Good afternoon, everybody. Welcome back after lunch. My name is Robert Quigley. I'm Senior Vice President and Global Medical Director at International SOS. And I have the distinct privilege of moderating today's session. And I want to thank the college for the opportunity to present today's message, which I think is somewhat topical, even though I'm getting a little tired of COVID-19 myself. But we've got an esteemed group to discuss this. And I'll introduce first on my extreme left is Dr. Myles Druckmann, who's a colleague of mine. He's also Senior Vice President and Global Medical Director at International SOS. And he serves as the Co-Chairman of the International Corporate Health Leadership Council, of which I am the Executive Chairman. And we'll talk about that in just a moment. And my other colleague is Dr. Brad Hirsch, who's a Senior Medical Epidemiologist and CDC Liaison Officer with the WHO. And before we proceed, I think Brad has a couple of comments to make about a disclaimer. Yeah, okay. I'll be brief. Please. And first of all, thanks for inviting me. It's a pleasure to be here. It's a pleasure to be with people. I'm a bit tired of doing Zooms all the time. And Rob, you promised me we would discuss everything here except COVID, right? I've run into some old friends here in the meetings. And I say, how are you? And all three came back to me and say, I'm tired. I'm tired. I think we're all tired of this COVID. It's time to move on to something else. But I'm cautiously optimistic. My job, I'm based in Geneva, Switzerland. And I am the CDC Liaison to WHO for COVID. And I'm the person in between CDC and WHO. But I need to stress here that I'm here today as a private citizen. And the views expressed by me are mine alone and may or may not reflect those of CDC or WHO. Although, I've got to say, there's a lot of alignment between the CDC and WHO. And finally, it's important to understand that CDC has got a mandate for the U.S. They report to the U.S. people, Congress, President, et cetera, while WHO reports to 194 member states of WHO. So it's a different mandate, a different population to work with. But the collaboration between CDC and WHO is very strong. Thank you. Thank you very much for clarifying that, Brett. All right. As I said, Dr. Druckmann and I are both members of a council called the International Corporate Health Leadership Council, of which I can see members of that council in this room. Just to be clear, it's a 501C6 nonprofit entity that's been around for about 12 years. The mission of the council is, as you can read, it's a forum where leaders in corporate health and medical services can assemble and exchange ideas. And we sometimes publish those ideas. We develop what we think are benchmark best practices. And then we disseminate that information through a variety of vehicles. You can see on the bottom of your screen, these are major companies that are represented on the council, the corporate medical directors, both past and present. And it's such a privilege to be part of that, because it's a one-of-a-kind forum where we can get together, Chatham House rule apply. We talk about anything we want that's on our mind. We share ideas. And what we talk about stays within that room. We've had numerous publications over the years, white papers, which we post on our website, ichlc.org, which you're welcome to look up at your own free time. We also do trend reports. In fact, we're working on another one right now, which are worth reading. Those are posted on our website. And finally, we do a lot of speaking engagements. As you can see, we've had an active role at the AOHC for the last five or six years, where we've had the privilege of presenting some of our work as we are today. So the way I want to run today's session, which I'm very excited about, is I want to just consolidate everything that we've been exposed to and learned as a group. I don't think there's going to be anything really new that you're going to learn. And then I want to nail down with the use of my esteemed colleagues here, what do we have to look forward to, what are the lessons learned, and how might we avoid this nonsense that we've been through over the last two plus years. So I'm going to ask a question. I will have the question posted on the top of each slide so that you'll remember what the question was. And there'll be some trigger points for the two speakers to use or not use as they answer the question. And I'll just keep things going as we move forward. So the first question I'm going to ask them is, what are the 10 lessons learned from the COVID-19 pandemic? And the first one is viruses mutate. And I'm going to ask Brad to comment on what's the significance of that, particularly in the context of vaccinations and efficacy of vaccinations and fears and the like. Yeah, I think that over the past year, two years, we've all learned the term variant. I'm not sure I knew what it meant before, but we've heard this over and over again, because like most viruses, and this is a RNA virus, single-stranded RNA, it definitely mutates over time. It doesn't have a correction ability to correct errors in transcription, and this virus recently made the jump from animals to man and is currently going through evolution. The more it passes through people's bodies and reproduces itself, the higher the increased risk of variants. The term is also used, scariance, that we hear about a new variant in this country, a new variant there, and it scares us that the epidemic is changing, and maybe the variant will not be responsive to vaccines or to treatment. But the good news is that so far, all the variants which have been identified, still, the vaccines still protect against severe disease and death, and that's what we care about vaccines. We'll talk more about vaccines a bit later, but I think that this virus is changing. There are now new variants in South Africa, the BA4, BA5. There's now a new variant in the U.S., which is increasing in frequency in many countries, in many parts of the U.S. The BA2 variant is in Europe. In most countries, it came through the U.S. first. But the good news is the vaccines we have now are effective for severe disease and death against the evolving SARS-CoV-2 virus. Thanks. Dr. Druckmann, you've been studying pandemics for more than a couple of decades, and I know that you know probably more than any of us about these wave patterns that are projected on the screen right now. Can you tell me a little bit about, I'm sorry, can you tell me a little bit about, are these wave patterns, these surges, which we have seen with pandemic after pandemic, are they applicable to COVID-19, or does it have its own pattern if we were to graphically project what we've seen? What are your thoughts on that? Yeah, I mean, I think it's a very interesting, you know, topic, Rob, around what the wave processes that we've seen and how this has evolved. I'm going to take a quick segue back because I just want to jump back to something we talked about yesterday. At AOHC, and again, this was May 1st, 13 years ago, we had H1N1 outbreak, and the outbreak, you know, hit everybody, and it was at the conference, and if you were here at the conference, everyone was scrambling around trying to figure out what to do. They were all calling their CEOs and going through this crisis, and, you know, at the end of it, the doctors were leading the way, and no one knew what that first wave, you know, of H1N1 was going to be, and everyone assumed it was going to be the next Spanish flu. And thank God it wasn't, but I think that was our first little lesson, right? And then this, you know, coronavirus really came out of the blue, out of left field. I think it caught a lot of us, and we've talked about this with the CDC and the WHO, by surprise. I think a lot of us were pretty, we weren't cavalier, but we were looking at this as, well, you know, we don't think this is going to go anywhere, and of course it did. And I think that, you know, when you're early in a pandemic, it's really challenging to know what the trajectory is going to be. You know, H1N1 didn't really ultimately do a global, you know, disaster like it did, like this has done. So you really have to model and monitor that trajectory. And one of the things that I've been really pushing throughout this pandemic is that those waves that you're looking at on the screen, you know, the data we typically get is at the national level. And, you know, the nation, if it's Singapore, that's great. It's a small, you know, city country, you know, you're covering a lot of the population. But, you know, if you're in the US, you're in Canada, you're in Russia, you're in large land masses. These waves are multiple, overlapping each other. So one city could have an outbreak, another city's got nothing, you know, you can be a short distance away. So if you really look at those waves, they are actually, you know, very much like an ocean, multiple waves on top of each other. And so as a corporate medical director, the challenge is, how do I make sense of where this wave is going? And you know, we are concerned about where our people are. And so therefore, we're focused on where our operations are. And I think part of the challenge has been, you know, the first waves were hard to predict. But as we've moved along, we've seen a lot better predictions. And you know, we were talking about how the corporate medical director has played a really important role through this pandemic. And it's trying to give a couple weeks notice to our management team of where we think this is going to go. So the wave concept, I think, is critical, and it's going to be something that is going to be ingrained in all of our minds, I think, for any kind of outbreak in the future. You bring up a good point, which is the corporate medical director, which is what this audience is. All of them have assets in different jurisdictions, and policies and procedures in jurisdiction A may not be appropriate in jurisdiction B, which I think is one of the challenges we'll get to. I'm going to ask you to talk about this. How do you like that? Yeah. It's a good picture for you. Okay. Well, actually, that's a good segue to what I wanted to say. Go right ahead. Bring this one. This is something we talked about, the wave pattern, a lot of WHO and a lot about CDC trying to explain why this happens. And I think that we found out there are three variables. I think you all know that. Debbie Burks said early on, we're trying to flatten the curve. And you flatten the curve by stopping contact between those infected and those not infected. And there are three really categories, things we look at. We look at transmissibility, contact rate between people, and the susceptibility rate. If nobody's susceptible, the outbreak will stop. But if there's high contact rates and the virus is very transmissible, like SARS-CoV-2, and susceptibility is low, we will see transmission. And the virus was introduced into the U.S. early in 2020. Nobody in the population was immune to this virus, because we never had any contact with this virus before. And you saw it wipe through areas with nursing homes, military barracks, schools, universities, etc. And because this virus is transmitted by aerosol, which took us a while to really understand that, to really agree to that, even though many people said early on that we're seeing rapid transmission because it's aerosol. And I think that we were fooled, all of us, most of us, because we were used to the SARS virus, the MERS virus, original, the Middle East respiratory syndrome, and we didn't expect it to be so transmissible, because those viruses were not very transmissible. Which is what this really is. It has an air knot, especially the Omicron, approaching that of measles. So therefore, if I were to be infected, and I were to sneeze in this room, and you were all susceptible, many of you would get infected. So this virus is transmitted by aerosol, and it's very infectious. Which is a great segue into this next point, point number four, it's highly transmissible when compared to other viruses. Miles, you spent a lot of time with SARS in 03, I can remember the issues you faced in Toronto and in Hong Kong, and then with MERS a little bit later, Brad brought up the idea of R-naught, and the R-naught value, I don't think any of us have fully understood with COVID-19, and in fact, Brad just said it might even be approaching measles, which if I'm not mistaken is somewhere around 16. Do you have any comments about this virus, COVID, this novel coronavirus, COVID-19, with respect to these other two? Well, I think this has been one of the big challenges with this virus, because it hasn't been at one R-naught, right? It started likely at a much lower R-naught, and as it's evolved, and no variants have come on play, they become much more transmissible. So it's a moving target, but I'll bring up one little vignette that a security director of a major organization kind of said to me early on, and he said, look, the challenge that a lot of companies have is that the science takes a long time, and they have a vacuum behind it that they have to make decisions. And he said, look, we looked at what was happening in Hong Kong. There was a study, if you guys remember, way at the beginning of a restaurant, and that there were a bunch of people at the restaurant, and one of the tables next door, someone got sick, and then there was a Hong Kong hotel, I think, or apartment building, and the air vents. And so the security guys said, hey, our judgment of this is airborne, right? So we think it's airborne until anyone tells us different, right? So they got masks way before it was finally said, you know what, it's airborne. So I think part of our challenge as physicians is that we've had to become soothsayers in a way, right? We're having to take a lot of disparate information or incomplete information and come up with a probability, because companies are used to dealing with probabilities. They're doing budgets. If any company hits their budget, absolutely, it's a miracle, right? So they're used to kind of that gray area, but they need something. So when you look at this transmission, again, we also have to be careful, because if we keep the transmission, we assume the transmission is at the same level all the way through, we're misinforming our organizations. So we have to have the confidence to say, it's going to change, and that's OK. It's not that we were wrong. It's that the virus changed. All right. Good point. One comment, Brad. Just on the same point, just that we mentioned this virus has mutated, has changed over time. And each time it's mutated, for the most part, it has become more transmissible. And that's a major question. We see the virus started out as two or three, then it was six or seven, 10 to 12, like mumps, and then all the way to measles, 15, 16. So as the virus has become more fit, more used to being transmitted in man, the more rapidly transmissible viruses defeat the other viruses, because they're competing for the same host. And those that can infect and reproduce at high levels with a short incubation period, and they're more transmissible, like through aerosol, that makes the virus more fit. And a question that you'll ask, but later on, will be about severity, which we'll wait for a bit. We will wait for it. Thank you. How about number five? The waistline impacts the bottom line. So does comorbidity. And I think many of you are familiar with the CDC graphic on the bottom. It's been out for well over a year, but it talks about the correlation between the number of comorbidities and the likelihood of you getting a severe illness and dying. So do you want to comment, Myles, on this particular concept that noncommunicable diseases, which we've all been dealing with on a regular basis, it's on our agenda, is very, very relevant to this disease? Well, I don't think it's the same. It's the same story of us having to understand the disease, right, and understand it over time, because we didn't know it was obesity at the beginning, right, until the data starts to come in. But then once we've identified that that's actually a very high-risk group, the challenge is how do you manage that? And there was a presentation this morning. The Procter & Gamble group got up, and they really focused on obesity within their workforce and had a whole program put in place. So I think the challenge is getting, you know, the data, understanding, okay, we have a specific, you know, high-risk group, and then the question is how can we rapidly put a program in place to try to mitigate and support that group to take them out of those high-risk categories. So I think that's part of our challenge as medical directors is that you've got to be assessing the data, and if you flag something, okay, how do we make this actionable? How can we try to move, you know, the needle and protect our people better? Brad, I want you to just make a comment on something you said to me the other day, which is your opinion of this particular disease with respect to comorbidities and age. What was the statement you said on that? Yeah, I mean, this is a virus which, if you're, you talk about probabilities, Myles. I like to think of it as risk, which is sort of the contrary of that, you know, sort of the opposite side, that if you're under 50, under 40, your risk of dying from this virus is very low. I have three grandkids, all under 14 years of age. Their risk of getting severe COVID is virtually zero. Somebody 30 years old increases gradually, but once you hit 60, 70, 80, it's exponential growth of risk. The relative risk of somebody 80 years old compared to somebody 10 years old can be 3,000. So we're seeing a huge elevated relative risk of older people. And I think what I've heard from a colleague of mine is that SARS-CoV-2, COVID-19, kills the elderly, the frail, and the weak. It doesn't attack the entire population evenly, but really the people who are over 60, those with chronic conditions, like the person on the right, obesity, diabetes, hypertension, cancer, heart disease, those together with age greatly increase the risk. So I think that, to me, this is a disease, a public health crisis of the elderly. And having comorbidities just increases the relative risk. It does. And I think one thing too is that, in a sense, the disease somewhat morphed a little bit because early on it was very respiratory driven. Remember, O2 sat, oxygenation, people were really having severe respiratory distress. And over time, it's moved more into chronic disease. It's just the weakened, the people who aren't able to respond and react to these stressors that are succumbing to the disease. Let's dive a little bit into the science. We know that the adaptive immune response, whether it's through infection or vaccination to this novel coronavirus, is very, very complex. So on the left of your screen is the T cell mediated response, and on the right is the humoral response, and clearly both of them get activated when you're exposed either through a vaccination or through the disease. I'll ask you, Brad, do you have any comments if somebody said to you, look, I've had COVID, I don't need the vaccine, and I certainly don't need the booster. Is that relevant in the context of this complex immune response to exposure? Absolutely. It depends how old the person is to begin, you know, so somebody is 12 years old, I've had COVID, they're not the highest priority for a booster. They should be vaccinated, not the highest priority. But somebody who is 70 years old with comorbidities, they're the highest risk, and I think that in preparing for this, I don't know much about immunology after I've finished medical school, but I found a word in Harrison's tech book of medicine, inflammaging, and basically when people are over 60 or 70, they have chronic inflammation throughout the body, and that's tied, inflammaging is tied with immunosenescence. So people are having weak immune system, chronic inflammation from other viruses, from the aging process, which is only exacerbated by COVID-19. This virus really exacerbates the trend of decreasing immunity among the elderly. Thank you. Miles, you know, you and I have talked about this whole aberrant post-immune response, the cytokine storm, and that was initially the explanation as to why a certain cohort of people got really sick and died. Do you still believe in that, or do you think there's other possibilities? Yeah, I mean, that's what everyone coming out of the gate was looking at was the cytokine storm concept. I think there's some other external, additional, you know, processes in play that might be causing this significant over-response of the immune system. I think that, you know, it's still, they're still sorting that out, and again, the virus is a moving target too, so, you know, what was happening, you know, two years ago versus where it is today, it may be having a slightly different effect on our immune systems. One thing I will flag, though, on the last one is T-cells, right? I think that's a little bit of our, an open story, because we don't really test for T-cells, right? Everyone's talking about antibodies, antibodies, antibodies, but T-cell response could be a real ace in the hole in how effective those killer cells are, and because we can't test for it, we really don't know, you know, globally how effective and important they are in the whole immune response. And nor, on that same vein, nor do we know what level, if you go back to the humoral side, what level of antibody is protective. Correct. Forty percent, is it? Forty percent, because we know it wanes. Yeah, I mean, I remember in the early days, you know, I was talking to some friends who had to go overseas, and he got his antibodies, and he said, well, I got 700, you know, is that good? You know, it's just, no one knows, right? And we still don't really know, and so, there's all, and again, you've got different tests that have different efficacy, so, yeah, it's still, there's still a lot we don't know about how the immune system works on this. And that may be an important point when we talk about the vaccines and hybrid immunity being more effective against severe disease and death. So, perhaps the neutralizing antibodies through the B cells can neutralize the infection, and we do know that after vaccination, whether it be primary, secondary, booster vaccination, after disease, the level of IgG is high, but it decreases relatively quickly. So, we do know that B cell immunity decreases relatively quickly, that we've known for a long time with coronaviruses, but the fact that these vaccines seem to be effective against severe disease and death tells me that perhaps the T cells are playing an important role in immunity. So, the virus gets through the antibodies, but the T cells are there to respond, memory T cells respond and can neutralize the virus and prevent severe disease or death. That's the depth of my knowledge of immunology. You've done very well. And Rob, Rob, so you're an immunologist as well, so just one question to you then. So, you know, when that IgG goes down, that doesn't mean the antibodies have gone away, right? That's correct. You still have your memory cells. So, the other issue is how quickly they will respond and start to reproduce, you know, because your body is not continually making antibodies to things that might happen over 10, 15 years. But historically, because of the concept of memory, that second response should be that much quicker than the initial one. Exactly. You're absolutely right. But there's still a lot of unknowns on both sides. That was a good segue, Brad, into this about the vaccines. Miles, I'm going to ask you about this. You know, there's a variety of vaccines and we in the global space have been in situations where clients and colleagues have gotten different vaccines for various reasons. This mRNA technology for both the Pfizer and the Moderna, I thought was fascinating as a scientist. I thought it was fascinating. And it was actually leveraging something that's been going on in the oncologic communities for probably a couple of decades. And they all of a sudden took that science and applied it to the vaccine synthesis. Do you think the fact that this was new technology has any role in why people are a little bit concerned about getting the vaccine? Oh, I think for sure. I mean, particularly here in North America, you know, which was the primary dose, I mean, there's J&J as well. But if you actually canvassed a lot of the medical professionals and we, you know, there's a lot of polling on health care professionals, there was a significant proportion that did not want to get vaccinated until they saw longer, longer longitudinal studies of its, you know, side effects. And then they tracked those people over time. And after about a year, 90 something percent had actually ultimately got it. So I think there's a window where, you know, all of us are, you know, like we should be skeptical of new things and new technologies. But and again, it's a risk, you know, risk reward kind of situation. How severe is the outbreak? You know, how high is the risk, you know, of the side effect? So I think we also saw in certain countries where there wasn't an outbreak, it was a lot harder to get people to get vaccinated with the mRNA vaccines, you know, in Australia, for example, until really the pandemic hit, you know, then people started to jump, you know, jump and get it. Brad, a quick comment. Yeah, I just fully agree with that. Most of my career was spent working on various vaccines in developing countries, measles, polio, yellow fever, rubella. And these vaccines are different than the mRNA vaccines, the measles vaccine, you give a dose to somebody at two, two years of age, and most people are protected for life with one dose. With two doses, virtually 99% are protected from for getting infected, transmitting the virus and getting sick or dying. This is a different kind of vaccine, you know, which, you know, I think we might may have over promised the public health community, plus the vaccine community of promising what this vaccine can do. And I've got to say, this is an incredibly good vaccine. It's not a perfect vaccine. But think about it two years ago, the virus was going through our communities, killing a lot of people, mostly elderly people. And we had no vaccine. We had no treatment other than steroids and supportive care, but we've come a long way with these vaccines. But these vaccines are very effective against severe disease and death. That's the point you've really got to take home with you because it doesn't stop transmission, you may get infected, you may be asymptomatic, but you can transmit it. I mean, a personal anecdote is that about a month ago, I was in Europe, and I wanted to come back to see my mother in Florida. And I went for a COVID test in Geneva, Switzerland. And it's basically they do it, you don't have to give your name, just go and get it done. So I went and got it done, antigen test. And they come back and asked me, Dr. Hirsch, we'd like to see your passport. And my because my antigen test was positive. I had no symptoms whatsoever. Which meant I couldn't travel to the US for 10 days, because the US requires a negative antigen test. So I had to wait 10 days and come back. But I just want to say that these vaccines are really miraculous. I think we'll have better vaccines in the future. I think that I've been on many research calls with WHO and CDC, with the private sector, with Pfizer, Moderna, Merck, other companies, trying to develop a pan coronavirus vaccine, which is good against all variants, all all coronaviruses. That's in the works. It's not going to be available this year, next year. But I do think that they will strengthen the current mRNA vaccines. But to your point, and I think of all the comments you've made on this subject, to your point, we were in a crisis, we needed a vaccine and traditional vaccine technology was going to take too long. And there was too much at stake. So right. We took with speed, I think is absolutely critical. You're right, wasn't perfect, but it did work. It's a great vaccine. So to your point, another good segue. It's almost like you've seen these slides before, Brad, is the breakthrough of infection and fully vaccinated. Do you want to comment on that, Myles? Yeah, I mean, I think it's well understood by probably everyone in the room that and exactly as Brad said, it's not a perfect vaccine. And I think, you know, it's doing ultimately what the key thing from a public health perspective is keep people out of the hospital, keep people from dying. And it's done an incredible job with that. But it's not going to stop, you know, breakthroughs. And again, with the variants that are coming in, we're having to continually test these variants against the vaccines. And that's going to be a continuing challenge. So so far, so good. Right. But we don't know what's coming around the corner. Let's look at number 10. With our list of 10, the long haul COVID-19 is real. And it's real from both a physical standpoint, as well as a psychological one. And the psychological one is particularly interesting to me. There's been a couple of really good papers. I'm sure you're familiar with the one that came out in Lancet Psychiatry a little over a year ago that talked about I think it was 70,000 plus individuals in America that had been infected with COVID. And it was all about chicken or the egg. Was there a bidirectional relationship between a COVID infection and the development of development of certain psychotropic manifestations, mild ones, but still. And there was a statistically significant correlation. And more recently in the British Medical Journal was a longer follow up of a year. And clearly there is a relationship between a COVID-19 infection and particularly stress anxiety and depression. So with that being said, Miles, what are you advising your clients who are calling you and saying, look, I've got a certain group of my workforce who are calling me either with behavioral health concerns or physical concerns. They're fatigued. They might have aches and pains. A lot of these sort of unusual manifestations of this disease chronically. What advice are you giving? Yeah. Well, look, I mean, I think this is really an evolving. This is what we're going to be dealing with for the next couple years and probably longer. Just one little personal anecdote. I had a close family friend who had the virus early on in the outbreak and literally for six months, short of breath walking and unable to focus, just that classic fog. And then one day watching TV and just reading the script on the TV, she says, I can now read it. And I mean, it was just like the flip, the switch flip. So don't know how long this is going to take. And I think there was a huge amount of anxiety and stress around this because you don't know, is this going to be for the rest of my life? Is it going to go away? Is it going to go away tomorrow? So I think the stress of it is significant. I think it's, again, very new. We're still learning as we go about this whole concept. And so it's going to be the challenge of the next couple of years. Thank you. In this moving away from that top 10, let's look at this. What were some of the obstacles for corporate medical directors who were attempting to address the health and safety of their global workforce? That's always been their job. CMD, that's their priority. How do we protect the health and safety of our workforce? And so all of these measures that were put in place that on the slide talks about the layers of protection against COVID-19, you know, at the end of the day, they didn't always work. Because as you saw two slides ago, there's breakthroughs. So give me a little bit of advice and give all of us a little advice, Myles, on what you can tell a corporate medical director colleague when they say to you, look, I'm losing credibility here, man, really quickly. Because I'm proposing all of these measures, mitigation measures, which I think are evidence-based and they're not coming through. So how do we deal with that unfortunate circumstance? Yeah, no, look, it's a challenge. I think that this concept of the Swiss cheese model, I think there was some discussion this morning about the layers. It's the same concept, right? Having these multiple layers of interventions. I think we have to look and I think we will look back at this pandemic and start to break it down into phases. You know, early on in the pandemic, you know, we have limited information. You know, we're throwing the kitchen sink at things. I don't know if you guys remember early on, everyone's washing every orange and apple that went into their place. So we had a very different view of what we needed to do. But as we gain more information, we started to maybe adjust with what each of these different layers were and prioritize them. Temperature screening at the beginning, then you say, well, that's not really very useful. So you had the concept of these interventions, how effective they were evolving. And they're also evolving with the virus too. So you're not playing against the same enemy all the way through. And you're adding additional layers. You're bringing in testing. We didn't have testing. Now we've got testing. How do you actually use testing? And I think the other thing about the layers too is that they are disruptive, right? There's a huge cost. There's a huge operational cost to the organization. So you need to validate that. And that's also where you're getting back to where you are in the wave is important. So if you're testing everyone every day and there's no wave around, you're not adding a lot of value. But if you're in the middle of a wave, suddenly that's really of value. So I think it needs to be a dynamic Swiss cheese sandwich. Right. Going back to your comment about the security director you had that dialogue with, your expectation as a CMD is to be clairvoyant. And that's what the C-suite wants. They want you to tell them whether or not something's going to happen in the near future. And if so, what it is. And I think that's what put a lot of pressure on a lot of the corporate medical directors. Brad, I want you to comment on this. How do you like that? Again, the same question, what are some of the obstacles for the corporate medical director attempting to address this health and safety of the workforce? And we're talking about organizations, regardless of what industry sector they're in, that want to keep people at work. And if they're not at work, they want to keep productivity so they make their numbers at the end of every quarter. When all of a sudden it turns out that people can be positive, asymptomatic, as you were talking about yourself, how does that complicate the world that we live in, the business world we live in? I mean, what advice would you give a corporate medical director in terms of what they should be telling the C-suite with regards to return to work? Yeah. I'm going to make two points on this. And I think that when you showed the previous slide, I thought back to where I was two years ago. I was working in a large public hospital, Department of Medicine in Chicago. And this is probably mid-April 2020. Our ICU was full of people with COVID on respirators, dying. No matter what we did, they were dying. And it was tough for the interns, the residents. We had a hard time getting masks available for them. Other PPEs, gowns were hard to find. And I was not allowed to even enter the ICU because I was over 60. And they realized that. And a lot of the attendings were not allowed because a lot of them, all experienced ones, were over 60. And they knew early on that people over 60 were at highest risk. And so I think we've come to a different point than we were two years ago, thank God. I think that we've made a lot of progress in vaccines and treatment and prevention. But it's still a big deal. My son is finishing up his residency at Emory University in Atlanta. And he's been through two or three years have been COVID. And he spent months and months in the ICU. He wears a mask from when he first enters the hospital to when he goes home at night. Only time he takes it off is when he's in the cafeteria. And they social distance in the cafeteria. So I think that the personal protection is really important. And now moving on to this, I think that, yes, these vaccines do a very good job in preventing severe disease and death. But they do allow breakthrough infections. And that's a term in vaccinology, we don't use that term. We use the term vaccine failure. The vaccine didn't do what it's supposed to do. And there's either vaccine failure or failure to vaccinate. And we're seeing both of this. This issue about the CMD, if you go back to the previous slide, that this is a big deal. I remember when Omicron hit the US very hard, CDC was forced to make a statement of when people could return to work. And Dr. Walensky, after being consulting with the private sector, with Delta Airlines, with other companies in the US, they were telling her, we've got a problem. We're having Omicron storms going through our cities, and people are calling in sick. But they're better within two or three days, can they go back to work? And it was a balance of public health versus the economy. And you've got to balance both of them. And she made the call that five days was sufficient, even though you may get an antigen test still positive after five, six, seven. My antigen test was positive for 10 days. But the relative transmissibility decreases. You may have antigen, which can cause a positive antigen test, but the transmissibility is low. It wasn't a perfect call by her, but I think she wanted to balance the Omicron storm, which is going on nonstop, and keeping the economy going, keeping workers working. It was a big problem at a hospital in Chicago, a big problem at CDC, a big problem with WHO. So I think it's a big deal. And I think it's not necessarily, it's an artistic call. The data are not great. We have limited data. But again, the CMD is forced to make a call on limited data. And you may call it wrong, but you've got to really call balls and strikes, and call it as you see it, and make the best recommendation you can. You can't say, I don't know. You've got to recommend to your boss, CEO, what to do. Right. And that's exactly right. And as Myles said, it's based on what we know today. It's not based on something three months from now. And that's where I think everybody in this audience has been challenged, because they have to make a decision based on what we know today. Is that going to be relevant in the future? So to that end, Myles, you know, there were so many therapeutic management protocols for patients that became popular. And this is just but one. My concern about looking at any of these protocols for people who were sick was, again, how did this impact our credibility as clinicians when the patients would say to us, well, wait a minute. They're doing this in that hospital, they're doing this in this hospital, doing that in this country. What's that do to our credibility? Yeah. Well, I think while our mitigation measures are changing, while the virus is changing, our therapeutics are also changing, right? I remember way, way back, way before ivermectin became an issue, you know, I was starting to sniff out all this stuff in South America and in Pakistan and all these studies that were coming out. They were like, this might be kind of interesting. But then you had to wait for that data to come in. And again, it got politicized. But you know, I think that also is very much our challenge. Everyone wants a solution, everyone wants a solution fast. I know that bleach is still, you know, it's still an option for some. But other than that, I mean, it is really a challenge. And I think, you know, we do have more ammunition now. I mean, we have, you know, the antivirals that I think is going to be hopefully, you know, the Tamiflu of COVID, right, which is going to make a big difference in how we manage things moving forward. Because if we do have that rapid response that's going to keep people out of the hospitals, then it's just going to be another bad seasonal flu. So, Brad, I know you made a very articulate disclaimer, but this particular solidarity therapeutics trial was put out by the WHO. So, wearing your civilian hat, so to speak, do you have any comments on this fact that a lot of these repurposed drugs proved out not to work? Yeah, well, I can wear both hats, CDC and WHO, because I was involved in these committees. And this committee at the solidarity therapeutics trial was made up of outside experts who were forced to review the data in double blind, randomized control studies, looking at the impact of these vaccines. Because often, I remember, probably two years ago, there was a clip on NPR from the University of Chicago ID rounds, where a doctor, somebody I knew from University of Chicago, was quoted on a MP3, that I had 20 patients on remdesivir, and they all survived. And then the stock market went way up for the manufacturer of that. And I think that a point I wanted to make earlier, which is related to this very strongly, is the important challenge of social media. The social media for vaccine hesitancy is not just the US, it's in France, where I live, it's Switzerland, very strong anti-vaxxers, but also it's in Senegal, it's in Burundi, it's in Ghana, it's, it's in Cambodia, where I spent several years, everyone I talked to a major challenge for responding to COVID is vaccine hesitancy. And let me let me just stop in that. I want to go back to something you said earlier on, which is about the fact that this virus mutates. And you said, well, that's not unusual. That's what viruses do. But we could then go on from that point and say, so long as there's a host in which that virus can replicate, we run the risk of generating another cycle of variants. Is that a fair statement to make? That's absolutely true. Right. And so that's why this whole business of reluctancy and whatever issues come into play with, with compliance and vaccination is going to be on our radar until God knows when, because there is still a tremendous division of opinions. Yes, the whole concept of herd immunity has, that was hot for a while. And now it's kind of not right. Because, you know, at the end of the day, the world has to have immunity for this to ultimately settle down. So Miles, you, you and your colleagues, in fact, I think I was involved in that as well. We put out on our website, the return to work, the time and the place about six months ago, seven months ago. So the International Corporate Health Leadership Council put that out. You're welcome to look it up if you want. And then, of course, my favorite publication that I read on a regular basis, The Rolling Stone, had an article on, is it safe to travel? Do you want to comment on both of those, Miles? Yeah, I mean, I think that's been what a lot of medical directors have been doing over the last year. I think particularly, you know, when you're looking at return to work and also return to travel, we've hit a couple speed bumps along the way. If you look back, you know, last fall, things were finally settling down after the summer wave in the US and everyone was gearing up for travel. And just as everyone was adjusting their travel policies and their return to work policies, you know, Omicron hit. So we flipped that back. Everyone's, you know, you know, hunkering down and delaying, you know, their return to office and travel. And now things are, you know, settling down. And, you know, I was speaking to one of the top, you know, travel agency groups, and they were saying there's more bookings now than there were pre-pandemic, you know. So everyone's desperate to get out, like this meeting, you know, we're desperate to get out and see people. But, you know, we also see, you know, things trickling up. And we also know in Europe, things are still, you know, pretty hot. So return to office, getting back to the same question of understanding what's happening at that office. So I think one of the lessons learned for a lot of companies is there's not one hard and fast, okay, everybody's going back to work tomorrow. Every, you know, every office is going to have to look at what's happening in its community. They need to look at what their healthcare infrastructure is doing. They got to look at, you know, their own workforce and make a decision. Now, they can have their own standards of where they think the thresholds are for return. But it's a very dynamic and office to office, you know, kind of decision. Brad, a quick comment. Yeah, I just want to respond to that. I think that what I've seen at CDC and WHO and countries, working with countries, governments of the French government, the Danish government, the U.S. government, that Omicron changed the game. It's amazing how things changed so quickly with Omicron. Both the occupational health departments at CDC, WHO, which I'm on committees on both, raised the same questions. And we saw that Omicron caused a lot of my colleagues in Geneva to get sick, including me. A lot of my colleagues in Atlanta. But based on discussions of the U.S. epidemiology, based on discussions of the epidemiology in Denmark, we had a call between the director of CDC and the minister of health of Denmark discussing Omicron. And this is February, mid-February, when Omicron cases are very high. But the minister of health of Denmark says our coverage with mRNA vaccines, Pfizer, is 98%. Our hospitals are not full. We're seeing cases being admitted to the hospital with infection, not due to infection. And that seemed to be a catalyst to change the thinking. And we started having planned back to work at both at WHO and at CDC in the middle of March, during the Omicron wave. People were seeing that everyone's getting infected, but life goes on. And when the minister of health told director of CDC, we're dropping all requirements for COVID, that sort of changed her thinking and changed my thinking a little bit. To see that a country with high coverage able to stop all requirements for masks, for social distancing, everything was stopped. And yes, they've had increased cases, but the number of deaths and number of severe disease hospitalizations has not increased. So the high coverage is a critical point. And I think, Rob, if you compare that to Hong Kong. So, you know, it all really depends on, you know, that your population, the demographics of your population, and the vaccination coverage and the healthcare infrastructure. If you look at what happened in Hong Kong, and Brad and I've talked about this a lot, because that was like an aha moment, where suddenly, you know, Hong Kong with a very good healthcare system is completely overwhelmed and has incredible fatality rates. And why? Because those elderly were not vaccinated effectively, right? And so if you have a window, you learned, just to that point, you and I both learned, and I was surprised when I heard this, because you were in the same conversation. Why weren't they vaccinated? Well, there was a lot of hesitancy, a lot of fear. And also, they were not making the decision to not vaccinate their family. Their families were saying, no, you don't need to vaccinate mom or dad. And as a result of that, they're all dying. So it was a sort of a comedy of errors. And the result was horrible. But we're also seeing other nations prioritize differently, right? So sometimes they'll prioritize, we're just talking about this, prioritize the military first, then the young workforce, because I want my young workforce protected, and they forget about the elderly, and suddenly they overwhelm the system. So I think it's very dynamic where you are and having that local intelligence. So let's, hold on, because I want you to comment on this. Let's start looking at moving forward, because we've got a little bit of time. And I think that's what, where the money is, is what we can go on and on about the past, but the past is behind us. Let's talk about moving forward. And let's go right down to the basics here, in terms of how we are educated as clinicians and scientists, and how little attention in our education focuses on public health, and how this virus may very well have catapulted us into a whole new educational environment, where there will be, and should be, more focus on that. Do you want to comment on that first, Brad? Yeah, I mean, I could go on for an hour on this. Don't, just keep doing that. I promise I won't, I won't. Okay, thanks. You know what, and I think that, you know, a milestone in Hong Kong. We saw an article in the Financial Times in early March, showing Hong Kong with a big outbreak of COVID, and many, many deaths. In the same graphic, they were comparing with New Zealand, which had a big Omicron wave, you know, with thousands of cases, few hospitalizations, few deaths. And that sort of changed my thinking quite a bit, and that's why we wrote the article in MMWR three weeks ago. And, you know, I think that when we look at the health care in America, I'm a physician, been a physician for 40 years, working in inner city hospitals, working in public health clinics, working in community health clinics. We have to admit, in the U.S., we don't have a health care system. We've got a sick care system of people who are sick with diabetes, hypertension, chronic diseases, infectious diseases, who come in with renal failure, with heart disease, with strokes. To that point, the money is going to what exactly you're talking about, and there's no money going towards prevention. Right, but let me finish my thought. Finish your thought. Yeah, no, I mean. Put it in an economic standpoint, but go ahead. No, it's critical. I mean, we have not invested in our public health infrastructure in the U.S. for 30, 40 years. Right. When I was starting with CDC in 1987, I was in Chicago, and we had 20, I believe, public health advisors from CDC assigned to the city of Chicago to work on immunizations, HIV, TB, other chronic diseases. You know, they were all working hand in hand with the city of Chicago to support surveillance, direct patient care, follow-up tracing of TB patients, you know, at the home. But we have the best sick care system in the world. No one's got the technology U.S. has, but it's not a health care system. If you're sick, you know, it'll take care of you, but it's not going to prevent stuff very much. And just to follow up on the Denmark comment, is that I was so impressed in Denmark, they have a public health workforce who would visit patients with COVID, follow-up, contact tracing. They did a study, a huge study, looking at secondary attack rates from COVID in households. They looked at 2,000 households with a primary case of COVID and looked at secondary attack rates, you know, in the household. And they found that COVID, that Omicron was less transmissible, was less severe disease than Delta. And I asked the Minister of Health, I said, how many people did you have working on this study? Because you interviewed 2,000 households, you know, how do you do that? And she goes, well, I think we had two, we had one medical student and one advisor working on this. Because all the public health data, testing data, hospitalization data, medication data, death data, outcome data, are in a database, all linked together. So they didn't have to do any interviews, they had all the data in the national database, and it was very easy to look at vaccine effectiveness, because you knew who was vaccinated, who wasn't vaccinated, and they were able to do a study like this, which would have taken us six months in the U.S. They did it over a weekend. Maybe you can take your information, which I think is we can learn from our neighbors, back to the CDC and WHO and suggest that. But to that point, Miles, Miles, I'd like to nominate you. I've often thought you'd be a great politician. Do you think the answer might be getting people like yourself into politics, maybe to make the change? Not me. No, no, no, no. First of all, I'm Canadian. So, you know, that's right. You can go to Canadian politics, maybe. But in all seriousness, do you think the answer may be that we need somebody with a medical background in a position who can make decisions? These kinds of best practices that Brad's talking about, it's got to be, we have to have a voice. Yeah, no, I think now, you know, we've been talking, the medical director group, a lot about how we take advantage of this moment, because it is in everyone's mind. It's in the forefront of everyone's mind. We're all looking at, you know, where things went well, where we didn't do, you know, didn't go well. And again, this is looked from a US context. If you think about, you know, Denmark, fantastic, but let's look at, you know, Burundi, let's look at some of these other places where there's no healthcare, you know, public health infrastructure. So and we also know that if we're going to continue to do this global surveillance and try to pick out when the next, you know, potential bug's going to pop up, we have to improve our public health infrastructure globally. So how do we look at gathering data from all over the world in a consistent way, monitoring all of those things? I mean, I think that's hopefully where the future is going to be, is how do we leverage some of this technology that's evolved out of this pandemic? So yes, there's an issue of leadership, for sure. So whether that's politicians, whether that's funding, but and again, the US is a mishmash of, you know, tying all these pieces together. But more broadly, you know, we're in a global world, right? So if something blows up in a certain country, it's coming home, particularly if it's a pandemic, there's no place to hide. All right. I want to run through these next couple of slides quickly because I want to open up the floor for questions. And I think everybody in here is familiar with the United Nations 17 SDGs, and we're getting close to 2030, and it's quite a Herculean task to get all of these done. But you can see circle number three and 13, you know, are they mutually exclusive with regards to the 17 SDGs? And I'm going to ask you, Myles, because you probably have some thoughts on these four images, which are a consequence of global warming, which was one of the SDGs to be addressed. Yeah. Which one of these do you think is going to be a player over the next 10 years in terms of facilitating, catalyzing, causing the next pandemic? Look, I think they're all going to be involved in it. I think that as things warm, you're seeing permafrost, you know, thaw and all kinds of weird or ancient stuff popping up. You're going to see more, you know, water in certain areas for vector-borne diseases. You know, you'll see fire and air quality issues. So I think all this is, this is, from my perspective, this is the next big thing is looking at how is global warming and just the heating of the world going to influence health and also going to lead to these types of culprits that are going to pop up, right? And if you were to make a guess right now, who do you think is going to get the prize? Well, I mean, probably bats just because they seem to be the, you know, good reservoir. But I think, you know, mosquitoes and vector-borne disease, we saw that with Zika, you know, we didn't see that coming. But look, all of those culprits, we've seen a lot of Lyme disease exploding and, you know, other types of diseases. So I think it's, it could be really, you know, any of those things. And I think that's part of our challenge is that we have to be watching all of those things. Well, in the spirit of that challenge, you're the one that's always talking about BCPs and promoting BCPs. And I think everybody in this room knows the blue side of the BCP. Certainly everybody who works in operations or security or in any other vertical within a company that's not medical understands the blue side of the image. The red side, the enterprise health plan, you can see the bottom box on the bottom left is all about having the pandemic plan. And I can remember being at meetings with you, Myles, over the last decade and a half where you'd say, look, you know, we've got the pandemic plan with this particular client, that particular client. It's on the shelf somewhere and nobody's updating that. How do we get to the point now, having just been through what we've been through and we don't even know where the end is, of having organizations focus on the fact that this pandemic plan needs to be dynamic. It needs to be rehearsed. It needs to be part of the regular protocol in any organization at all levels to be familiar with it so that it's not just pulled off the shelf the next time somebody comes up with an unusual chest infection. Yeah, I mean, the medical director needs to be like the security director, right? Security directors are monitoring, you know, civil unrest, you know, terrorist attacks, bomb threats. And then they're testing, they're drilling. They're saying, okay, if we did have a threat here, what are we going to do? I think the medical director has got to play a very similar role. We're monitoring what's going on. We're going to see more, you know, false outbreaks, you know, in the next, you know, decade than we know what to do with. I mean, there'll be all this weird wastewater, you know, viruses that are going to pop up and everyone's going to freak out and then nothing's going to happen. That's just because we're going to be doing a lot more surveillance. So I think it's going to be there for the medical director to say, look, don't worry about this one right now, but let's focus on this. And I think when it comes to planning, you know, everyone is going to be reviewing, you know, their pandemic plan. I never liked the word pandemic plan because people always just thought it was generic and that most people built an influenza pandemic plan, right? So then they repurpose that for COVID. But it needs to be, the plans need to be specific to the threat. So if it's a respiratory disease type plan, you know, we've seen a vector disease plans, you know, the mode of transmission is going to be very important. And the NBC nuclear biological chemical, of course, with Ukraine, I mean, here we are again and a lot of companies kind of revisiting kind of where they are with that. So to make it live dynamic, and there's a lot of technology now that people can leverage. So you don't have it sitting up on a shelf, but it's actually a dynamic portal that people can access and pull stuff out when they need to. And it needs to be focused on specific locations. So your plan, unfortunately, is going to have to be specific to that location because what you do may be very different with the same threats. But I think, I know you want to say something, Brad, and I'll let you in a moment, but I just want to say that the, we had the last two days, we had the, this year's International Corporate Health Leadership Council meeting, and the whole meeting was talking about the new role of the Corporate Medical Director and how we believe it's never going to change again. But that new role has catapulted the Corporate Medical Director into the C-suite. So we now have an opportunity to talk to the C-suite, counsel the CEO, and so therefore we can push this BCP rather than waving our hands and saying, what about the BCP? We are now in a position where we can provide recommendations, and they will listen to us because they know at the end of the day, if they haven't got a workforce, if their workforce is sick, if their workforce isn't there, productivity goes down, revenue goes down, and they don't meet their numbers. So we're in a very, very unique position right now, which should focus on taking ownership of the business continuity bond, particularly what's in red. One comment from you, Brad. I just want to say what keeps me up at night is global warming, because there definitely is a link with the pandemic that's coming. These are not independent areas. I finished medical school in 1980. The number of new pathogens we've seen, HIV, West Nile virus, chikungunya, you go on the list and the coronavirus is down the list, but we had a pandemic of H1N1 in 2009, H3N2 in 87. So these outbreaks are coming. I think that the changing world is definitely facilitating these new pathogens, causing wide transmission, and we'll be seeing other ones down the line. When you're ready, I did a survey of my colleagues of what's next. Hold on to that survey. I can hardly wait. All right. So this is a huge list that I don't want us to go through, but I want you to just each grab one item off this list and tell me about it. We'll start with you, Brad. Pick one item off this list. Let me tell you what I did. So I asked 10 of my friends from CDC, WHO, people who I trust, who know global health, know epidemiology, know infectious disease, and infectious disease, I said, what's next? What's coming down the pike? And most of the answers, you know, they were SARS, influenza, but the most common was agent X, the unknown pathogen. They all, all 10 people identified that as a major concern, as something coming down the pike, the unknown pathogen, like coronavirus. and also two people mentioned smallpox, which is another long discussion which I won't go into, but smallpox has been eradicated, but the virus still exists in two laboratories in Atlanta and in Russia, so bioterrorism is something most of the people I interviewed or I sent the survey to are concerned about. Good, thank you. And I would pick sharing real-time data. I think that that's gonna be really key, and we were canvassing a couple security directors who were running their COVID response, and we said, look, if we were able to give you this information two months in advance that you knew that COVID was coming, would you have done anything differently? And he kind of thought for a moment, he said, no, I probably wouldn't have done anything different, but I would have done it sooner. So I think having that timeline of preparation, of getting things together, and it's like Spinks said, every boxer walks into the ring with a plan until he gets punched in the face. So I think everyone's gonna have a great plan there, which is gonna have to be adapted. It's the old military thing, right, where you're gonna adapt to what's happening on the ground. But I think having some of the core ingredients well-identified, and I think we kind of know what protective measures companies can put in place, but we've got some of that ready. So the challenge now is how do we know about this early? How can we get in front of it? How do we flip the switch earlier? And you know what, we can flip the switch, and if it turns out it's a nothing, then we just turn it back off, but at least we've made the decision. It goes back to your focus and emphasis on surveillance, and it's just sad that we don't have a consistent surveillance methodology that covers the globe, and so everything's piecemeal. So I think all of these points, which I'm sure the audience has read by now, are pertinent, but it's all about funding, it's all about consolidation, it's all about sharing of information so that we get ahead of the curve if we're gonna get anywhere with the next one that comes out. Right, yeah, and that's a big priority for WHO. Good. CDC and WHO got beat up terribly for not alerting the world about COVID-19 too late, even though they did inform the world very early, but they were beat up by many people. And a priority for WHO now is public health intelligence, trying to get the data early, share the data early, and through a grant by Germany, WHO will be opening up an office in Berlin only focusing on public health intelligence. We talked today at lunch, and I said it would be great if we bring the private sector into this, international SOS and other partners, to share information between WHO and your organization to get the word, to find out early and have early awareness and response. So I think that's a priority. I agree. And I think that one of our medical directors had a great comment where his bosses were saying, how can I trust you more than the CDC? Because our doctors have to be ahead of what the CDC is saying. And that's just the nature of a pandemic, is that we're ultimately gonna be following the science. And, but I think, you know, hopefully we can get the WHO and CDC to close that gap so that window is shorter, right? And I think that's gonna be- Let me interrupt you on that, because that's a comment that I've heard a thousand times, which is follow the science. What do we do when we're promoting that principle, follow the science, and the science doesn't prove to be correct? Does that not just embolden, if that's the right word, all those anti-science people? And that's why I'm really scared about using that term, follow the science, because you said yourself earlier on that science is not right, Brad, you said the same thing. And it can't be right, because we don't know anything. It was a novel coronavirus. So I think we have to, as physicians, clinicians, scientists, we've got to look at our traditional remit, and that's why I've got this slide projected, and the new remit. And we've got to start focusing on public health. We've got to regain the trust of the community, which means our workforces, which means our C-suites. And we've got to learn how to collaborate, and that is, I think, the way moving forward. So it's up to us. I'm going to stop there and ask, are there any questions in the audits? Because I've got a couple of online questions as well, because this is being taped, and there's some interesting questions popping up. Does anybody have anything to say? They can go to a microphone and speak. Yes, sir. Please introduce yourself by your name, and then ask the question. Thanks so much. My name's Dr. Michael Caldwell. I'm an Associate Vice President of Vaccine Research and Education at Meharry Medical College. I'm here for Dr. James Hildreth. I was real lucky to attend the World Vaccine Congress last week, and Dr. James Campbell, a professor of pediatrics, spoke in a very impassioned and pleading case to everyone who listened to say, please remember that over 1,000 children have died of COVID. And he made the point that while a lot of us are focused rightly that this is an adult problem, that we need to look at children through the lens of what kills children. And he made the point that COVID is now the number one infectious disease cause of children, of death, that it is now one of the top 10 causes of death of children. And for all we do to try to protect children, we're not succeeding in getting them vaccinated. So I just wanted to revisit that and to see if there's a way that we could better protect the children. Before Brad responds, it's an excellent question. Thank you. Was the population, the 1,000, were they American children? Yes. This is CDC data, nearly 1,100 children under 18. In America? In America. I mean, when I heard it, I was surprised, but you're talking about about 500 children per year for the last two years. And he made an important, this wasn't me, this is Dr. Campbell. He's a professor at University of Maryland. And I think a lot of people are surprised to hear that number. Brad, do you wanna go ahead? It's a great question. I'm not surprised, because I've been following the data very closely. I've got three grandkids who I love dearly and I want them protected. But at the same time, when you look at mortality in kids under 15, the 1,000 deaths by COVID are a small proportion of injuries, suicide, firearm injuries. So I think we have to look at all issues which kill children. But I am personally pro-vaccination of children. But again, when you look at the population in the US, the people dying of COVID are those over 60. So I would prioritize, if I had one dose of vaccine available, I would give somebody 65. To give it to my 13-year-old grandson, the marginal benefit is small. But I agree with you totally. It's a major, 1,000 deaths, there's a lot of kids dying. But so I would, also I would work for homicide, suicide, injuries at the same time. So it's not either or. I think we've gotta do both. Thank you. Make sense to you? Yeah, I appreciate, and I appreciate the feedback. It's ongoing conversation. Yeah, I follow this closely. Thank you for your comment, sir. Yes, sir. Good afternoon. Jaime Vega, Military Seal of Command Pacific. Actually, two questions. First question is, I heard earlier that we were seeing kind of COVID-19 January of 2020. Any evidence to suggest that maybe it was in the country earlier, November 2019, December 2019? I've just, I've come across a couple of anecdotal case reports where young people suddenly succumb to this weird vascular inflammatory disease, and they succumb pretty rapidly. Heart attack and stroke, and otherwise, healthy person, maybe they're a little overweight. And then the second question, actually, I'll stop there. Brad, do you wanna take that one? Yeah, I mean, that's something which I've thought about a lot. And when you look at what we know now about COVID, you get infected today, you get sick four or five days from now, you get admitted to the hospital in two weeks, and you die three weeks later. So by the time we were seeing the major increase in February and March, it means the virus had been here for a long time, had been here for probably since late November, is what I've heard. So it grows exponentially, but the hospitalization and death are latent indicators. So by the time you're seeing hospitals filling up and death, it means this virus was circulating a long time. So by the time the president, President Trump, stopped the flights from China, the virus was here already. But then he let Europe come in for another couple of weeks, and Milan was going crazy. And I was living in Geneva, and we saw that Milan was going crazy. One will hit Geneva. But the flights, so basically I think that we reacted too late. We were not aware on time. But once it gets in, it's hard to stop. And then another issue with maybe zero COVID, that's another discussion. But with Omicron, impossible. You can't stop the wind. Sorry, one other thing I'll add to that is the wastewater issue. So wastewater is gonna be another area we're gonna be focusing a lot of time on. And I know that, I thought I saw some studies early on that on November 19 and even 18, sorry, 19, October and November of 19, they saw some of the virus and some of the wastewater when they went back. So it's likely that it was already around in the fall. Yeah, I don't think that was anecdotal. What was part two quickly? So second question just pertains to immunity, like evidence of immunity. You talk to medical students, interns, residents, they come through the hospital, and we look at MMR and varicella, and we accept clinical evidence of having had the infection as evidence of immunity. We accept a titer, or if you're older than 65 or whatever. Why is it that with COVID-19, having had the disease does not really comprise evidence of immunity? Why is the recommendation in favor of the vaccine versus, we understand you've already had it, but in order for you to be really immune, you have to have the vaccine. I was wondering if you could shed some light on that, just in terms of immunity. Is the immune response better with the vaccine versus actually having the infection? I think I'll comment on that one. There was a slide we projected, which was the response, the adaptive immune response, from either infection and or the vaccine. And we still don't have a complete answer on what you're asking, but the thought process is the vaccine will actually enhance the reaction you had from the exposure. So the exposure is good, but it's not good enough, and the vaccine will enhance it. But in both cases, your immunity wanes, and that's why we're promoting the boosters. If I can, I think that there's the term natural immunity. I don't like that term, because immunity, all immunity is natural, whether you're getting vaccine or from wild virus. And I do think from the studies we've seen recently, it seems that both vaccination and infection with the virus both increase your immunity, but the people who've had longer immunity have been the hybrid immunity, with basically an infection followed by vaccine. But the hybrid seems to have the highest rate of neutralizing antibodies, which lasts longer. But again, the data are changing, but we're finding with Omicron, people with a previous history of infection, plus the vaccine later, three months later, have very high, sustainable, neutralizing antibodies. This is what I've read, and this is my understanding. Good understanding. And just to add more excitement to your question, this whole idea of mixing and matching your vaccinations in Canada and a couple of other countries where they didn't have the availability like we have here in America, they were by circumstance mixing and matching, and in hindsight, that proved to actually boost your immunity a little bit more, as did the time interval between the two vaccines. So there's a lot still being researched. Yes, sir, thank you. Hi, Mark Hyman. I helped write the ACOM guideline for corona. So a couple of things. First of all, if you look at the data, just on this question, from Qatar and South Africa, natural immunity is probably more durable than vaccine-induced immunity, but I do recommend for everybody to get both. Go get the real infection. That's what I'm trying to say. Go get the real infection first, yeah. But not in that order. The second thing is, on the messaging, in your work with the CDC and WHO, I think one of the things that a lot of people reacted to, and certainly I had to handle, is there were absolutist statements that had hubris in them about masks don't work, and then one month later, with no new studies, there's a mask mandate around the entire country, rather than an honest assessment of just what we're doing here today, of saying, here's what we know, here's how science works, it's gonna take us some time. By the way, in our guideline, just so you know, compared to one of your slides, we have data that ivermectin used in the first three days of infection does have a beneficial impact on a shorter course of symptoms. I'm not saying that I want everybody to go get ivermectin. I'm saying that it takes time to get that information out, and it would be very healthy if the CDC and WHO could continuously message that the process of science is some trial and error, and it really helps. And then finally, the one other thing you brought up, which I would like your comments on, is that the WHO, in particular, and the CDC in general, but is very dependent on the reliability of the governments disclosing their information and providing direct access to their information. And one of the things that animated some people was the sense that the WHO director kind of parroted whatever he was told by governments, rather than the WHO doing its duty of doing an independent open investigation to really try to drill down on things. But I would like your comments on that. Actually, I'm gonna ask him not to comment on that because out of respect for Dr. Hirsch, I asked him to join us here, and I didn't want him to give an opinion on behalf of WHO or CDC. So your points are well taken. We have to talk afterwards. We'd like to get there. I don't know if that's appropriate in a public forum, but I don't disagree with anything you said, but I just would rather we didn't broadcast or we're also being taped, and I don't want to put him on the spot. So Rob, maybe I could comment instead. But yeah, no, I think a couple of interesting facts that I've kind of learned about the WHO. So the WHO has no laboratories. So they're relying on all the world's laboratories to get the data. They don't control the laboratories. They have, you know, who has more staff? The CDC or the WHO? Any idea? Yeah, the CDC is about 16,000, 15,000 employees. WHO is around 8,000. Who has a bigger budget? CDC is around 15 billion to 8 billion or 6 billion. So there you go, right? So I think we have to, you know, understand and manage our expectations. And I think that's part of our challenge is that, you know, we're supposed to be people of science, but we're giving, we're actually having to predict what's gonna happen in the future. And organizations like the WHO, they are the standard. So when they try to get out in front and say, okay, this is what it is and they're wrong, you know, that's part of the challenge. No, I don't want to talk about that. Yes, ma'am. Hi, good afternoon. I'm Dr. Francesca Litto. I'm one of those people that was catapulted. I'm Ford Global Medical Director. And I was wondering if you could say your feelings or your thoughts on what we're going to see in Shanghai and now Beijing and Guangzhou where they don't have mRNA vaccines because the government will not allow them to be imported and where they don't have an adequate supply of Paxilid for the same reasons. I'm gonna ask Dr. Druckmann to comment on that. Yeah, so for some of you that know me, I spent five years in Beijing. It's been a while now, but, you know, speaking to, you know, our team in China, it's really, you know, it's a real crisis in particularly in Shanghai, but now starting in Beijing as well. And from the perspective of the zero, you know, zero tolerance concept. And, you know, as we've talked about with this new Omicron and its ability to transmit so easily, you know, most of us think that there's no way you can keep that under control. I mean, things are breaking down also socially within China. There's a lot of angst. There's a lot of frustration that's not in the media because it can't get into the media. I can tell you, like, we have a call center in Shanghai and our staff literally have to sleep in the office because they're not really allowed home because they'd have to get tested. And so there's a lot of angst right now in China. And I don't foresee them being able to escape it. Now, and we can talk about the Sinovacs, you know, the different Chinese vaccines versus the mRNA vaccines. You know, some of the initial research was that it was, you know, less effective, where we may be seeing that it may be as effective for fatalities and hospitalizations. But again, we're gonna have to wait and see. Also remember that the testing they're doing, they're doing mass testing, massive testing. And what is still amazing is that, what, 75, 80% of those are asymptomatic or they say they're asymptomatic. So we're really getting actually quite an interesting epidemiological picture of the community because they're doing so much, you know, asymptomatic testing. But I think, you know, over the next months, we're gonna probably see these spikes happening. Short? Yep, we're short. One sentence, we gotta go. Real short. I think that in China, I've been involved quite a bit with that with CDC and WHO. WHO and CDC are supporting China, but I think what we've learned from that at both CDC and WHO, that Omicron changed the game. I think that China, other countries with zero COVID strategies were very confident they can keep it out by testing, by surveillance, but Omicron changed the game. It's much more transmissible. And the strategy used to keep zero COVID is not very effective against Omicron. You can't stop the wind. Yeah, and I think it's gonna be an economic issue too. I think the reality is this is slowing down the supply chain of the world, right? The engine of the world. And I think the Chinese government is gonna get to the point where it's, you know, they're weighing, you know, the whole economy benefits against the community benefits. All right. I know we've run out of time. There are still some outstanding questions from the team of colleagues that are online. I would ask that the college gather those questions and email them to myself or the two panelists, and we'd be happy to answer those questions. I just don't wanna take up anybody's, any more time. Wanna thank everybody for your attention. I wanna again thank the college for giving us the privilege of presenting. And most importantly, I wanna thank my two friends and colleagues, Dr. Druckmann and Dr. Hirsch for their expertise. Thank you. All right, there you go, brother. Good job. Thank you. Thank you. Thank you, Dr. Druckmann. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.

COVID-19

panel discussion

lessons learned

virus mutation

transmissibility

comorbidities' impact

immune response

vaccine effectiveness

breakthrough infections

long-haul effects

public health

economy