Celine Gounder and Ashish Jha

What the Delta variant means in our fight against Covid. This Week on Firing Line.

JHA: We are in for a very tough August, probably a very tough September before this really turns around. 

The Delta variant is here and it’s driving a new summer surge across the county, around the world, and at the Olympics Games. In May the message to the vaccinated was: take off that mask. 

BIDEN: If you’re fully vaccinated you’ve earned the right to do something that Americans are known for all around the world: greeting others with a smile, with a smile. 

Now, a reversal.

WALENSKY: In areas with high transmission, CDC recommends fully vaccinated people wear masks in public indoor settings.

FAUCI: Something has changed, and what has changed is the virus. 

Dr. Celine Gounder is an epidemiologist and infectious disease specialist who advised the Biden transition team. Dr. Ashish Jha is a leading voice on COVID and Dean of Public Health at Brown University. 

With questions about breakthrough cases, how to boost vaccination rates, and the obstacles to herd immunity, what do Dr. Gounder and Dr. Jha say now? 

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HOOVER: Dr. Celine Gounder and Dr. Ashish Jha, welcome to Firing Line.

JHA: Thank you so much. 

GOUNDER: Great to be here.

HOOVER: The Delta variant, which was first detected in India, is highly transmissible and now makes up an estimated 83 percent of new Covid cases in the United States. Dr. Gounder, why is the Delta variant more concerning than all the previous versions? 

GOUNDER: The Delta variant is by far the most contagious, most transmissible of all of these variants. It spreads more easily from one person to another. And part of that is because the levels of virus that people get in their airways, in their nose, in their throat, are so much higher than what we’ve seen with previous variants up until this time. 

HOOVER: The former CDC director, Thomas Frieden, says that the US could soon see as many as 200 thousand new cases each day. Do you, Dr. Jha, agree with this assessment?

JHA: Yeah, so I do agree with the assessment that we could get to 200 thousand infections a day. The last time we got to numbers like that, we had three to four thousand Americans dying every day. I don’t think we’re going to hit those numbers ever again. And that’s because most of the people who are at the highest risk — the elderly, the people with chronic diseases — most of them have gotten vaccinated. And so the vaccines are going to protect hospitalizations and deaths. I think we’ll still have an enormous amount of suffering and death. 

I don’t want to underplay that. But it won’t be quite as bad as it would have been had all of these people not gotten vaccines. 

HOOVER: You know, there’s growing evidence that there’s a pretty big difference between some vaccines and other vaccines in terms of how well they protect us from the Delta variant. Can you, Dr. Jha, give us some context between the one-dose Johnson and Johnson vaccine and the mRNA vaccines like Pfizer and Moderna. 

JHA: The two mRNA vaccines, the Pfizer vaccine and the Moderna vaccine, are essentially identical in my mind, and they’re probably the best vaccines we have right now in terms of efficacy against the Delta variant. The data on Johnson and Johnson is just much less clear. There is enough data out there in my mind to suggest that the J&J vaccine is still going to do a very, very good job of protecting against severe illness and death. The question is, how good a job is it going to do against preventing breakthrough infections, symptomatic infections? And the short answer is we just don’t know. And we’ll know more in the upcoming weeks. The thing that I worry about are the Chinese vaccines which have been used maybe– about a third to half of all the vaccines in the world so far have been the vaccines made in China. And we don’t have a lot of data on them. But the data we have suggests that they’re far, far less effective against the delta variant. That worries me because it means a lot of the world that’s been vaccinated is actually potentially quite still vulnerable to the delta variant. 

HOOVER: You just mentioned breakthrough cases, which refers to fully vaccinated individuals who get covid-19. How much is the Delta variant, Dr. Jha, driving these breakthrough cases? 

JHA: So the vaccines are not 100 percent, meaning we do expect some breakthrough cases. They’re still pretty infrequent. Very, very few people end up getting sick enough to need to be hospitalized. So the vaccines are working quite well at their most important job, which is keeping people out of the hospital and keeping people alive. But I’m not, I would not be surprised as the data comes in, if the Delta variant is really a major culprit for why there are more breakthrough infections right now than there were in the past.

HOOVER: You know, this week, the CDC recommended that vaccinated individuals wear masks indoors in areas that have high transmission. The New York Times called this latest move from the CDC, quote, “a sharp turnabout from the agency’s position since May that vaccinated people do not need to wear masks in most indoor spaces.” So, Dr. Gounder, your response when this new guidance came out was, quote, “I think that’s great.” Tell us why. 

GOUNDER: So when the CDC issued its guidance in May, the Delta variant had not hit us yet. So we really did not understand what the implications would be. So the CDC’s guidance was really appropriate at the time. I think the issue with the guidance that was issued by the CDC in May is that it was blanket guidance for the entire country. And we know that the rates of transmission, the vaccination coverage in different parts of the country, are different. 

HOOVER: Dr. Jha?

JHA: My general take is that at the end of the day, guidance should be based on the facts on the ground as they are. 

And in May, when the CDC said vaccinated people are largely not getting infected and they’re not transmitting it to others and therefore they don’t have to be wearing a mask indoors, I thought that was right. One of the key points of a pandemic is that it is evolving. Right, that the situation on the ground changes as evidence changes, data changes. And as it does we want our public health agencies to update their guidance. To me, this is not a sharp turnabout. This is not a flip flop. This is, the evidence changed so our recommendations changed. It’s exactly what we want the CDC to be doing. 

HOOVER: Guidance on masks has changed, as you both know, throughout the course of the pandemic. Take a look at this. 

REDFIELD: There’s no role for these masks in the community.

BIRX: Wearing this as a healthy person will not protect you.

FAUCI: Right now in the United States, people should not be walking around with masks. FAUCI: Masks are very important. They protect you from giving infection to someone else.

WALENSKY: Anyone who is fully vaccinated can participate in indoor and outdoor activities, large or small, without wearing a mask.

WALENSKY: In areas with substantial and high transmission, CDC recommends fully vaccinated people wear masks to help prevent the spread of the Delta variant.

HOOVER: Dr. Jha, to you first, do you worry that the latest guidance and the change in mask guidance can further undermine the public’s trust in health officials? 

JHA: I think the job of public health officials is to help Americans understand that what is happening here is exactly what we want happening. You do not want the guidance to be consistent from February 2020 through July 2021 when we have learned so much in those 17 months. And there are always going to be people who are going to take things out of context and try to claim that this is somehow the CDC or Dr. Fauci being inconsistent. 

I think what we all need to do is help people understand that this is the way science works and, most importantly, this is what we want public health agencies to do. 

HOOVER: Dr. Gounder, what would you add to that? 

GOUNDER: I do have concerns that the messaging was muddled at the beginning of the pandemic because there were very real concerns about supply and whether people working on the front lines like myself would have the masks and other personal protective equipment that we needed. 

And I can tell you, working at Bellevue Hospital at the beginning of the pandemic, we did not have enough N95 masks. But I think some of that was not communicated well to the public and I think that’s where the confusion comes in. 

HOOVER: So the Biden administration just announced a requirement that all federal employees be vaccinated or take other preventative measures. Veterans Affairs Administration has mandated that some of its employees be vaccinated. California and New York are also requiring vaccines and tests. 

Dr. Jha, you have been very clear that you believe that all healthcare workers should be required to receive the vaccine. And you are even trying to compile a list of which hospitals are requiring vaccines for workers and which ones are not. What do you hope to achieve from that effort? 

JHA: So I practice in the VA and the day that the VA announced this I had spent the morning at the VA seeing patients. Some of the patients I saw were immunocompromised. Others had really severe chronic illnesses. And I thought if that patient ends up encountering an unvaccinated person, he or she has a really high risk of getting infected, getting sick and dying. So a key principle of medicine is that we should not be harming patients. We should not be putting patient’s lives at risk for things that are preventable. And my gosh, asking immunocompromised people to have to deal with unvaccinated health care workers feels to me to be a totally unnecessary risk. So I think this is not something that there’s much debate on. The entire medical community leadership agrees with it. And basically every hospital should be requiring this. And the fact that many are not yet is mostly about a lack of courage. They’re worried about pushback. They’re worried they may get some bad press. You know, what I say to them is, worry less about bad press, worry more about not killing your patients. And basically, at this point, I would not go to a doctor and I would not have my family go to a doctor at a hospital that had not required vaccinations for everybody.

HOOVER: You know, I think we understand that the administration has also felt hesitant to require mandates because of the potential backlash. New York City, on the other hand, is going to offer a hundred dollars to anybody for getting their first vaccine. And in Massachusetts, through a lottery, one million dollars will be given away to a vaccinated resident. Dr. Gounder. What do you think of financial incentives? 

GOUNDER: Look, I think we need both carrots and sticks. We have seen that certain financial incentives have worked really well in some states. 

For example, in Ohio, they were giving out college scholarships and the like. I think you need other incentives as well. So making it more burdensome, so to speak, to do the wrong thing, not getting vaccinated. And I think that the Biden administration, the larger New York City system, by giving people the option, either get vaccinated or get tested. People are being given a choice. 

However, I do think most people, when they have to be subjected to weekly testing, eventually will decide it’s just simpler and easier to get vaccinated. 

HOOVER: Dr. Jha, as the first vaccinated Americans make it past their six- or seven-month mark, many of those individuals, especially the ones who were the first to receive the vaccine, are medical professionals. Often they’re being exposed to a virus on the front lines, to higher viral loads. Do you expect that we will see more breakthrough cases? 

JHA: Yeah, so this is definitely an area where the science is still evolving and I think we’ll know more in the upcoming weeks and months. 

But the way I have seen the data so far suggests that there is some waning of immunity over time, and that then when you subject yourself, or are subjected to, a high viral load from, say, an unvaccinated person, that there are going to be more breakthroughs. And so I worry immensely that in the weeks ahead, we’re going to start to see outbreaks in nursing homes again, because we’ve got Delta, we’ve got a lot of unvaccinated nursing home workers, and you have nursing home residents who are going to be vulnerable.

 That all means that I think we are heading towards boosters for certain populations. Not for everybody, but certainly for the most vulnerable populations a booster shot may end up being quite useful. We’ll see what the FDA has to say, but that’s where I suspect we’re headed. 

HOOVER: We understand that Pfizer is applying for an emergency use authorization for a third dose as early as August. Dr. Gounder, do you think we need boosters?

GOUNDER: Well, think about if you’re doing a high jump. If you can clear that bar jumping, I don’t know, six, 12 feet do you really need to be able to jump a hundred feet? Similarly, not everybody is going to need a third dose to clear that bar of immunity. There are certain groups of people who may, in particular immunosuppressed people, perhaps some of the elderly and particularly those over the age of 80, people living in nursing homes. 

HOOVER: So are you both arguing that maybe there isn’t as much of a need for a booster, 

at least for some, or maybe not a universal need for a booster? 

JHA: We may see data in the upcoming weeks or months that changes my view on this, but based on the data we’ve seen so far, do I think every American has gotten two shots of an mRNA vaccine needs a third shot by six months? No. I’ve seen no data that suggests that that’s the case. 

HOOVER: We understand vaccine hesitancy is real and it’s and it’s pervasive. Dr. Gounder, you advised the Biden administration. 

What do you think should be done to address this kind of hesitancy?

GOUNDER: So there’s a whole range of reasons people have for not having confidence in the vaccines, so there’s not going to be one solution here. I think you have communities of color that have very good reason not to trust the medical system. In addition, you have other people who may feel that, well, this has been politicized, the development of the vaccine, the approval of the vaccine, the timing of that approval. 

And I think at this stage in the pandemic, we need much more high-touch, one-on-one, personal approaches. So that’s not a PSA. That’s not blasting something out on social media. It’s really recruiting people from communities who are trusted to have these conversations. 

HOOVER: Take a look, Dr. Jha, at the former surgeon general, Jerome Adams, and Heidi Larson of the Vaccine Confidence Project. 

ADAMS: I want to applaud your use of the phrase “vaccine hesitancy” because I never say “anti-vax.” 

There’s a small, albeit vocal contingent who are what I call vaccine-resistant, but most vaccine-hesitant people simply have questions or barriers that when addressed with compassion can be overcome.

LARSON: People are asking all kinds of questions. They’re asking, what’s the wisdom of so many vaccines? These are not crazy people. They’re not uneducated. They’re actually worried mothers. But some of them have come to me and said, “We feel ignored, we feel judged if we ask a question, and we even feel demonized that maybe we’re part of some anti-vaccine group.” So we have some listening to do. 

HOOVER: Dr. Jha, do you think that on some level we’ve demonized the unvaccinated in a way that it’s become unproductive? 

JHA: Absolutely. I think the approach of calling everybody who has not gotten vaccinated “anti-vax” is not only unhelpful, it’s just wrong. 

And people have lots of questions. There are lots of reasons why people haven’t gotten vaccinated, and yelling at them rarely works. So we do have to do a lot more listening. 

GOUNDER: One of the things that I have found to be most effective in encouraging people to get vaccinated is not actually trying to encourage them to do anything, but rather just to listen and ask a lot of questions. And then very often they will feel the need to ask questions in return 

and that’s when I get a chance to give a little bit of information about the vaccine. 

HOOVER: The New York Times reported this week that the FDA is urging vaccine makers, including Pfizer and Moderna, to expand the size of their studies for younger children ages five to 11 years old. This month, President Biden said that emergency clearance for pediatric vaccines would be coming quite soon. How soon do you think we’ll know, Dr. Jha, about whether vaccines are safe for the younger children? 

JHA: So I expect that we’re going to have data on five to 11 year olds,

 that’s really the next group, probably in the next month or so. So sometime, let’s say by September, we will all have much more information about the safety and really the effectiveness of these vaccines in younger kids. 

HOOVER: Last year, as you know, there are some states like Texas — there are other municipalities around the country — that wouldn’t require children to wear masks regardless of the CDC guidance. From your perspective, would you like to see all children in school this fall wearing masks? 

JHA: I think we really should make this based on both local factors, in terms of how much infection there is, and whether children are vaccinated or not. So I think about a 14-year-old in Vermont. Imagine a school that everybody has been asked to be vaccinated, and the infection numbers are very, very low. It’s not totally clear to me that all those kids and the teachers need to be wearing a mask. Whereas schools in Missouri and Arkansas and Louisiana, where infection numbers are very high — and then we can talk about kids under 12 who are not vaccinated — wearing a mask makes a lot more sense.

HOOVER: Dr. Gounder, what would be your advice? I mean, if you were running the CDC, what is the best guidance for students in school in terms of masking? 

GOUNDER: So students will not be able to get vaccinated, students under the age of 12 will not be able to get vaccinated before the start of school. So for sure they should be masking, we should be optimizing ventilation. 

But even after kids under 12 are eligible for vaccination, we are in a very different world now with the Delta variant than we were with prior strains of the virus. The Delta variant is far more infectious and we do not know if children will transmit the Delta virus, Delta variant, at higher rates than they did the earlier variants. 

HOOVER: Dr. Jha, what do you say to the people who say, “You know, children really aren’t getting sick from this, at least not seriously. 

There are so few cases of children who have become critically ill or or died with covid. It’s just more important for children to be in school.

JHA: It is undoubtedly true that it’s incredibly important to have kids back in school. And there is no question in my mind that we know how to get every single child back to school in person safely this fall. And what I would say is, to people who minimize the effect of this virus on kids, is first of all, kids always have lower risk for almost everything compared to adults and compared to the elderly. 

That’s really not the question. The question is, how does the risk of covid compare to other risks that kids face? And the truth is that covid is much more dangerous than many, many other risks that children face. And we should be careful. I’m not sure why we would subject kids to a really infectious disease where we don’t know the long term consequences. That strikes me as irresponsible.

HOOVER: Let me ask you about Tokyo. The Olympics are currently underway, as you know, 

and Tokyo itself has recorded a record number of new daily cases just this week. Despite that spectators have been banned from the games and many other precautions have been taken, the local media is now reporting that hospitals might have to start adding beds and postponing non-emergency medical procedures. Dr. Jha, is this the outcome that you expected? 

JHA: Yeah, this is a bit of the outcome that I think many of us expected. I feel like the Tokyo Olympics organizers did some things very well to try to keep the outbreak under control 

among Olympians and others participating, but they could have done so much more. Personally, I think they should have required vaccinations of everybody. And if they had everybody vaccinated, that would have made it much, much easier. But holding an Olympics in the middle of a horrible surge of a very, very contagious version of the virus is, is high risk-behavior. 

HOOVER: Dr. Gounder, what do you think?

GOUNDER: I think, unfortunately, many of us were expecting that this would happen. 

When you bring in people from all over the world for a big event like this, what is normally a big celebration, you know, some of those people are not vaccinated, some of those people were probably harboring virus and introducing that into the community. And, yes, there are protocols to try to prevent that. But I also have friends who are journalists on the ground there right now who have told me that they’ve seen some of their colleagues circumventing some of those protocols, going out into the city and socializing. And so there is a very real risk to the local population, 

which in Japan, they do not have the access that we do to vaccines. Their population is not as highly vaccinated. And so they are very much at risk. 

HOOVER: Should the Olympics even be going on? 

GOUNDER: Oof. Many of us have questioned whether it was the right decision when their population is still very much at risk. 

HOOVER: Sounds like that’s a no. 

GOUNDER: Yeah, I would say no. 

HOOVER: At what point does COVID-19 move from being a pandemic to becoming an endemic reality? 

GOUNDER: So I think we’re looking at the pandemic phase of this for at least another year or two. We will continue to see waves and surges of the disease around the world. I think in the United States and other countries, where hopefully in the next year or so we can really get more of the population vaccinated and drive down transmission rates, where we don’t have surges at least, 

I think you will start to see a transition to an endemic phase, which means you have a lower but ongoing level of transmission in the community. 

HOOVER: How much longer do you think we have, Dr. Jha?

JHA: Yeah, I think in the United States, 2022 is going to be a much better year. You know, I actually thought that in the US by this summer we would be in really good shape. But I didn’t expect that after a horrible year with this pandemic, we would have these life saving vaccines and a third or more of Americans would choose not to get them. 

That, to me, has been the big surprise. As long as we can get many, many more people vaccinated, I do think 2022 should be a really good year for the United States. And 2023 will be sort of the first year I think the world will be fully back to a new normal. 

GOUNDER: So look, I know people are really frustrated and exhausted. Trust me, those of us who are working on the front lines of this very much feel the same. But the faster we can get people vaccinated, that’s how we bring the epidemic phase of covid 

to an end in this country. And unfortunately, with the emergence of new variants, that level of vaccination that we need to hit keeps going up.

HOOVER: What’s the magic number, Dr. Gounder?

GOUNDER: There is no magic number, and here’s why. We’ve seen Rand Paul and others in Congress grill Dr. Fauci on ‘what is the magic number,’ that threshold for herd immunity. And that is a moving target because as we have more infectious variants emerge,

 that threshold for herd immunity also goes up. 

HOOVER: And what would– what would make you comfortable? 

GOUNDER: Based on what we’re seeing right now with how infectious the Delta variant is, to reach herd immunity, we may have to vaccinate as many as 85, 90 percent of this country. 

HOOVER: Wow. Do you agree with that, Dr. Jha? 

JHA: Yeah. My take is that based on everything we know about the Delta variant, we probably need 85 to 90 percent of Americans with immunity. So that doesn’t mean you have to vaccinate all of those people. 

I do think natural infections give you some degree of immunity. But that said, we really have to get probably about 80 percent of Americans fully vaccinated if we’re going to have a shot at really putting this pandemic behind us. 

HOOVER: OK. Final question. I’d like to end on an uplifting note, or a more uplifting note. What gives you hope? Dr. Jha first. 

JHA: Oh, I have a lot of hope for what comes out of this pandemic. I mean, I think, first of all, there have been these incredible successes in global science, and the cooperation among scientists around the world to pull together these fabulous vaccines. I hope that becomes a model for how we do science moving forward. And last thing is, there are these deep seated problems, structural racism, for instance, that I think the pandemic has kind of, has made much more visible and plain. And pandemics create an opportunity for societies to tackle big problems they haven’t before. So I’m hoping we use this opportunity, this moment, to start having some of those bigger conversations and working on those more structural problems that lead to a much better America.

HOOVER: Dr. Gounder, what gives you hope. 

GOUNDER: I think the pandemic has really shone a light on the importance of public health. And I really hope that leads to ongoing, sustained investment in public health, because this is not going to be our last crisis.

HOOVER: Dr. Gounder, Dr. Jha, thank you for your time. Thank you for joining me on Firing Line. 

GOUNDER: Thank you. 

JHA: Thank you so much for having us here.

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