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May 19, 2021

Living With COVID


Neha Nanda, MD
Neha Nanda, MD | Medical Director of Infection Prevention and Antimicrobial Stewardship, Keck Medicine of USC
Scott B. Laurie
Scott B. Laurie | President and Chief Executive Officer, The Olson Company

Neha Nanda, MD is joined by Scott B. Laurie and Richard K. Green to discuss the ongoing recovery efforts from COVID-19, how organizations might manage returning to the office, and when everyday life has a chance of achieving a new normal. Nanda also reviews rules of thumb for mask-wearing as well as what vaccine hesitancy may mean for California's herd immunity.

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- Let's get started on this and said it was going to be my pleasure to introduce Scott Laurie. Scott is the person who invited Dr. Nanda to be with us today. Scott serves on a board at the Keck School of Medicine and that's how he has gotten to know Neha Nanda. She is a hospital epidemiologist, medical director of infection prevention and anti-microbial stewardship. I probably did not say that correctly, at the Keck school of medicine. Very widely published, very involved in the formulation of policy with respect to COVID over the past the last 14, 15 months here in Los Angeles county. And again, we have had a series of discussions in this real estate podcast about the intersection of public health and real estate, COVID in real estate. And so in that tradition, we have a particularly distinguished speaker on that matter today. So Dr. Neha Nanda, thank you very much for being with us today.

- Thank you, Richard. And thank you, Scott. We can't see you, but we know you're there. So I think I'll start by just sharing few things that are perhaps on everyone's everyone's mind as it relates to the pandemic. And then it's nice to have a dialogue with everyone. With that I think let's talk a little bit about trends across globally and then come down to our own county. Many of you may know already that if you look at us as a global community, the number of cases are trending down about 6% reduction if few compare the prior two weeks to our current week. Having said that the deaths stabilized but you know that number doesn't have a lot of meaning because as you all know what's happening in the Indian sub-continent, it's just sheer havoc. It's a crisis. And if fortunately, some countries like the US and the UK, the race between vaccines and variants, the vaccines are winning. And that's where we see numbers like what we are seeing in the US right now, I believe about the number of cases diagnosed have gone down about 25%. Again, if you compare two weeks, prior two week to the current week, hospitalizations have gone down to I think about 12%, 12% reduction I should say. 12% reduction in hospitalization. Deaths have also reduced by around 5%. And all this is happening in the face of rampant vaccination. So in the country, as you may know, about 36% of the people are fully immunized. The definition of that being two weeks after your second dose and about 45% of the people have received at least one dose. If you look at California and LA county, our numbers mirror what's happening at a national level in terms of vaccination. If you look at the number of cases and hospitalizations in California and LA county, there's also a dramatic reduction. Again, there's been less about 25% reduction in the number of cases in LA county and hospitalizations also. There's a 15% reduction. And I can tell you from a medical enterprise standpoint, the number of patients we are seeing in the hospital today are in single digits. It's been several weeks that our numbers have been less than five. You know, obviously they were double digits earlier on in the pandemic. So clearly vaccination is working. And with that, I wanna talk a little bit about the vaccines that are available to us today. And I think as everyone knows, three vaccines have received emergency use authorization under FDA. That's our two mRNA vaccines, Pfizer and Madonna and J and J. And what starting out to be really a wonder of science is that they are truly effective. So we learned about efficacy. That is what we learned in clinical trials. And we learned that they are 95% effective or the efficacy was 95% in preventing clinical disease, severe disease, especially severe disease. What's reassuring is this is getting translated into real world data. And that is clinical effectiveness. And, you know, numbers that have always stuck with me is, you know, if you can hear some hammering, I'm sorry. That's the office, there's something happening somewhere. Okay. So the numbers that have really stuck with me is this huge database that CDC has. So we vaccinated about 95 million people today. And the reinfection, percentage of people who have been reinfected after fully immunization is less than 0.09%. That's huge. And about a month ago, we learned that when they looked at a couple of people who got vaccinated, this was around, I think it was 400,000, it was a huge number, of the healthcare workers, essential workers and first-line responders in December, we noticed, we recognize the efficacy was 90%. So that's huge. What you saw on trials was 95% and now it's getting translated into real world. In addition, I think as everybody knows what's happening in Israel, where number of people vaccinated are 60% and currently last I read, in fact, in the last week, there are less than a hundred people who are hospitalized in the entire country and it's the lowest ever bit that it's ever been in Israel. So I think all this tells us that basically these vaccines we have been very lucky. They are truly effective. Now, obvious questions that come up. Is the vaccine currently effective against all the variants that we've heard of or read off that are emerging? So I'm gonna talk a little bit about variants later but the simple answer is yes, by and large, yes. There are some new variants that have surfaced. We don't know about those variants, but if we had to guess, they likely are effective. How long does the immunity last after we get vaccinated? That's an obvious question. It's likely longer than what we know today. Based on studies, we know that it is def our immunity is is robust for at least seven months after your vaccination, if not longer. And those studies are ongoing. So I think one thing we have talked about is that it reduces disease. The other piece is does it reduce transmission because that very nicely translates into do I need to wear a mask after I'm vaccinated? So today, the scientific data as we know it tells us that it reduces the risk of transmission by 70 to 80%. In the background there are studies looking exactly at this question where it's Moderna actually that's doing a study with NIH where they are looking at around 6,000 students, 18 years of age in that range where they had an arm that was about 6,000 kids were vaccinated students and 6,000 were not. And they are letting them mingle in their routine life. And they're gonna look at the transmission specifically. However, putting things together, given that we know the viral load goes down tremendously after vaccination when you're fully immunized, it's plausible. And it's very reasonable to assume that it has a major impact on the risk of transmission as well. So with that, there's amazing news that we all have read that it has vaccines. Pfizer vaccine has received a e-way for children between the age of 12 to 15. And hopefully this week they'll start getting vaccinated. At this time, we are not privy to all the scientific data but the data that is available and it was made available to us by Pfizer earlier on was very encouraging where they talked about around 2,300 students, 12 to 15 years of age not students, children, they were vaccinated and the efficacy, they were followed for a period of time at least two months. That's by the way a requirement before any vaccine even receives an e-way. The efficacy was north of 95%. And Moderna has again corroborated similar results just yesterday in this age group. So very encouraging data around vaccines and children. So the next question that comes up is when you think about children. Is it really that COVID doesn't get to them? And I think here let the facts speak for themselves. Overdose gets to them. However, the risk of there getting severe disease is very low when you compare it to someone who's more than 65 years of age. And the numbers really speak for themselves. So in the United States, all of the cases that we've had, around 14% of the cases have been attributed to individuals less than 18 years of age. In that category one to 3% have required hospitalization. And in that group about a third who are hospitalized actually required care in the intensive care unit. And in that one to 3% there is a very small proportion that actually developed the most severe form of COVID in children, that's multi inflammatory syndrome, that's MIS-C that you may have read about. Having said that, there is some data from Italy that has just become available where they talk about, they looked at about hundreds of students and about a third of them continue to have symptoms after COVID for about 120 days. And when you talk about symptoms I'm talking about fatigue, headache, difficulty functioning. So the risk is low of severe disease in people who are less than 18 years of age. The risk is not zero. The number of deaths in the US have been in the range. When you talk about children, has been in the range of 350 to 500. So if you're translated, you know, one child is perhaps we are losing a child every day in a year. The risk is lower. Having said that we need to live by our mitigation strategies that we've been talking about up until now. So that's about children. Now, the second question that comes up is, is it safe to send children to school and what'll school look like in the fall? The answer is it's safe to send children to school if you have all the right mitigation strategies in place and not all at least a combination of strategies. And that includes daily screening, testing, distancing, masking, encouraging vaccination and importantly ventilation, and using outdoors, leverage the outdoors. It's very clear if you do all this, it can be quite safe. And we've learned that from data that came out of Wisconsin, I believe, and North Carolina. And this was done earlier on, in the fall where the number of cases that were attributed to in-school transmission were anywhere from 20 to 15, something like that. And they were looking at, you know, 5,000, 10,000 people in those big cohorts. But also not one other thing I forgot to mention is that, another piece is small stable cohorts of students to keep the numbers small. So the risk of transmission is further reduced as you have these other non-pharmaceutical interventions. Hopefully in September are 12 to 15 years will also be vaccinated. And then now we are talking about five to 11 years of age. At this time, it appears that Pfizer will be able to share their data with the FDA in September for this age group five to 11. And then in the subsequent months perhaps in fall or winter regarding the group that's six months to five years of age, they'll share that. So I think as time goes by, things are gonna open up, more people are gonna get vaccinated. So school will start looking like what we are used to seeing school before the pandemic. But I would recommend that the group that's not vaccinated, we should still believe in mitigation strategies for that group till they are completely vaccinated, till they are fully vaccinated. It's just a few more months. And then your entire student body at least has had the opportunity to get vaccinated. And that leads us to the question of, will we reach herd immunity? I think as a country, I wanna be optimistic. I wanna believe we will, but I think we likely will not. And with that, we have to keep following our numbers in our community and be good about pivoting to re-implementing our non-pharmaceutical interventions if need be. With that, another thing that I think the group had asked me to speak about was is it safe to get back to the office? As time goes by, it keeps getting safer and safer. Last March was the beginning of it. Last fall was not very safe because our community rates were so high. Look where we are today. Our positivity rate is extremely low in LA county. In the office setting, if we have the right mitigation strategies namely distancing, namely ventilation and screening strategies in place and access to testing when someone has symptoms, it is safe to get back today relative to where we were last year. If you were to ask me, is it safer than being at home and not leaving your home at all? That's a very difficult question because I think there are many things that have to be taken into account when we say a yes or no. It's not a categorical answer. And I think I'd conclude by saying what's on the horizon is that SARS-COV2, the virus that's implicated in COVID disease, it's here to stay. It's not going away. And what we have to keep an eye out as we encourage vaccination and get vaccinated is keep an eye on the variants, the story that's unfolding and keep an eye on your local numbers and just get vaccinated and encourage people to get vaccinated around you. Maybe I think Richard and Scott I'll stop. I did want to talk a little bit about variants but maybe let's open it up for a dialogue and I can elaborate as questions come up.

- So Scott and I... I didn't get a chance to introduce you before but I think you all know Scott Laurie runs the Olson Companies, a very valued member of our Lusk board and producer of Very Creative and what I'll say is more affordable housing and housing as a general in California and again a member of the Keck board. So that's how we got to know Dr. Nanda. So Scott, thanks for inviting her. And let me ask you to start the questioning.

- Yeah, you know, first of all, hi Dr. Nanda. Richard and I apologize for not being right on and I wanna blame Dr. Nanda for that because we're not able to fully go back into my office. So I'm still in a remote work environment but I think that's something that we're all facing and that's why I bring it up. And Dr. Nanda has been working with me and my team now for probably seven, seven and a half months on how we reopen, how we open safely, what all the protocols are and what I think is important to discuss. One of the things we're all challenged with is how we get the team back and comfortable re-entering the office. And Dr. Nanda was touching on some of the safety protocols at distancing, in vaccinations. It's challenging. And Dr. Nanda knows with my office team, we're at 90% right now and we've plateaued. And now we have to deal with the 10% that aren't vaccinated. And I think that may be something to discuss with this group, but I was gonna show but my technology isn't working today. Every single day before we go into the office and we're on what I call our teammate TB concept where half of the office is in one week the other half is in the next week and it's worked very well for us. But the most important thing that we've done is something called Healthcare 360. And everybody has different apps. It's a daily check-in and it's our first line of defense for the office. And I believe in facts. And that's why I believe in Dr. Nanda. And she's really been an incredible resource but the facts are that people need to take their temperature. They need to look for symptoms before they go into an office environment. And we have to prove to the other people in the office that it's safe. And so what we've been able to do, we've been in this two-team concept for many, many months. We have not had one person sick from the company. We've had people that get sick outside of the company and what we've been able to show people is the office is actually an incredibly safe environment. What's not safe for some of the things that people may be doing outside the office. But I think Dr. Nanda might be helpful as well to touch on some of the things that we've worked on and what works to really bring people back, you're back at Keck. How do we get people comfortable coming back to the office again?

- So I think, yeah, Scott, it's been a pleasure working with you and your team. So I think it's important to be transparent in communication with the team members and give them confidence in our mitigation strategies that we have in place. So as Scott mentioned, we've created, Scott has created with his team two cohorts and there has been, they haven't encouraged transparency. As in when people fill out the app as I hear from that team, they have confidence in their team that if they are not feeling well, they'll say yay or nay. And that is huge. It's that self-awareness and knowing that you're gonna be celebrated, I shouldn't say celebrated but there's gonna be no finger pointing. There's gonna be no stigmatization if you're diagnosed with COVID, that's very important. And within that, I'll tell you, yes, outdoors, indoors is not controversial. And we will talk about that like Richard alluded to at the beginning of the thing but the fact is that indoors is higher risk than outdoors. Offices are indoors. Therefore, we need to rely on things like distancing. We need to rely on easy access to testing. We need to rely on surveillance testing, maybe because remember there can be asymptomatic people who are positive and then if you have an unvaccinated person, that person can contract the disease. So there are several things that can be put into place but it has to be tailored to the organization to make it effective.

- And Richard, I just wanted to add one thing to this because for us, the biggest challenge we faced, there was no playbook for COVID and there's a lot of noise out there and there's a lot of information. And a lot of it is factual. A lot is not. And we can't block what people hear outside of our environment. So the transparency I think is critical, but there's a lot of planning that has to go in to the office environment. And, you know, there's things that we thought were important to do. For instance, spending $30,000 on the shields in between cubicles, which Dr. Nanda asked me, "Why did you do that?" And I realized we did not need to do that. But in our minds, we had to raise the cubicle heights. And I'm still upset about the $30,000. Now it looks nice, but here was the reality. She told me, she goes, "You know you're not protecting anybody." Now, we may pretty protecting them from a sneeze but the virus is airborne and it doesn't just see the partition and say, "I'm stopping here and I won't go over it no matter what." I think there's just all these things that we mentally think feel good for us. And it's really important to understand what are the ideas. What are the protocols and processes to implement that don't just make us feel good but actually keep people safe. And I will add one of the challenges with us bringing people back into the office which we're coming fully back in on June 1st. There's people that sit too closely together in cubicles. We can't bring them back. And it's just sharing that transparency and discipline and explaining to the team why they're not coming back. And one thing we had to look at and Richard or Dr. Nanda may wanna touch on this. We're gonna be in a two-class system. We're gonna be in a system of the vaccinated versus the unvaccinated. And you're just, in my opinion, there's gonna be certain privileges that you will have and we just rolled them out to the company. If you're not vaccinated in our company, you're getting quarantined if you go out of state or international travel. Everybody will be quarantined on international. But if you're not vaccinated and your work for our company and you go outside the state of California, you will be quarantined and that's per CDC. If you are vaccinated, you're free to travel and people may or may not think it's fair but that is one of the challenges. We really have to be able to say, "This is what we're doing and this is what we're following and stick to it and be disciplined."

- So I guess I have three burning questions. I don't know if I should just ask them all in a row and by the way, please feel free to type your questions in the audience to the Q and A chat or the chat box. We will get to you, as many of you as we can. But I like to think of things probabilistically. It's a way I know I'm very strange and very nerdy.

- [Scott] Did you all lose Richard.

- Before I do things like. Can you hear me?

- [Scott] I think we lost you for a second, Richard. Sorry.

- Okay. So like, I know for one of the reasons I have no trouble I am never afraid to get on an airplane is I know the chances of dying on an airplane if I get on it is one in 6 million. And that to me is an acceptable risk in exchange for getting to go somewhere. All right. So I've been trying to decide how to think about what being vaccinated means from a risk standpoint. So our case rate in LA county now is a little under three per 100,000 people per day. And so if you're contagious for let's say 14 days which is the long end, that means on a typical day you would have 40 out of 100,000 in LA contagious, right? So four out of 10,000. And then the efficacy rate of the Pfizer vaccine which is what I got is 95%, which means that if I am exposed to somebody who has the disease, any one random person in LA, I take one divided by 20 and multiply it by four divided by 10,000 and I get, what is that? Four into 200,000. So one in 50,000. But then on top of that just because I was exposed to somebody doesn't mean I'm necessarily gonna get the disease anyway. So I'm under estimating the efficacy of the vaccine. So am I wrong trying to think about it that way in terms of determining what my risks are is I do things and now I look at that risk and I say, "Yeah, I'm gonna go grocery shopping. I'm all right with that."

- I really liked the way actually you put the numbers together, Richard, and you are not wrong in thinking. When we are thinking numerically that's as objective as we can get with all the information. What I will share with you is, and I wanted to talk a little bit about variants. So this is actually a perfect segue that Pfizer and Moderna, they were tested in trials at a time when we have the wild type strain, the initial strain. We did not test the other variants that are circulating currently. So yes, if all the strains around us are wild type strains, I think numbers speak for themselves. You're relatively safe. However, we know that viruses and bacteria, they all go to outsmart us. So therefore, we still want to be cautious as we are doing that. And I'm not saying don't do what you're doing. I'm not saying don't travel but I don't think taking additional measures like masking and something else that is logistically possible. You hard wire that for a little bit till the dust settles on variants. And I think, let me talk a little bit about the variants. In California, since you shared numbers about California, at this time, the predominant variant is the B117. This is what was first identified in the UK. So more than 50% of our isolates today are 117. The good news is that this variant, the vaccine can get this variant. So we don't have to worry about it. The other variants that are circulating in California today is 351. That was identified in South Africa. We have data from Qatar where they looked at 400,000 people. They followed them for a while. And what we learned is that the predominant variant was 117 and 351 in Qatar, that Pfizer vaccine. And I would say, when I'm saying Pfizer, I mean Moderna as well because the mechanism of action is so similar. It is effective in preventing disease for 117 by about 90%, 90% effective and for 351 it was 75% effective. This is any disease. For severe disease, for both these, Pfizer is effective in preventing 95%. So it's 95% clinically effective. And also in that study, what we learned. Remember the big discussion around whether we should instill ongoing, whether we should give one dose versus two dose. This study tells us, gives us the answer. The group of people who will got only one vaccine, their protection was seven... The clinical effectiveness was 17% if they had the 351 strain. But if they had two doses, the protection was 75%. So two doses is better than one. But I digress. Let's get back to the story around variants and why we still want to be vigilant as we navigate through the pandemic. So we talked about the 117, variant 351 variant that is circulating in smaller numbers than P1. That's the one that was identified in Manaus, Brazil. That is circulating in you know, it's around 50, 60 cases. That's about it, not a whole lot. And then the CAL.20C variant. That was identified few weeks ago. The good news is our vaccines are effective against all these variants. But the last variant, that's the B671 variant that has just been identified in India, it originated there. There are some cases in California of that variant, far and few, and all are related to traveling. We don't know enough in terms of clinical effectiveness of the vaccine against this variant, but as you can see, it's just a matter of time, more variants show up. And then it's a competition between the variant. So fortunate for us, the 117 variant, which is the predominant variant is the fittest of them all. And fortunate for us, our vaccine gets them, gets it. So it's a long-winded answer. That what you're saying, the numbers make a lot of sense and you're safe to do the things that you talked about. But if you think you are in a indoor setting and not in an outdoor setting, and you can't be sure in a flight if everybody's vaccinated or not. And for that reason, masking is something you should consider or you should do actually.

- So I'm curious about how other... Once the vaccine came out, before I got vaccinated, that's when I just totally holed up in my house, because the idea of catching the disease when there was a vaccine available for it was just too horrible for me to even think of. But like the first thing I did after two weeks passed was start grocery shopping again. I do it with a mask. And again, I went through the series of probabilities, oh and the mask reduces your probability too. And I said, eh, I'm willing to put up with that kind of risk in order to enjoy grocery shopping. I actually enjoy grocery shopping. So, you know, what would be useful? And I know these things are hard but if you could tell people what probabilities are for different activities, masked and unmasked, and so then they could make their decision. Now, not everybody thinks probabilistically but I think that could be very helpful way to inform people about what it's like to do things outside versus inside, for example.

- So a simple, absolute number when you compare inside to outside is 18.7 times lower risk when you're outside compared to inside without a doubt. And in fact, and I agree with that. Now that you're vaccinated, majority of the people are vaccinated in your small group. You can think about letting go of masks because the community rate is so low and importantly in your small group, if you know they're all vaccinated, if you know none of them are immunocompromised. And that's another piece actually, immunocompromised, because it's very clear based on how we measure whether we have bound to the response or no. If you're immunocompromised, our response as how we measure today, it's not as robust. It's about a 10-fold reduction. It's at 17% of the people who are immunocompromised monitored a response opposed to 85% who are immunocompetent. So keep that in mind and be sensitive to people who are around but going back to outdoors, it's definitely safer. But let's say you have someone who has, who's undergoing active chemotherapy at this time is a part of your small group. I don't think it's a lot to ask if all of us wear masks and we are outdoors we are in California and everyone's vaccinated. So it comes down to really being your own public health officer in your own small setup. Another number that's very useful.

- Dr. Nanda, I'm gonna stop you for a second. 'Cause we go through this every single week, it is less safe to sit in a restaurant with strangers. This is the one thing you tell me not to do indoors. It's okay to be outdoors, but being indoors with unmasked people who are not in your circle or in your cohort that I believe is one of the more high risk activities. Is that correct? Indoor dining.

- Yeah. If you have an option to sit indoors, outdoors, Scott knows this very well, I would highly recommend choosing outdoors. When you go indoors, it's not as safe as it is outdoors. That's just based on numbers that we just talked about.

- And I think that plays into as well, because a lot of people on this call are trying to figure out their businesses. It's the same thing for the business and how you manage that and what you tell people. 'Cause everybody asks that same question. Richard asked, "What can I not do, what has changed now that I'm vaccinated?" And I tell them, which I like you to reinforce. The biggest change is the likelihood of dying or going to the hospital. Is that correct? What is the likelihood of that happening to me now that I've been fully vaccinated?

- It is extremely low, less than... When you look at the big study, 95% of the time it's not gonna happen to you, right? So it's that five or less than 5% of a group if you take 100 people, will actually develop severe disease, who will require hospitalization. It's extremely low. Look at the numbers. When you're vaccinated, the number of people who got reinfected on a 95 million is 0.009% who got reinfected. That is very low. And of those a few hundred actually required hospitalization for severe disease. So the numbers are extremely low if you're vaccinated.

- And the number, and again, this is a... The number of people who have died relative to the number, of COVID relative to the number, who have been vaccinated is one in a million. I mean, literally one in a million. Now, you know, more time will go by and a few more people will die but we're also vaccinating more people. So I want you to turn you to what I'll call more political questions than medical questions. And if you're uncomfortable with this then... But we need to get everybody vaccinated. And there are two things I think about here. Is one, there's been some criticism, for example of president Biden, for continuing to wear a mask even though he's fully vaccinated and even though everybody around him is fully vaccinated. And the argument is you should take off the mask to show people, see this is the reward that you get if you go get vaccinated. And so there's a tension between the yeah, it's better for us to continue to be careful. And there are people out there that just won't believe this thing works if they don't see their leader expressing the ultimate confidence in it. And then the second thing is there are all these stories about the vaccine out there that are completely fabricated. So for example, people saying, "Well Pfizer and Moderna were tested in animals. So they weren't appropriately tested." When in fact they were tested in animals. And this is, I will say certain outlets, media outlets propagate these stories. And when someone like me tries to push back against it, I get, well, what do you want? You're a liberal, pointy-headed academic idiot. And I wanna own you when I don't believe you. And yet we need to get people who have those attitudes vaccinated. So I just on two issues, first modeling behavior. And second, how do you convince maybe not everybody but more people who have these points of view that no you really got to go get this thing.

- I think the first thing around masking, you know, it's political, yes. It's also cultural. It's a culture. In East Asia, Southeast Asia people typically wear masks routinely. And I wouldn't be surprised this fall several people will be wearing masks because of influenza. We've seen that you can control it. The numbers were appalling, appalling. Like you had like five cases of influenza in the county, something ridiculous, right? Compared to thousands. So, okay. But let's get back to the question you posed. After vaccination, our president is wearing a mask. Why is he doing that? Okay. He has his own public health officer. He has a personal life. I don't know but I think we need to give every individual the liberty to based on their personal situation. We know that vaccine, it definitely reduces the risk but it's not eliminating the risk. And maybe some people are comfortable with 5% risk or, you know, 20% when you talk about risk of transmission, 70 to 80. Maybe they are comfortable with that. But on the other hand, maybe some people are not. So I would say that people who want to wear mask, that's perfectly fine. However, it is not something with the time that we will be able to mandate when people are vaccinated, when the group is vaccinated and they are outdoors, especially with, you know, if even if you have additional mitigation strategies. So I would just say, give every individual the liberty to craft their own practices. And you are allowed to craft your own. That's masking.

- Are you still wearing a mask Dr. Nanda?

- Oh, yeah. Scott, I wear two masks.

- [Scott] I know you. Two masks.

- I guess you'll see it on my desk every time. Yeah. And I'll tell you why I do that. I'll tell you why. I can't speak for president Biden. I can just speak for myself. I'm no president, I'm a simple doctor, but I can speak for myself. The reason I do that is, I'm vaccinated, is because there are all these other variants. I'm coming in contact with patients. I'm coming in contact with patient families. I think it's a bit much for me to probe and ask every time, "Have you traveled? Have you done this? Have you done that?" And I am double masking the right way because if there's a more transmissible strain, I've protected myself and thereby protect the next patient I see who may not be vaccinated at this time. Remember it became, it opened up to everyone on April 19th. So you have to give it at least six weeks. And even as a county the intent is to go into green tier on June 15th. So there is time, you know, that six weeks from your first dose before a person will be immunized. So I think Richard, that's about masking. The second question that you had about animals. I really wanna elaborate on that. And I think it's again, it's a lot of information. And so some of it becomes misinformation. So to put it simply is the technology that Moderna and Pfizer have leveraged, it's not as novel as has been advertised. This has been studied for years prior to it being deployed. If you recall MARS, Ebola, all these things were tried and it has even been deployed. So it's not as novel. The other thing is FDA does not grant an EUA till they have a up of two months in a trial. And the reason why two months is chosen because typically, when you have to see major adverse events associated with a vaccine, it's within eight weeks. If we see it with a vaccine and we did not see it. All the data that's out there and CDC of all the people who were vaccinated in December and Jan, we are not seeing adverse events like we would think that, you know, we would be open to accepting. That's why we were signing that concept when we were actually getting vaccinated in December and January. It's relatively safe and I'll even go on to say that it's even safe in pregnant people up until four weeks ago, my own friends, when they were pregnant I was recommending, you know, let's get to second trimester because the fetus has kind of developed or, you know, it's a safer stage. Get vaccinated in the second trimester. But now I'm recommending first trimester because we have confidence in from the studies that were done because some people who got vaccinated didn't know they were pregnant. And we know it's safe. They've had healthy infants. So more and more data, just arms us with more safety data. And today let me just be a little bit of a clinician here and say the only absolute contraindication to getting the vaccine today is if you had a severe allergic anaphylactic reaction to the first dose of vaccine, or you know that you are allergic to a component in the vaccine and that also a severe allergy, that's when you want to think twice and check with your allergist as to how you can prep yourself to get the vaccine. And if you are allergic to one of the components of the vaccine, look at the other vaccine. J and J vaccine where I know it has received. We have learned that there were a handful of cases who actually had a thrombotic event associated with that vaccine and so therefore there's a warning when someone's less than female, especially less than 50 years of age, there's a slight risk. But also again, if you want to talk about numbers, 6.8 million people were vaccinated. Of those six people in the initial report developed that clot within six to 13 days of their vaccination and all those people were women less than 50 years of age. I'm gonna stop. You guys need to ask me question.

- You know, Dr. Nanda, why don't you touch on... Because a lot of people say this is just talk and do you know this so forth and so on? I believe when you were at Yale that you know personally some of the people that worked on the Moderna vaccine. And I think in pursing to talk about the vaccine, and also, we just had this conversation. What happens when it goes into your arm and how is this graded? What does it do to your body? 'Cause I think there are a lot of misconceptions of what that vaccine is doing when it enters into your body.

- Yeah. So I'll tell you, the group that is led by Dr. Peter Marks at FDA. The Virbac arm. He is a person who, when my training was at Yale and my earlier years on the faculty were at the Yale School of Medicine. He is someone who I would trust. He's a hematologist oncologist. And as you see FDA going through this process, when you know the person, you worked with the person on board seeing patients. There's just this level of confidence you have. I say this it's when you're I say this because when you work with people and they have the humility to say when that they don't know, that speaks volumes to me. And you're talking about a group who embraces the humility that I'm talking about. So this I have confidence. And my group has confidence here that vaccines work. When they undergo approval we can have the confidence that we wished for in this pandemic.

- I'm sorry.

- [Dr. Nanda] Go ahead.

- There's a question from the dean I wanted to make sure it gets to you but if you weren't finished, please finish.

- The mechanism I think Richard I'll touch on that. The mRNA vaccines. So what is happening in our body when mRNA is introduced in our body. What is mRNA? It's a code for a protein. That code is injected into us. It enters the cell very simplistic, very simplistic and, you know, we can get into a detailed discussion, which we want. It gets into our cell. That protein, that code signals our cell to synthesize a protein that is then showcased on the surface of the cell. And then our body undergoes a dress rehearsal and behaves like it is actually seeing the virus, but it's not really. All it's seeing is that protein, the spike protein, and that's all that's happening. There's no real virus. It was simply a code of the protein and that protein disintegrates within hours once it enters your body. It doesn't integrate with anything else in your body. So it's quite safe. Majority of the people who've had side effects, 70 to 80% of those it's fevers, chills, a sore arm. That's about what it is. Yeah, that's what I wanted to talk about. The mechanism. Richard, go ahead. You talked about a question.

- So the dean has a question about you've been talking about the Moderna and Pfizer which is a different mechanism from the Johnson and Johnson. Could you comment a little bit on how the Johnson and Johnson vaccine is different? How much confidence you have in it? Why is it different, et cetera.

- Yeah. So all vaccines are great. J and J, Pfizer, Moderna, they all prevent severe disease with similar effectiveness. And we are saying not of 90%, the mechanism is different. We've been talking about mRNA vaccines. Now the J and J vaccine. What it does is it's a weakened slash dead virus that is introduced in the body. And again, a similar reaction happens. It's a dead virus. It can't do anything to us. That's what the J and J does. And that's similar to what AstraZeneca does. Again, it's a viral vector, but it's a dead virus. It can't do anything to us. And the same dress rehearsal happens. With that, another thing that has happened in California is we are now for the right reasons saying that if you have been vaccinated internationally with a vaccine that has been approved by WHO. That's AstraZeneca today and Sinopharm, the vaccine that was manufactured in China. They haven't commented. California DPH has not commented about Sinopharm because it just happened. But what they saying is that it's fair to consider AstraZeneca if someone's fully immunized. It's fair to consider that person fully immunized like you would a person who is fully immunized with Pfizer, Moderna and J and J. So that's something new. And if someone, you know, let's say your friend or your relative has traveled from overseas has received only one dose of AstraZeneca, they can start the next series here because now they can't get AstraZeneca but you can start by Pfizer, Moderna and J and J. As long as there is a gap of 28 days. Having said that there are several studies that are ongoing right now, looking at the combination of vaccines to complete a series. And also there are studies, ongoing looking at the durability of immune response to the vaccines. And today we know it's seven months but it's like you longer than immunity is gonna last. And that's a very long answer, Richard.

- A very good and very helpful one. Left. Oh, there's another, let me, just gonna ask you a question. Thoughts on Governor Cuomo's mandating all in incoming public university cities to be vaccinated before starting the fall semester. Also, is there any company working on a single vaccine to cover the majority of variants? Much of the vaccine hesitancy might stem from having to get multiple vaccines.

- You know, the first question, whether universities should mandate it or not. And speaking as an infectious disease physician who functions as an epidemiologist, it would be great. But you have to look at it with different lenses and everybody has to win. And that's what is gonna be right for the university or any university. Speaking from a biological or from a medicine standpoint, more people vaccinated, the safer the place becomes. Now that leads us to the second question about the booster vaccine. The booster dose. What's happening currently is that about two weeks ago, it was very encouraging to know that the investigators were looking at the booster dose, Moderna. It seems to work against the 351 variant, the south African variant. And the government you may have read this morning is planning on making it available when it's ready to everybody free of cost. Like it should be. Yes, the true north will be when we have a universal platform that can target all variants. And at this time where we are with that is that there's a lot of buzz and a lot of discussion on what that platform will look like what it will contain. At this time I'm not aware of a commercial company looking into that. I think first we need to figure out the science of what that platform is gonna look like but there is a lot of interest in investing in that for the right reasons.

- So we're coming up to the top of the hour. So let me turn it over to Scott for any last questions or comments.

- Well, thank you, Dr. Nanda. It is always a pleasure. And you know, one thing I would suggest that we try and do for this group, Richard is just get some further information to make it available as people are looking to get people vaccinated within their companies, it's something we all need to do. We support it. It's not always easy. And it's sometimes hard to find the right resources for information. I think it would be good. We can help to make some of that available for what we've worked on. And, you know, I think what we've learned at our company which I greatly appreciate from Dr. Nanda is that if you have followed the process you can reopen, you can get back to some form of normalcy. And I would like to end really quick with this question for Dr. Nanda, when do you really think that we are gonna be able to be back in an office environment, no masks, sitting back in a conference room with seven or eight people having a meeting?

- This is not the first time you've asked me that question, Scott.

- But I'm asking it for everybody.

- But you're asking me again. Okay. So we are getting there. When we'll get there the path is going to be we will likely have small blips depending on how many people are vaccinated of COVID infection. I don't want to be a pessimist, but I want to be a realist. And I think as we keep vaccinating, at some point as a country and as a global community the vaccines will win the race against variants. If you don't let it multiply it can change it's face and it can't become a variant. And just given the proportion of infection today in the world, travel doesn't stop, I would say it's likely gonna be at some point in 2022. It is the last innings. Scott has heard us from me, but it's a very long .

- And I wanna point out when Dr. Nanda talked about innings she's talking about cricket innings, not baseball innings. And if you've ever watched cricket, you know that a cricket inning can last a very, very, very long time. They get to hit the ball with a flat bat. So the batters are much more successful in cricket than they are in baseball.

- You said it. Yeah. Scott, does that answer your question?

- It does. And Richard, thank you. And I will let you know I was at Disneyland. I'm not sure that Dr. Nanda approved that, but last Wednesday I took an opportunity to go with only 20% occupancy at Disneyland. So hopefully we'll all be back to Disneyland. I think it's gonna take a few more cricket innings before we're back to normal in all getting together. But thank you Dr. Nanda.

- I approve it, Scott, because you told me about you shared all the mitigation strategies and everything you did.

- It was well done. And thank you for your advice.

- So Scott Laurie, Neha Nanda, thank you so much for spending an hour with us this morning. This is a very informative presentation, Q and A et cetera. And I just wish that everybody could listen to this and pay attention to this. Again, thank you for attending and we'll look forward to seeing you again soon.