Press conference from the Harvard T.H. Chan School of Public Health with Barry Bloom, the Joan L. and Julius H. Jacobson Research Professor of Public Health and former dean of the school. And William Hanage, associate professor of epidemiology and a faculty member in the Center for Communicable Disease Dynamics. This call was recorded at 11 a.m. Eastern Time on Tuesday, September 29th.
MODERATOR: Dr. Bloom, would you like to get started? Do you have any opening thoughts?
BARRY BLOOM: I would just open by saying we passed two rather depressing landmarks, a million deaths worldwide and two hundred thousand deaths in the United States over the eight to nine months of this pandemic. And it is not under control in this country and in many other parts of the world. It's coming back again. So it remains a really serious concerning problem.
MODERATOR: Dr. Hanage, do you have any opening thoughts?
BILL HANAGE: I'll start by saying good morning to everyone. I would echo what Barry said. That is, the million deaths either have been reporter will very be reported over a very short period of time. Unfortunately, they may be only the start. Our future handling of the pandemic is not going to be helped by the fact that it is not if we lose control of it. As you are well aware, cases do appear to be increasing in a number of different locations, in particular some European countries from relatively low levels that are not directly comparable with the surge that happened in the spring because of better testing. But it is an indicator that the pandemic is very, very, very far from over, as I guess we're going to be talking about the next hour or so.
MODERATOR:OK. Thank you. All right. First question.
Q:Hi. Thanks. I want to ask about bars and restaurants. Do you think in areas where there is a significant amount of spread going on, that bars should just be totally closed? Or is it OK if there are just capacity limits on it? And also, indoor dining with restaurants, do you think some places should just be totally closing that? Or can there be capacity limits assuming you're in a place that's not in a green zone, if you're in a red or yellow or whatever, if it's pretty bad around you? Thanks.
BILL HANAGE:It's a very important question. You’re absolutely right to say that it depends on whether or not you are in a state of community transmission, which is happening around you at the moment. However, it really has to be noted that bars, restaurants, indoor dining are associated with transmission that has been shown. It was an MMWR from CDC, which came out, I think, last week, maybe a little bit before. So eating indoors is a risk factor for transmission. These gatherings also give the opportunity for something else which is clustered transmission. The transmission dynamics of the virus are over dispersed, meaning a minority of infections leads to the majority of transmission. That means it tends to transmit in clusters. And obviously, if you've got a bar open, then the size of that cluster can be that much larger because more people are gathering together and interacting together in ways that maybe I'm sure you can appreciate. But as people consume alcohol, they tend to become less physically distanced. And as a result of that, falls are a major source of transmission into communities. And because of the super spreading event, they can very rapidly increase the number of cases in the number of transmission chains which are going on. So I personally would very, very, very strongly recommend keeping limits upon bars, indeed shutting them. If you've gotten a certain amount of infection, a certain increase of infection within a community, which is essentially could be threatening health care and be very careful of indoor dining and restaurants.
MODERATOR:Dr. Bloom, is there anything you'd like to add?
BARRY BLOOM: No.
MODERATOR: OK. Next question.
Q: Hi, thank you for taking our questions this morning. So, you know, we're rounding up to the fall now. Things are getting cooler. People are retreating indoors to eat, to exercise. So what are some essential dos and don'ts of staying safe while being indoors?
BILL HANAGE: Well, you're right. We have the fall and the winter coming and people are going to be getting together indoors more. Indoors in public spaces is one of the places where the largest amounts of risk of transmission are likely to be happening. If you're going to be doing that, I would recommend mask use, certainly. If you are going to be coming back, the kind of things that we were saying in the spring, keep as much distance as you can, limit transmission, if you can, limit the number of contacts that you are making. If you are going indoors, masks are an extremely important part of limiting the amount of onward transmission that could be happening within that. And indeed, the potential cost to size. They cover multiple different modes of transmission, including aerosol transmission, which can happen. But we're still not entirely clear exactly how much of it can happen. But masks will help also practice good hand hygiene and so on and so forth. If you take all these things together and put them into decent practice, it should hopefully slow down rates of increase.
Q: Any comments on like ventilation and UV lights, I should have?
BILL HANAGE: I really should have mentioned ventilation. It's one of the reasons Barry is here. Yes, well-ventilated spaces are particularly helpful, and you can achieve ventilation by opening windows and putting fans in places. And that, too, will decrease the risks of large cluster transmission events. So indeed. The role of UV lights is not particularly clear. As far as I'm aware, it's not been extensively studied to the extent that I would be comfortable commenting on.
MODERATOR: Dr. Bloom, do you have any other things to add?
BARRY BLOOM: Two things. I think I would emphasize Bill's point. A lot of behavior should be determined by the community level of transmission in the places that we're talking about. When it's very, very low, there is a real possibility of opening up, partially not filling up restaurants, completely maintaining some distance. But when it's as high as it is in many parts of the states, it's just asking for trouble. And second comment, we'll keep our eye on UK and Europe, where they opened up the pubs, the restaurants. Numbers are going up. They're going to have to contemplate shutting down at various levels again. It makes a great deal of difference whether you're in a low transmission environment or a high transmission environment, how much flexibility you have to stay safe.
MODERATOR: Do you have a follow up?
Q: I think I'm all set. Well, actually, you know, now that I'm here, why don't I just keep going? Are there any comments on, like, little gadgets that people are starting to use, like the plug-in air purifiers and humidifiers and stuff like that? Is there any promise to those?
BILL HANAGE: I know nothing about those, other than that humidifiers are generally used to help respiratory illnesses. I don't think there's any evidence at the moment on the ability to make a big difference to the progress of a pandemic.
Q: Totally fair.
MODERATOR: Very good. All set?
Q:Yeah, I'm totally set now. Thank you.
MODERATOR: Excellent. Next question.
Q:Thanks very much. I just wondered if you might be able to unpack a little bit about the role of cold and flu season coming in amid this pandemic. There's the observation that we're having a lower rate of flu than we usually do, but the seasons heading towards us. There's this dispute between Tony Fauci and Scott Atlas over the role of both the pandemic coronaviruses and things like rhinoviruses and somehow priming the immune system in kids or anyone to lower rates of infection in the pandemic virus. I was wondering how you see these sorts of questions and what we should we be telling people with cold and flu season heading towards us?
BARRY BLOOM: Bill?
BILL HANAGE:I’m happy to snag this one. There are multiple ways in which cold and flu season is going to interact with the pandemic. So the first and the most important one is to note that flu season is it's actually really going to kick off in a few months. Sort of around the start of December, it will be starting to increase. We would expect to be starting to increase in the near future, but it wouldn't really take off until then. However, other respiratory viruses, yes, they are there with us. And as kids go back to school, which I'm sure we'll talk about later, you're going to see people with them having sniffles and not all of the sniffles are going to be due to the pandemic. Now, when it comes to the expected impacts of cold and flu season, there's evidence in Australia that they actually had a milder or less amount of flu disease than they would ordinarily expect. And that's likely because of the shutdowns and the various things which were put in place there. And it's not clear the extent to which the same thing will happen here because of the fact that different parts of the country are in fairly different states, literally, but also in different situations regarding restrictions, physical distancing and so on and so forth. There is some evidence which has emerged recently that co-infection of COVID or SARS-CoV-2 with influenza may be particularly dangerous. And if that is the case, then we would expect there to be a very considerable concerns as we approach that sort of turn of the year, December, January. But there's also the very simple, practical issue, which is that if you get flu and you walk into your doctor's office, the doctor is not going to know immediately whether or not you have flu or COVID. And one of the best ways to stop getting flu is to get a flu shot. So flu shots are an important part of the public health response. As we move forward, there's likely to be an overlapping of these various different respiratory viruses which are going to make it more difficult to deal with. And how that actually plays out remains to be seen.
MODERATOR:Dr. Bloom, anything you'd like to add?
BARRY BLOOM:Terrific answer.
Q:Did you have any thoughts on this issue raised of the notion of colds, either rhinoviruses or the endemic coronaviruses?
BILL HANAGE: I don't think there's any serious evidence that that is actually the case. There is evidence that people vary in the amounts of t cell immunity that they have to SARS-CoV-2 and that this possibly reflects exposure to other beta corona viruses. However, the nature of the immune system is such that it's by no means obvious what this actually means. It could lead to more severe illness. It can lead to a milder illness and so on and so forth. Essentially, any appeal to existing immunity that there is, regardless, has to handle the fact that even in places which where we're still doing relatively large amounts of physical distancing and mask use, infection proceeds at a sort of steady pace, which does indicate that if you'd provide the opportunity for it to transmit more, it will. And I think that any plan which is relying on any reliance upon existing immunity from other beta rhinoviruses, unfortunately, is wishful thinking.
Q: Very good. Thank you very much.
BARRY BLOOM:I agree.
Q: Hi, thanks for taking my question. I was just wondering if you have any sort of update on your thoughts on the role of schools and transmission of the coronavirus. The White House has been citing some of the Brown University dashboard that was created. And I'm just wondering, what are your most current thoughts on how people should be thinking about the role of schools?
BILL HANAGE:I'm guessing that's directed at me. So, yeah, we are at an interesting time because schools across the country are opening up. School districts are opening up with various different ways of trying to handle the problem. But where prevalence is low, which is a theme which I would like to be able to come back to over and over again, where prevalence is low, you can do more. And in person, education is something which would be certainly possible under such circumstances. However, it's also true that the impact of opening schools will be felt in terms of community transmission. There are a few papers which are coming out, one of which was in JAMA Pediatrics. It fits with the emerging evidence from elsewhere that suggests younger people, when I say kids under 10, may be less likely to become infected given exposure. But it wasn't able to say anything about that role in transmission. There's also another MMWR report which came out yesterday which indicated that over the summer, as testing has gotten better, we have been finding more cases among those younger age groups, which indicates once again that they can become infected and that they can transmit.
Now, you're going to hear a lot about transmission happening in schools. But when you hear about outbreaks in schools, I would like you to remember all of the other schools which I've seen if I'm not reporting outbreaks and to reflect upon the fact that if you are finding an outbreak, that's actually a pretty good sign of situational awareness and it's not necessarily a bad thing. Remember, the consequences for children are very, very low indeed of infection because the risk of the most severe outcomes are extremely low. I've said it before and I'll say it again, it's probably a greater risk in getting them in the car to drive them to school. However, the risk to their families and the community is not necessarily in the same category because in fact, older adults are much, much more likely to suffer severe consequences as a result of this. I think that it's going to be very important to take stock of the many different plans and many different sort of individual almost experiments which are being undertaken in different school districts around the country going forward and trying to figure out how to maintain schooling, because schools are extremely important for both education and for society in general. And if we can keep them open, then we really should do our very best to do so. And the best way to do that is keeping community prevalence low.
BARRY BLOOM: I would just add I thought there were two very interesting opinion pieces: one in today's New York Times by Emily Oster at Brown. And one last week by Marc Lipsitch at our school with Yonatan Grad. And one of the reasons it's tough to answer these questions is no one is collecting national data. One of the frustrations, certainly everybody in public health has, is what goes on in schools and school districts and what goes on in health. Our responsibility is primarily of states and every state has its own system for organizing data or not organizing data, making it available, making it public or not making it public. So asking public health people to give you an analysis of what's actually happening and transmission in schools is very difficult. It's supremely difficult to get any kind of systematic data at a national level. We need to do better on that. There needs to be a demand for some central way of given the importance of schools at every level in education, we have to be able to get better data to answer those questions.
BILL HANAGE: Yeah, I couldn't agree more. That's a brilliant point and that's a wider point as well, because it's very relevant to schools, but it's also relevant to other ways we're trying to collect data to deal with the pandemic. The one thing I will add, which just reminded me of, is that, again, different states have different criteria for who gets tested. And if you are directing tests at people who are symptomatic, then you're going to systematically under detect transmission infection in children because of the fact that children tend to have milder symptoms or indeed no symptoms at all.
MODERATOR:Do you have a follow up question?
Q: Yeah, I mean, I guess I'm just wondering, since I did read that that op-ed by Emily Oster this morning and the White House has cited that the Brown data. So, I mean, I don't know if you guys have looked at that. I realize it's not complete. But, is that the best snapshot we have, given that there isn't any national data being collected or any caveats you want to point out about that data set?
BILL HANAGE: I've not seen the up and the comment I make about the caveat in place of the data set is not what Barry was talking about. It ends up being, we would like to have a coherent, systematic sort of approach to collecting data in different places, such as they can be compatible. And we have something at the moment. I mean, you have something which is an attempt to do the best that people can under the circumstances. But really, we could do so much better.
Q:Thank you so much.
BARRY BLOOM: It's a noble effort that is, as far as I could tell, really done by volunteer efforts in a circumstance where it should be a national government overseeing support, well supported.
BARRY BLOOM:That is shame on us.
BILL HANAGE: Voluntary acts can be very good in public health. And I've worked in various voluntary sort of submission of epidemiological data myself, and I still curate data bases of it. And it can be very good, but for a pandemic, no. You have to be more serious.
Q: Thank you so much.
MODERATOR: Next question.
Q: Hello. Thanks. You've both mentioned at different times the importance of knowing whether community prevalence is lower or high in a given area, like with regards to making a decision about schools. So how do you define low or high?
BILL HANAGE: Well, it's a great question. Unfortunately, it's one which has not straightforward answers because people want there to be simple cutoffs. The first thing that I will say about it is that in order to be able to determine the amount of community prevalence that's going on, that does depend on the amount of surveillance you're doing. That means to an extent, the amount of testing that's happening. And you can get some sense of how good the testing is by the percent positivity rate. But that's a very, very clumsy, crude metric. I can point out here, locally, for instance, our test positivity rate has just dropped hugely. But that's partially because every student in dorms, of Boston University, is being tested twice a week. So we're having a huge volume of tests which are being run. And comparing places based on test positivity is not really a sensible thing to do. That said, if test positive is very high and cases are increasing where you are, that's a sign that things are getting out of control. And that's exactly the sort of situation which you would hope local public health officials would be taking on board when giving advice as to whether or not to do things with schools.
There is another thing which you could do which is relevant, in some places around the country there is active wastewater monitoring, which is looking in sewage, which can give you an indicator because people stop shedding virus by that route, as I call it, delicately, before they start developing other symptoms and present to their doctors. It can sort of give you some indication of the amount of underlying transmission that's happening. It's a very, very bouncy metric with a lot of variation. But, you know, consistent changes, consistent increases can be detected a little bit earlier on. So I think taking all of these things together is extremely important. Now, there's one other thing that I want to add here, which is that. These things also depend on what school districts are doing. So, for instance, if you have a school district which is very well resourced, in which every student, every teacher has a mask that's somehow managed to arrangement a little bubbles of about twelve people, then the consequences of transmission or prevalence within the community for that setup is very different from a situation where you would have in-person schooling, larger groups of people, much less significant attempts at infection control or PPE. So different school districts, different neighboring school districts may be taking different approaches to what they're doing. And so at the level above that state, you are going to be generating some of this data. Because as Barry said, each state does things differently. They have to account for both of those schools. So it's a tremendously difficult problem. And unfortunately, there isn't really a one size fits all question answer. But I do think that maintaining a state of good situational awareness will be key to handling the pandemic in schools and in general.
BARRY BLOOM: I would support that, and I would add one other facet that I think has not really been emphasized as much as I think is important. There's huge geographic variation at a small level. The epidemic is highly localized. And there's been recent data from testing of pregnant women in New York City, for example, using serologic testing that doesn't tell you who's sick. It tells you which healthy people have been exposed to the virus in the past and have antibodies. And that can be a 15 or 20 percent different across five boroughs in the city of New York. So changes that are occurring, there's not an absolute number that answers your question. But what you're looking at is changes whether Queens is stabilizing, and Manhattan is going up, what tell the public health people that you really have to start testing much more intensively in a place where the numbers are going up and try to hold the numbers down.
Q: Now, just one quick follow up. I mean, if it can be so difficult to look across the five boroughs in New York City, does it make sense to even ask how a particular state is doing? Because the state is going to have many different stories within it? I'm not sure.
BILL HANAGE: That is really quite a smart question. I mean, overall, they will tend to line up. But you're completely correct. I mean, in the sense that you can see back in the spring, New York City has had a very different pandemic from upstate New York. And it doesn't really make a huge amount of sense to lump them all together. But in general, overall, looking at a state, the overall trends in the state will not necessarily be affected by single individual cluster transmission, or super spreading events. But if a state has a particularly conducive sort of set of conditions for transmission, then that will be reflected in the change. You want to be thinking about it in terms of the change rather than necessarily only absolute numbers. And you also want to be thinking in terms of testing. If there was one thing I wish people could understand, it's that we have so much of a better grip on where transmission is happening now than we did in the spring, because in the spring we had such a shameful, dreadful inability to test and actually track the pandemic as it was arriving on these shores. So there were a lot of infections back then that were not picked up. And it's not so much that the virus has changed between then and now, as if we're just doing a much better job at understanding transmission with younger age groups.
Q: Gotcha. Thank you.
MODERATOR: Quick note for me. If you haven't noticed already, I'm putting some links into the zoom chat. Just put in the link to the Lipsitch and Grad op-ed in Washington Post. Barry, there is something else that you mentioned, and I didn't catch that, if you recall?
BARRY BLOOM:New York Times today, Emily Oster.
MODERATOR: All right. I will grab that and stick that into the chat as well. Next question.
Q: Guys, thanks so much for taking yet another question. Wondering if you have a sense of the second wave, if we can even call it that. How will we know when we're entering it? What are the danger signs? What should we be looking for? What should we be worried about? Or are you seeing that happen already? Or are we still OK?
BILL HANAGE: Thank you for deferring to what I think, you know, is my dislike for the word wave, because I think that it provides inappropriate comparisons to influenza and suggests that you cannot have waves in the summer and so on and so forth. I think my sort of image of a wildfire is a bit better than a wave. So if we are going to call it surges, flare ups, whatever you want to call it. I think that, we're definitively seeing the start of flare ups in various European countries. Like I said, it's not actually comparable directly to the spring. And the increases that we're seeing are actually reflecting the stuff that we were not observing directly in mid to late February. So that is what the situation there is like. The sort of wave that you'd be suggesting, or surge would reflect a bunch of sorts of parallel increases in a large number of places. And I don't know if that's going to happen.
I suspect that what we're more likely to see is, as I say, this kind of wildfire pattern, which is kind of illustrated right now at the moment. It's an interesting stage of this pandemic, because if you look at the Midwest, know, we start off with the Northeast. Washington state is like an honorary member of that for the Northeast. And then you have the Sun Belt summer surge. And now we are seeing it in that sparsely populated Midwest region where the numbers of cases themselves are pretty small, but proportionately, they can be pretty large. So they're definitely in that circumstance. Now, whether or not the winter and school openings and people getting together indoors and fatigue leads to increases in other places. We'll have to wait and see. And that situational awareness is going to be absolutely crucial to seeing that. Again, I know that you know this, but it's worth reporting still, cases in young people, especially very large numbers of cases and young people are not themselves likely to be a very direct threat to local health care. However, if they are then able to infect older age groups, you are more likely to require serious critical care than it can. And that's likely to be happening but at a local level. I'm hoping that we can manage to avoid ending up exactly where we were in the spring by being very aware of what's happening with the pandemic. But, you know, whether or not I'm right in that is something that will be empirically proved or not.
BARRY BLOOM: I would think back to earlier discussion of the question, where are things going? Put it this way. We've thought this repeatedly that if you're thinking about COVID or flu, certainly with COVID, you have to think three or four weeks in advance. You have to understand that what you see now is not what's really there. And you have to be able to anticipate what's coming. And the best way to do that, Bill said, is to get testing data, which you can get at any time, which will precede hospitalization data and death data, which are way after you can do very much from a public health point of view. So I would make a pitch, go back to data. We have a influenza surveillance network that reports to CDC every year in surveillance centers, hospitals or municipalities that collect regular data on serologic testing or viral testing for cases of influenza. If they were generalized and they were located in every state, you could have continuous monitoring for respiratory disease as a symptomatic surveillance, for example. And then with the diagnostic tests, you could say whether flu is going up or down, which is what the network has been able to do and whether COVID is going up and down. If you added another test for COVID and I would point out some of the earliest transmission epidemiology data came from the Washington State Influenza Network. It started to begin to test for COVID without surveillance networks. It's very hard to be able to answer the question, where is it beginning to rise so that you can really move quickly enough to do anything, usually react after the hospitals start to see admissions.
BILL HANAGE: Which is way too late, because then you're going to keep seeing the increase in infections for a good few weeks after that. This is a whole other conversation, which would be interesting to have with Barry, but I'm wondering if a silver lining that a more coherent national state of surveillance for respiratory disease might be, that would be exactly the kind that you're talking about. And, you know, with consistent testing and so on and so forth and improve that. But that's something which, I hope. I'm saying that more in hopes, not necessarily expectation.
MODERATOR:Do you have a follow up question? I just didn't understand.
Q:Well, when you were first talking about Europe and what was going on?
BILL HANAGE: Oh, that we're seeing increases in cases quite large increases in cases in Spain and Italy and in the United Kingdom. Spain and Italy have seen large increase in cases. But because they are largely the younger people, cases that are less likely to be leading to people being severely ill, they have never resulted in an increase in deaths, but not a very steep increase in deaths. The odd one out in that may be the United Kingdom, where they had an increase in cases, which was largely associated with open schools and then promptly lost the ability to test because the children in the schools did what children in schools do and came home sniffly. And then all the parents wanted to have tests for that, among other things. And then ended up in a situation where the government ended up saying, you will not have to drive more than seventy-five miles for your coronavirus test. And following that, there has been a worrying increase in hospitalizations just a few weeks after the increase in cases. So that looks like a place at the moment where control has been lost. And you can see it in the interventions which are being put in place, which by the standards that we've been looking at around here recently, have been in the northeast, quite large changes.
Q: Thanks both. Appreciate it.
MODERATOR: Next question.
Q:Thanks for taking this question. This is going to be hyper local. Because we have at least three universities in Cambridge and two of them are large and two of them are testing people as much as three times a week. I'm wondering, you did talk about the positivity rate. I wonder if these repeated tests are going to mask anything that's happening in terms of positivity?
BILL HANAGE: In terms of positivity, you said you would want to think about that when interpreting it. And I know there have been discussions about thinking about how to do that. So people are aware of it. I think the comments that I think my friend Natalie Dean in Florida made a very, very smart comment about positivity, which is that it is a crude metric for how good your surveillance is. But if you are in a situation where a very large number of tests are being directed at a very large number of people who are very unlikely to be infected, it can mask things which are underlying it. Another thing, we will know, too, that there is substantial sort of things in terms of socioeconomic status and racial and ethnic disparities, which are very important in terms of the criminology of the pandemic. And so directing a lot of tests and a bunch of comparatively well-off, comparatively unlikely to be exposed individuals may make it much more difficult to interpret directly. But I will comment that your point is correct. But you know, the pros looking at the data are aware of it.
Q:All right. Thanks. And the other question I have is about in Massachusetts, you have something like 350 different local health departments, and the state puts out a statistic once a week that gives a lot of information about each individual community. But each individual community is counting and looking at only people who live there. Well, here in Cambridge, I mean, you can't say that nobody ever goes across the bridge into Boston or comes back the other way. How much does this interfere with seeing what's actually going on? The fact that it's so local.
BILL HANAGE: And, well, in some ways, it's worth remembering that, like Barry was saying earlier, about the pandemic is global and any one time, it's also very hyper local. So while I have some sympathy for the fact that in Massachusetts, again, these systems are so fragmented that it's quite difficult to get an overarching view of them. But in terms of understanding what's happening at a local level, it can be pretty useful. I mean, where you are talking about there is, again, quite relevant to the fact that, as we've been saying many times, one of the things about an infectious disease is that it's quaint. You cannot consider an individual location or individual locality or city in isolation of others and that the amount of transmission happens, and one can end up posing a risk to other neighboring ones. So some random schools, because you can remember, just because all of the kids in Cambridge public schools are there in Cambridge, that's not necessarily true of the teachers and staff. And it does mean that those people making decisions going forward should not have a narrow lens focus upon them, only their own community. They should also consider it within the context of the wider neighboring communities and the wider social framework of the state and indeed the nation. Also, I mean, I can think of cases of transmission. I know that happened to the summer from people who were returning from vacation in Florida when they became infected.
Q: OK. Thank you very much.
MODERATOR: Next question.
Q:You couldn't ask for a better transition than that, Dr. Hanage. We appreciate it. So here from the hotspot of Miami-Dade County, we're in a bit of an odd situation. I was working on a story last week about the potential of school reopening to spark another outbreak here. And since then, we've had the development on Friday of the governor basically forcing local municipalities to remove the restrictions on restaurants. We also have no ability to levy fines anymore for mask mandates. And on top of that, the state is also pressuring these school districts here to reopen by Monday. And that's this coming Monday. And the school board is saying, you know, basically we don't have a plan, we're not ready. We have looked into the details of that plan, but they do have so far, and there's a lot of questions about testing availability, about ventilation here in South Florida. A lot of the schools are designed to have the windows closed at all times because it's hot. So they're struggling with how to, you know, rejigger the ventilation and install filters and stuff like that. And basically, there's no indication that all these schools are going to be ready in time. With all that said, I guess I just kind of wanted to further question back at both of you and say, you know, given that the framing was kind of what potential do schools have to spark another outbreak here, I guess the question now is, you know, is that even something that we will be able to tell anymore, given that there's also all these restrictions being loosened on restaurants and others, things like that?
BILL HANAGE: No, I don't think you will be able to tell. I mean, I guess I noticed this when it happened. It means that any increase, and I suspect we will see an increase of uncertain size, is going to be possible. In fact, what Florida is doing sounds rather like what Israel did. And it was followed by a sharp increase and a very, very high rate of action, relatively. Quite a large increase in the per capita mortality and the second lockdown. So again, just like Florida's doing here, Israel opened a lot of things, including schools and a bunch of other stuff pretty much at the same time. And the increase is was associated with outbreaks in high schools. But I think a few of you in other cores and private cores, it's very difficult to say that's necessarily education because they did so many other things at the same time that it could be just that the education was what happened to be noticed first because people were looking back. Now, having said that. Right now, I think that the long-term outlook for Florida, even though there is going to be an increase as a result of this, I don't think it's possible to base what we're seeing anywhere else. It's not possible to have that many more opportunities for transmission without some of that happening.
I do hope that across the South and the Sunbelt, as the fall bite's up here, you guys are able to go and grill outside and socialize and that those kinds of outdoor contacts will increase and so transmission will become more limited. That's my hope. But as I say at the moment, if you wanted to find a comparison, then Israel might be a good place to go and look.
BARRY BLOOM: I have pretty strong feelings that in a way, one could look at what's happening in Florida as an experiment in public health without informed consent of the population. And I am very concerned that once, as in Israel and in many other places that have relaxed without reducing community spread to a very low level, the numbers will go up again. And the victims are people and the politicians. And I am hopeful there's an epidemiological mechanism called regression discontinuity where you can look at subtle changes before an intervention. The classic. And what happened to the life expectancy in South Africa when antiretroviral treatment was introduced. And one could look at a year before any year after and find an 11-year gain in life expectancy every single event, the ability to give a drug. This is a single event that's putting everybody at risk in the state of Florida. And I do hope our colleagues start to collect data on that. Bill, maybe you're right. It may be warm weather and outside. Makes it much less worrisome as compared to what I'm fearful of. But someone needs to collect data and there are ways to analyze that relatively short term to see whether that this continuity is what's responsible for the increase in cases.
BILL HANAGE:I agree. And I should point out, I think that you know this, but what I'm saying, outside might help. I'm not for a moment suggesting that it will be sufficient to relax.
Q:Understood. But, you know, one other thing I wanted to just add real quick to this is last week, the governor hosted a roundtable with some notable kind of COVID contrarians, including Michael Levitt and others who have kind of you know, he was kind of spinning that in the science, so to speak, and suggesting a whole lot of things. Among them, that 15 to 20 percent population immunity is enough to prevent further outbreaks, which I know you and I had discussed, Dr. Hanage in the past. And you know, there's a lot of nuance area that was missed. He also suggested that schoolchildren don't need to wear masks or distance. I just kind of wanted to throw both those ideas to you, Dr. Hanage and Dr. Bloom, to get your thoughts on, A, what the evidence is for these suggestions, and B, if it's irresponsible of the governor of a state to be presenting science like this when there is, as far as I understand, a lack of evidence.
BILL HANAGE:Well, the first thing I'll point out is that Michael Levitt being there is another thing that Florida has in common with Israel. Michael Levitt persuaded Israel to do a rapid reopening, saying that it was not necessary. At one point, indeed, he stated that he would be surprised if there were 10 deaths in Israel over the entirety of the pandemic, despite having been proven to be wrong. Again and again and again and again and again. He continues to be taken seriously by politicians who hear what they want to believe and go with that, rather than people who actually have experience of infectious disease. I hope that Florida realizes that he is not an expert worth listening to on this. I think the more general point about the contrarians is there is a range of scientific opinion. I mean, one thing that I think I've spoken to various people on the call about and which I think Barry and I, we come to when we keep talking about low community prevalence, is we trying to drive this idea that you take a number of perhaps individually mild, sustainable steps, the goal of which is to initially reduce transmission to a very low level is something you can have much of relatively large amounts of normal, if not normal, then more comfortable society. And then you keep that level rather than allowing it to get out of control. There are, however, people who seem to be, and I think that is the view of a basically some people, a little bit more of the kind of get it low, throw it out completely, make sure it never comes back. Then other people are kind of well, let's keep it burning along at a rate which is tolerable, which doesn't threaten health care. Those are both, I think, responsible attitudes, the viewpoints of other people who repeatedly make claims which are disagreed with by the vast majority of infectious disease professionals. I will note Michael Levitt is not an infectious disease professional. He has no experience in infectious disease. And essentially, if you were going to go and have a heart transplant, would you go and ask a physicist or a chemist, even if I had a Nobel Prize to do it? No, he does not have the relevant expertise, and so he should not be listened to. However, unfortunately, people hear what they want to believe. And as a result of that, people like him have a disproportionate impact. He's not the only one.
MODERATOR:Dr. Bloom, do you have anything you'd like to add?
BARRY BLOOM: I agree.
Q: Are there are there any comments? I've just one last thing just on the idea that schoolchildren shouldn't need to wear masks or distance. That struck me as very surprising.
BILL HANAGE: It's based on the idea that school children are very unlikely to suffer the worst impacts of disease. And that's true. However, it completely misses. I mean, there is this sort of notion that if you managed to do something where you've got a whole load of infections among children, then you would build up a large amount of immunity, because these people are saying that you only need 30 percent of the population to be immune in order to get immunity. Which I don't really think is true, but, all right. Let's go with it. And I say that it is so you use the children to make up 30 percent of the population. So, great, you've got that. No, you haven't. Because it depends on the network. So just think of the villages as you're in Florida, those are a bunch of older people making contact with each other. And if none of them have become infected and immune and that's those networks, they will still be just as vulnerable to introduction of the virus from outside. Even if the immunity in the kids is pertinent down to low levels, that kind of argument depends on actually eliminating the virus through herd immunity rather than, you know, keeping a presence of low levels. And I think that lots of people don't understand that because, again, they are just casting around for whatever they can find to get back to something which is normal. As I said before, normal is not really on the table. More comfortable could be. But to get there, we first will have to accept that we have to take it seriously.
Q:Thank you both so much, I always appreciate it.
MODERATOR: That may be our last question. Dr. Bloom, do you have any final thoughts for us?
BARRY BLOOM: Oh, I thank you all for very sharp questions.
BILL HANAGE:Yes, I agree they were very sharp. I'm looking to see if I have anything else. No, I'm good.
This concludes the September 29th press conference.