosters and do whatever we can to really push for people to get their bivalent boosters. It's a pretty urgent thing that we do, especially for those over the age of 65.

Ashish Jha: [00:11:06] Absolutely. And part of it is I think simplification helps. As you know, Carlos, there's been a lot of bad information, misinformation. A lot of people who are elderly, most people were elderly, did get vaccinated in 2021, and a lot of them got vaccinated in 22 and the early part. And so I think a lot of them may have thought, well, I just got my booster. I don't know if I need it. I'm hoping that as we get to this fall, we get into a rhythm where people are very used to going and getting their flu shot. And if the updated vaccine is happening at the same time, we can really rely on both that mental model and that infrastructure to get a lot more people vaccinated this year.

Carlos del Rio: [00:11:44] Yeah, there's also a component, of course, that many people have gotten infected. Right. And many people are saying, well, you know, I got my two vaccines plus I got infected recently, so I really don't need to worry. And in a way, I think for most individuals, that's probably true. You know, if you're under the age of 50, that's probably fine.

Ashish Jha: [00:12:00] No question. I think of getting infected, I mean, it's just one more boost to your immune system. It's not as safe as being vaccinated, not as pleasant because you have to deal with an infection, but it is a boost to your immune system. And then the question really becomes, how long do you wait? All of that. I think FDA is recommendation of waiting at least until four months until you get that next shot makes a lot of sense. The key here is if you're older, really keeping your immune system as up to date as possible is absolutely critical because as you know, Carlos, protection against serious illness, while that remains quite good for young, healthy people for quite a period of time, either from vaccinations or from infection for the elderly, you see a clear waning against serious illness after some period of time. And so keeping your immune system up to date is really critical here.

Carlos del Rio: [00:12:48] And that takes me to the other component that you and I have discussed a lot, is that if you're over 65 and you get infected, we got to get you on therapy. And I still think we are under utilizing our available tools.

Ashish Jha: [00:12:59] No question. No question. You know, it's interesting. We've done a lot of work on this, obviously pushed to understand better why have so many clinicians been hesitant? In my mind, there are 2 or 3 issues that keep coming up - drug-drug interactions. And here I am going to give a big shout out to IDSA. What you guys did in terms of creating a very straightforward way of thinking about drug-drug interactions was extraordinarily helpful. I have used your sheet and shared that very, very widely with lots and lots of organizations, but it's a reminder that most drug-drug interactions can be managed and you can still get people Paxlovid. Another issue that often comes up, which drives me a bit crazy is I have family and friends who are clearly in high risk, will call their doctor and the doctor will say, Well, your symptoms are mild. And I always remind people it's not about the symptoms being mild or serious about how serious your risk is, not how serious your symptoms are. And often what we see is a 70 year old might have mild symptoms, doesn't get Paxlovid because of that. And by the time they get severe symptoms, they're day six, day seven, and out of the window of really benefiting from Paxlovid. So it's very, very important that anybody who is at elevated risk get treated.

Carlos del Rio: [00:14:09] And it's duch an important piece of communication that I think we as physicians have to get out there. That it's not about your symptoms. It's about your risk.

Ashish Jha: [00:14:16] Exactly.

Carlos del Rio: [00:14:16] So going forward, predicting the future is hard, especially when the future is not necessarily in this virus has been particularly hard. But what do you expect will happen with COVID? Is it going to be something that will just continue waxing and waning and we'll continue seeing cases and we'll just have to pretty much learn to live with it? Or how do you see us moving forward over the next 2 to 3 years

Ashish Jha: [00:14:38] It's interesting. I mean, often the question I get asked is, is it going to be just like the flu? And I say, no, it's going to be just like COVID. I mean, in the sense that COVID is not flu. It's just different. Flu is super seasonal. Right? Like we just don't see a lot of flu in May, June, July. We have every year, we've seen a good amount of COVID in May, June, July, Right. Especially June, July and August. It is a very different virus. It is behaving differently. We have learned to live with it. I mean people say, well, we have to. Yes, we will have to. We do live with it because the alternative is to try to eliminate it, which is not on the table. It's not realistic. It's not possible. And so then the question is, how do you live with it? And I always sort of say, you know, do you want to live with it safely or do you want to live with it dangerously? Living with it safely is being update to date on your vaccines, getting treated when you get infected. Living with it dangerously is not being up to date on your vaccine, particularly if you're at elevated risk and not getting treated. Both of them you can live with the virus,  but the question is, how much damage will the virus cause? How disruptive will it be? And what we know is we can live with it in a way that is safe if people keep up on these things.

Carlos del Rio: [00:15:42] Absolutely. Well, you know, as we talked about, the still the low uptake of the bivalent booster, when the recommendation came out for 65 and older, I was hoping that at some point in time, CMS, Medicare will pick it up and say, you know, we're going to make this a Medicare facilitated requirement. Because really we need to get people, Medicare-eligible populations really, get their boosters. It's going to be really important.

Ashish Jha: [00:16:05] I agree and I think you're going to see more and more actions from CMS really pushing providers to make sure that they're offering it, that they're doing everything they can to help people get vaccinated.

Carlos del Rio: [00:16:15] As you said, we're getting out of COVID. This is getting no longer in a pandemic phase. Do you think we are better prepared for the next pandemic or are there lessons we need to take into consideration so we're better prepared? Or where do you see ourselves?

Ashish Jha: [00:16:29] Yeah, it's an interesting question, Carlos, and I was at an event recently and one of my public health colleagues said he worried that we were even worse off now than we were four years ago in terms of preparedness. I gently and respectfully disagreed with that. And let me make the case for why I think in many ways we are much better prepared and in other ways we have work to do. So how are we better prepared? We have phenomenal surveillance in a way we didn't have four years ago. I mean, if you think about the National Wastewater Surveillance System, majority of the country now lives in a place where we're able to do surveillance of wastewater. That's obviously super helpful for COVID. We've used it for M-pox, we've used it for polio. And when there is the next outbreak, we're going to be able to use it for that. That surveillance system is extraordinary. It's not dependent on people going and getting tested. It is very, very helpful. That is going to make us better off. You know, there were some serious challenges in the early days with creating tests from the CDC. Dr. Walensky and the CDC team has done a lot of very good work on improving the testing infrastructure at CDC. We have demonstrated we can build vaccines very quickly, and we're working on building platforms for new generation of vaccine development.

Ashish Jha: [00:17:39] We just announced this $5 billion program for next generation of vaccines and treatments that are primarily focused on SARS-CoV-2, but will have huge spillovers on building better vaccines and treatments for other diseases. So that's all the good stuff. And I think all of that leaves us better off. So where are the challenges? You know, we are in a situation where obviously the country is exhausted and if we were to get a bad, let's say we got avian influenza happening right now, I would be very worried about the capacity and the energy of people to deal with a new virus. So that, I think, leaves us worse off. Obviously, there has been a ton of misinformation about vaccines and therapies and this virus that we have to counter. And until we counter that and rebuild trust in public health, that leaves us worse off. And then the last but not least, is we have a very spent health care and public health workforce. And so there are some real challenges in front of us. I am mostly optimistic that we are going to come out of the emergency phase of this virus, of this pandemic with a lot of strengths, but we also have a lot of rebuilding to do, Carlos, I think we've got to focus on those other areas as well.

Carlos del Rio: [00:18:47] There's a road map that we all need to follow. And I think in IDSA, we are very committed to being part of that roadmap and to strengthen our workforce, strengthen our capacity to respond to pandemics. Because the question is not if, the question is really when, right?

Ashish Jha: [00:19:01] IDSA, I know I've told you this personally and I will say on the podcast, has been such a fantastic partner. I mean, at each step over the last two and a half years and certainly in the last year or so when I have been in this role on critical issues where we have needed intellectual leadership or we have needed guidance from expertise and experts, IDSA, you, yourself, other members of IDSA and the society has just delivered. And that has meant a lot to me and other people here at the White House. I should say thank you for that. We needed it and the country needed it. And IDSA has really just been there with us. So thank you.

Carlos del Rio: [00:19:33] Well, thank you, Ashish. We appreciate that. And again, you know, our members are the boots on the ground, right? They're the ones that are in the forefront of responding to infectious disease. So it's important to have this communication with policy because otherwise you feel like there's a disconnect. So I think it's good for you as policymakers, but it's also good for us as frontline providers to feel like we have a say and we are being listened to into the national discourse and to the policy making.

Ashish Jha: [00:19:57] Well, absolutely. And you have had a say and rightly so, and very much listened and appreciated.

Carlos del Rio: [00:20:02] Well, listen, thank you very much. I appreciate you joining us today and thanks again for your service in the White House and your service to the nation. And I look forward to continuing collaborating with you.

Ashish Jha: [00:20:11] Sounds great. Have a great day and thank you again for having me on.