 Thank you. Good afternoon. This is part three on Thursday, January 13th of House Human Services Committee in Vermont. And we are continuing our education and discussion about the public health issues and responses and information around COVID-19. And with us this afternoon, we have Dr. Levine, who is the health commissioner in Vermont and who is our COVID-19 guru. Dr. Levine. Hi. Thank you for inviting me to speak today. I do want to allow plenty of time for interaction, as I'm sure there are always lots of questions. But I did assemble a few slides, if I may. Yeah, you certainly may. I guess I need to have you allow me to share. Okay, hold on. You're all set now, Dr. Levine. Thank you. We're here. But we can't hear you. You all seeing one slide? What we're seeing, we're seeing you're not in, we can see the slide, we all, that's fine. You're not in presentation mode, so we know that there's other slides, but we can't see them. There you go. There you go. Now you're good. Okay. I'm going to try to go through these briskly, but what I really want to do, based on the question you asked for me to appear on, is to work my way up to the answer to your question with a brief really journey through where we've been in the pandemic, and how each phase has taught us new things and caused us to adapt new strategies. I'm going to call phase one, the beginning, novel virus. It was way back in the beginning of 2020, and there were many relevant themes that come from our experience at that time. As you know, we had a very successful time initially, though traumatic for everyone. We rapidly responded with a sense of urgency, activated our health operations and state emergency operation centers, recognized that there was widespread community spread, had very little in the way of a playbook. The pandemic flu playbook from three years prior was somewhat, but not totally applicable, and we hadn't really seen a pandemic in a century. One of the things that you know about with viral illnesses is that containment is a great strategy. However, to do containment, as you could see in this review slide, you need to be able to test widely. Well, there were no tests, so we couldn't do that. You need to be able to define what an infected person is, and we had trouble doing that, and we knew nothing about the duration of time for isolation, quarantine, all of those things, because things were so novel. So containment was not, as it became later, an essential strategy early on. We looked at the epi curve, which I'll show you in a second, and understood clearly we were in circumstances of exponential growth. And then of course, we applied in a very phased, progressive manner, but in a very brisk period of time, abundant mitigation strategies that included closing down various sectors of our state, including the schools, and phasing in other things like gathering size limitations, etc. Fortunately, we had a governor who prioritizes health and safety and listened to science and the data, which was really critical to the success at that juncture. Here's that familiar curve. I hope nobody gets PTSD by looking at it, but it is the flattening of the curve, showing the exponential growth in the red, where you very quickly overwhelm the healthcare system capacity, which is the dotted line across. We chose to go with abundant protective measures, which culminated, of course, and stay home, stay safe. And we're able to successfully flatten that curve and protect the capacity of the healthcare system. Throughout the rest of the year 2020, we had great success with our death rates, incident rates, percent positivity, all of that. And I'm not going to belabor the point here, but it was clearly through cooperation of Vermonters, their ethic, their sense of civic engagement and community involvement and prioritization of health that we were able to succeed. A great protection of the most vulnerable effort by everyone. And then we reopened very slowly so that we could keep the virus suppressed. We understood contact science, meaning don't be in large groups of people indoors, but that even one-on-one contact could eventually become very safe. And I won't spend too much time on this slide any further. We then entered the second phase when the UK variant came around, a little less than a year after the first inauguration of the virus occurred. Because it was a variant, and that's what we've been seeing since then, it's important that we talk about variants. What makes them transmissible? Are they more transmissible than what came before? The answer is almost always yes. Do they cause increased severity of illness? Can they evade the vaccines? Or even someone who was prior infection, their sense of immunity? And we learned a lot about the fact that this is natural selection and molecular evolution, if you will, real time while we're living through it, which is pretty incredible. So what we learned about the UK strain and each subsequent strain is that if you're a more transmissible strain, you generally become the more dominant strain because you keep infecting people left and right. And that usually becomes part of the pandemic, the worldwide aspect, not just the US outbreak. And we learned about spike proteins and how they work and what the virus does to try to fool us all the time, especially as we develop vaccines. We learned about the fact that it's often unclear to much later in the phase if this is causing more severe illness or greater risk of death. But even if it doesn't, just the fact that it's more transmissible means that you get so many more cases that you can still overwhelm a healthcare system because there will be more hospitalizations and there may be more deaths, even if the rate of those doesn't increase. Fortunately, every variant we've seen can succumb to the same measures that we use to slow spread, which we'll get into. They tend to have a rather unexpected or unanticipated positive effect of increasing vaccination rates. This was especially important in Delta when a lot of people, especially in the southern US, saw their family members, friends, and neighbors succumbing to the virus and said, gee, maybe vaccination is a good idea. And they outcompete all the other strains that are around as we've seen each time. So how did we deal with B117? Well, we didn't need to do, stay home, stay safe. We rarely focused on our public health data. And the data showed travel and size of household gatherings were critical determinants of where cases were showing up. And by impacting just those two areas, we were able to do a lot to impact the growth, if I will say, of this virus. And we were able to do a lot to prevent shutting down the rest of society. We learned that retail could continue, lots of commerce could continue, one-on-one contact could continue, hairdressers, healthcare providers, dental, et cetera. Telework was still a good idea when it could be done. Outside was always safer than inside. Schools and child cares actually could still operate with a lot of the usual mitigation measures in place. Restaurants outdoors seemed fine indoors. There were still some questions. And certainly bars were a hotbed. So closing them was one of the exceptions we made. And we got through U.K. Then we came to the summer of last year and Delta appeared. It was a summer of fun. Everybody was taking their masks off, joining together, having a good life. And then Delta really hit the U.S. People don't like the term pandemic of the unvaccinated, but it is real and it is true. So I put it there. Clearly Delta was even more transmissible than the U.K. variant. We learned a lot by looking at places in the world that it had previously. And we learned a lot by looking at some of the states in the country that had similar profiles to Vermont in terms of vaccination and what have you, but were suffering more than we were at the time. The difference in the Delta phase, of course, was the presence of a more heavily vaccinated population, which had been going on the whole first half of 2021. And we were the highest fully vaccinated rate, somewhat naively, but somewhat scientifically based. We thought that that would make a huge difference in the ability of this virus to spread. This virus was about twice as transmissible as what we had seen previously. Keep in mind that what we have now with Omicron is supposed to be a minimum of twice as transmissible of what Delta was. And we learned about the importance of being fully vaccinated with two doses and boosting. The question that's always asked is, well, why did Vermont continue to have so many cases in a setting of high vaccination? So certainly the virus itself and its mutations plays somewhat of a role and its ability to transmit so readily. Our population was one of the earliest and most aggressively vaccinated population and most efficiently vaccinated. And because of that, we basically found that there was waning of vaccine-mediated immunity, which now, of course, science has validated along the way, showing that six months after you've been fully vaccinated, didn't cut it. You needed to actually replenish that immunity with a booster. We also have been so successful in the preceding year that only a few percent of our population had ever been exposed to the actual virus and could definitively be shown to have been infected. So the virus had a lot of unvaccinated people who had no experience with the virus and could become infected. And, of course, there was a tangible but not high breakthrough infection rate in the vaccinated. And then, of course, there are population factors. The virus finds the unvaccinated and it finds people living in social clusters or interacting in that way and in rural pockets of states where it can still have a field day. It's been very adept at doing that. We had a much more mobile population than in the previous phases. The population had a bit of pandemic fatigue setting in, their appetite for restrictions was lower and their attention to some of the traditional do-it-yourself mitigation strategies was not as high as previously. So the mitigation strategies during the Delta phase, vaccination is the primary strategy and I don't mind saying that over and over again because that is a game changer in the history of infectious diseases throughout time. We learned, as I said, that you needed to be fully protected and up-to-date, which means have the full series and the booster on schedule. And we continue to have a significant interaction with the public about that. Obviously, the traditional strategies of wearing a mask indoors, the personal hygiene and respiratory etiquette issues, to stay home of sick, all of those continue to be strongly recommended. And recognition of where the public was at with regard to its pandemic fatigue, the fact that by their actions the public was showing that they were really into being a reopened society and economy, attending events, attending restaurants and bars, etc. With less appetite for restrictions and mandates and these opposing issues that we always had to take into account when we made any decision about how are they doing otherwise? Well, mental health, we all know, we talk about it in our youth, but it's also in our adults. Suicide is at a higher rate than it has been in quite some time. We all know about the impact on substance use and misuse and the opioid overdose death rate, the impacts of social isolation on everyone and psychiatric health, and then the setbacks in education for our youth and the need for a recovery program for them. And then this concept of health debt, meaning lots of things not tended to during the pandemic, which explains a lot of why hospitals are overwhelmed with cases now because of repaying back some of that debt. And then, of course, another strategy which I'd never like to talk about too loudly is therapeutics, predominantly at that time, monoclonal antibodies. And the reason for that is, of course, people who are in the anti-vaccination contingent use that as an excuse to not be vaccinated because we have therapies now. It brings us to the present Omicron, clearly the most transmissible variant we've seen. It really does seem to be bearing out that it is a less severe virus. We're getting a lot of that from South Africa, which of course has a younger population and had a more highly previously infected population than our country. But even early experience in the U.S., illustrated by a report just this week from Southern California, does illustrate that this probably is a less severe virus. Not to mean it shouldn't be taken seriously. It also is more likely, through all of its mutations, to evade vaccine. But when I say evade vaccine, it means your ability to become either infected by being a positive test or being infected and mildly ill, as opposed to being severely ill with a bad outcome, like a hospitalization or worse. And that seems to be bearing up. But again, even something that gives you less people potentially to be hospitalized will end up giving you more people in the hospital because it's infecting so many more people. It's also having an impact on other aspects of society, like some of our emergency personnel and even infrastructure, like water treatment plants, wastewater, gas and electric, things of that sort, things that keep our society functioning. And of course, impacts on schools are well known to everyone. Probably is going to play a significant role in our march towards endemicity, meaning when it becomes part of the fabric of what we live with all the time, like many other respiratory viruses. I hate to use that as a silver lining, but it is going to be an outcome. Finally, the mitigation that is being used against this variant, obviously the usual things, hygiene, but masking being much more strongly recommended, change in the tone about masks in terms of wearing the highest quality mask, and not far more, but equal attention to protecting the most vulnerable, especially when we were talking about the three holidays that have come and gone, thanksgiving Christmas and New Year's and how people needed to approach those. We now have a variant where containment is less achievable, and that's why some of our school guidance has changed. Traditional contact tracing is actually very labor intensive and delayed. Traditional PCR testing isn't nimble enough, though it's still an important tool in the toolbox. And surveillance testing doesn't really cut it at this point. You need much more rapid testing, which is of course why we're pivoting to the at-home antigen test to really manage spread of disease and manage people's lives. There's also been a change in the guidance regarding isolation and quarantine that I think balances workforce needs and getting people back to the workforce who aren't really sick anymore or have never been sick, as well as understanding how to get more compliance from the population to follow isolation and quarantine guidance, because these are much more reasonable. Everyone is now saying the question is not if you'll get Omicron, but when. I hate to sound like the Grim Reaper, but that is to some degree true. And the imperative to maintain in-person learning has been one that we've really had as our North Star. In spite of this incredible surge of virus activity, pandemic fatigue at least in my eyes is still playing a significant role. People who have taken the trouble to follow every step of the way with vaccination feel like they should be able to have some personal choice and some freedoms. And I think we just have to be cognizant of that and recognize it. We continue to do a lot of advising, as I illustrated about the holidays, but even outside the holidays about avoiding crowded indoor events and having small gathering sizes at the most. We are unrelenting, not only in trying to tell people it's the right thing to do, but also providing abundant, even at this stage of the pandemic, opportunities to vaccinate and boost. I mean, you'd have to, you know, you can't help but stumble over vaccine somewhere in Vermont. Travel restrictions don't make sense. The whole country is the same color on the map and much of the world. People need to be reminded that even though they want and wanted before Omicron for the virus to be endemic, it isn't yet. It's coming, maybe in the spring, maybe a couple months, but it's not there yet. And then we and, I guess, and the Biden administration have been doing a lot of recommendations regarding businesses about vaccine mandates, about mandating proof of vaccination to get into certain venues or activities. And that's all well and good. Final slide is just to sort of give you the public health view of what's in, what's the toolkit and where their opportunities are not. Obviously, the personal things like hygiene and respiratory etiquette, always there, stay home of sick, distancing and avoiding crowds, all common sense. Masking indoors with high quality masks, continued important part of the toolkit, whether it be strong recommendations or mandates. Using testing in an appropriate proactive sense. In a symptomatic person, in a person who may have been a close contact, who may have engaged in activities that put them at higher risk, etc. And using that in your daily life to help protect not only you and your family, but others. Continuing with the vaccination role and making sure we get even a great state like Vermont, a great state like Vermont with its vaccine data, we're number one and boosted across all age categories and we're still not good enough in that. We're in the 50 to 60% range depending on the age range and that isn't good enough with such a transmissible variant. Vaccination obviously can come in a do the right thing mode or can come in a mandate mode. And you're all witness to the same thing I'm witness to in the courts right now, the Supreme Court specifically evaluating what those mandates are all about in terms of their intersection with the legal system. Certainly lots of parts of the world and selected parts of the United States have required some form of proof for entry into events or for even employment. And you've seen what we've done in Vermont with state employees really saying that vaccination is what we prefer but giving them an off ramp with frequent surveillance and testing protocol. Gathering size limitations, whether they're suggested or required. Obviously, state of emergency is always part of a toolkit. It's not usually the public health toolkit. It's more the state government toolkit. And then obviously where we started in the beginning, stay home, stay safe, which I hope I've made a compelling case to show that we have a lot more in the toolkit now and there are a lot other factors at play that might limit our opportunity to want to and enact something like that all over again. But those are my comments and I'm happy to stop there and return it to you chair Pew. Thank you. And I'm looking to see. Operational question. Yeah, we still seem to have your public health. We still seem to have it on me. Yeah, I'm working on it. Okay. Thank you. Thank you. Your first question, Dr. Levine is from Representative McFawn. Good afternoon, Dr. Levine. Thanks for everything that you've been doing in terms of this whole mess that we're in. I'd like, help me understand this statement, avoid crowded indoor settings and keep gathering safe and gathering size, size limitations. Tell me what you mean by those kinds of statements if you went police. Yeah. So at a time of very high community transmission of virus, like we're in now and at times like we were in with Delta, obviously that's how the virus spreads from person to person. Being too close to too many people indoors, almost exclusively, very much less likely outdoors. There are no numbers attached to the gathering size. It's a bit of an arbitrary thing. I prefer to look at it in terms of households. So a single household versus a multi household gathering. And obviously the more in the multi, the more risk. So gathering with one other household that you have a lot of information about and have interacted with previously versus having Thanksgiving dinner with 25 people making up five or six households potentially. And then there are obviously ways, as we did early in the pandemic, to put numbers on that and say 50 or less, 25, 10, and pretty soon you're at stay home, stay safe. But that was the kind of progression that we had in the very early part of the pandemic. So that is obviously within the power of a government under more emergency operations. And Dr, keep you gathering safe versus gathering size limitations. What's that mean? You know, they're both probably the same thought, but the gathering size limitations means you've actually, through an executive order or legislatively stated what your view is on what is allowed, what's not versus the more personal choice of keeping them safe by using the kind of guidance I just provided about number of households. And now I'm going to ask you a question that's probably going to be very controversial. I'm going to ask it anyway. Right now, the legislature is trying to decide whether we're going to come back in person. And based on what you just said to me, I'm thinking that in my particular instance, if we go into a committee world, we're having at least 11 different households come together in a very, very confined space. And if we add staff, we have more. And our committee room on the outside of it says 18 people can be in here. And I'm trying to wrestle with this because I personally have two underlying conditions. And I'm very worried about this in person thing. And I'm sure there are a lot of other people that feel the same as I do. So how do we deal with this so we can function? You've never been hesitant to ask me the tough questions before, so I completely anticipate this. So some of this is timing when one looks at the Omicron predictions. And I hate modeling and predictions because those projections don't often come out the way they were advertised. And generally, there's a high end of the prediction, which goes like straight up in the air. And there's a lower end of the projection that's more gently sloped. And everything in between is where the modelers say it could land. So it's very wide open. With Omicron, most people are still thinking this could be a fairly brisk experience where it kind of races through the population, peaks somewhere late January, early February, and then comes down sloping very quickly. Now, South Africa, it really down sloped quickly. The UK is showing a little bit of a hiccups along that continuum. And the US, it's too early to tell. But that's what we need to watch. Clearly at a time when active transmission is still occurring. And it's really very high levels. I think most people would use common sense and say, I don't want to be in a room with a lot of different people, even though I'm trying my best to keep separated from them and wear masks. I'm most concerned when I think about what you just said about yourself. And I look at the demographics of the legislature. And though there are a number of I'll compliment everyone on this meeting, young people in this committee, some quite young. There are also, I think if you look at the median age in the legislature, it's not quite young. Doesn't mean everyone of a certain age has a lot of medical conditions, but that's how life usually goes. And age alone is a risk factor. So I would be cautious about when I would choose to come back based on the actual progress of the virus through our region. Thank you, sir. Representative Rosenquist. Thank you, Madam Chair and Dr. Levine. I know when we spoke earlier on the similar subject, I was concerned that we were not able to differentiate between the cases of regular influenza and COVID. And I was wondering if we've gotten to a point where we can understand that better. How many of the cases that we're dealing with are the regular influenza versus COVID? Can you comment on that? Thank you. So anything we call a case of COVID has tested positive for COVID. So anything you see on our case counts every day for COVID is COVID. Influenza has surfaced in Vermont, but it is not at anything more than sporadic levels at this point. Now, admittedly, most people with respiratory symptoms are being evaluated for COVID first, and that may be the only test they receive. They could actually have influenza and COVID concurrently, but I think that's probably unlikely at this point, because so many of the cases of Omicron are on the milder end of the spectrum. And if people had influenza with that, I'd expect there'd be a lot more sick people and more vulnerable people getting hospitalized, et cetera. And we're not seeing that yet. So it's a little bit of understanding how often influenza is being tested for. And it's probably not being tested for as much if people are testing positive for Omicron, because there's no need to go further usually when they've presented during a surge of a certain virus. Thank you. And what are we seeing as far as the rate of people getting vaccinated for the regular influenza? Is that a good amount of people doing this? Well, the best year ever was last year where people really had extraordinary performance for influenza vaccine. And of course, we didn't see any flu, but there were lots of factors behind why we didn't. This year's flu vaccine experience isn't over yet, because it's only January, but if we compare it to the other January's in the last two years, we're a little lower than the year before last year. So it's not as robust a performance as I wanted to see, especially even though we kept cautioning people about twin demics and having both viruses active at the same time. But that's just the reality, not as good as two years ago and certainly not as good as last year, which was the best year on record for a long time. Thank you. Thank you. Dr. Levine and Representative Wood has a question. Thank you, Dr. Levine, for being here. And thank you for amazingly, I don't know how you do it, but maintaining a sense of humor through all of this. That really, believe it or not, is something that many Vermonters appreciate. So thank you for that. And my question relates to testing. And you've talked about the importance of testing. And I know that you're aware of the concerns in our child care community around access to testing. And I know that there's a program being rolled out to get tests in the hands of our child care providers. Could you speak a little bit to sort of, you know, we're thinking about these are the youngest, youngest folks who aren't even eligible for vaccines yet. And for people in that position, it feels like they are sort of last on the totem pole when it comes to access that, you know, that's what we hear from from our childcare providers. So could you speak a little bit to that dilemma? Yeah, that's that's a great question. So the Test for Tots program is what's being unveiled as we speak. And I can understand completely the feedback we've gotten from and you've gotten from the childcare community, which is kind of like, well, what about us? The reality is, and I commented on this at a meeting earlier this morning with the governor and team, it's a little bit like it was in the beginning of the pandemic where we had the very beginnings of testing available. But it was a scarce resource. And we couldn't test everybody. And everybody wanted to be tested and we didn't have any supplies or reagents or anything of that sort. And then when we did, we learned we quickly had to diversify our portfolio because one supply chain would sort of use up and then we'd have to find another one. So we became the most successful state for testing through a lot of good strategizing. Same thing is happening now, real time in Omicron, because though the president has promised, you know, millions of antigen tests into Americans hands, there's a little bit of a supply chain issue that prevents that from turning into reality as quickly as possible. Nonetheless, we've gotten our hands on a lot of supply chains and are working as feverishly as possible to get more and more into the state. We really did feel that there are so many people who could be on the priority list. It's very challenging to say one group versus another group. One of the major crises and issues we've had is K through 12 school. And as you know, there were cases appearing after vacation where all of a sudden school classes were closing. Sometimes schools were closing. People really needed to have a handle on how to handle that better. And so we really did prioritize that in a very important way. We also have other parts of society's infrastructure that I alluded to earlier that need to be prioritized. And the reality is we want all of our monitors to use these tests wisely to help control the pandemic. So I think we've kind of briskly gotten them out to the preschool and child care community when you look at the fact that Omicron wasn't even here more than a few weeks ago. And now suddenly we have antigen testing platforms and multiple arenas, whether it be K through 12 or child care. And we're just moving as feverishly as possible to make that happen. But I do understand their concerns and issues with that. But I think, you know, the guidance is going to become out at any day for them. And obviously the test kits have already started coming out for them. So I think we'll find that the feedback is going to change in tone based on the fact that things are happening in response to the concerns. Thank you, Dr. Levine. I think that, you know, the biggest concern was that they're dealing with a population that's unvaccinated, you know, the young children are unvaccinated. And I think that stems, you know, that concerns stems a lot from that fact. But thank you for your response. Representative Small. Thank you, Madam Chair. And glad to have you here today. Dr. Levine, always appreciate your clarity as we're working through one of the most confusing times, I would say for both our communities and ourselves. And one question I have is actually in regards to testimony that we had earlier today from Dr. Leahy, which shared that with more transmission, we have more opportunities for variants to present themselves within communities. And so I know we're moving away from looking at case counts in the state as kind of this predictor, but knowing that we're having these records setting case counts across the state, are we worried about these variants appearing and potentially delaying that endemic mark of having spring be this time of getting through COVID? Yeah, that's a really good question. So the way I look at it, I will always be worried about these variants. And the fact that we may be fighting this whack-a-mole game over and over again, if you will. But the reality is, it's going to race to our population rather briskly. We have a very heavily vaccinated population. The combination of those who have vaccine mediated immunity and those who have infection mediated immunity will be quite a large number in both types of immunity for that matter. So the ability for the virus to actually keep replicating over and over again is not, it's going to be very limited in time. And that's important. It's in places where the vaccination rate is so low that I worry the most. And that's why there's a whole push on the global stage for vaccinating the world. When you've got countries in Africa that have less than 3% of their population exposed to vaccine, that's the fertile ground for more and more variant strain development. And then if you combine that, like happened in South Africa with a population that is more immune compromised, and in South Africa that's HIV and the percentage of the population who live in a perpetually immune compromised state because they don't have access to treatments for HIV to suppress their viral load and keep their immune system functioning better. Those two in combination, low vaccination rate, high immunocompromised rate, are the fertile ground for variant strain development. So that's where I worry the most. I'm not worried so much about the US at large, certainly not the Northeast. We've got to get our vaccination rates up in the Midwest and in the South because I do worry about those regions. But that's sort of how I view the variant strain development quandary you're talking about. Oh, great. That is encouraging to hear. And in building on that, we know vaccines are really great and important tool and masks, of course, are an important tool to be using. And so we're hearing this move away from using cloth masks to these upgrades to N95 and KN95 masks and wondering, is there any barriers that we have in getting these tools out to communities at large? I know schools are really hoping for these resources and beyond. Yeah, so we have a storehouse, I can't think of a better term for it, and a stockpile of masks in Vermont. So we are having active discussions several times per week about where those are best deployed. We also heard, I think, just on this morning's news that the Biden administration is planning something to have a mask in every person's hands, essentially, they use the word high quality. They didn't say what kind of masks. So stay tuned on that one. But I think we're all thinking in the same direction, making sure that people have the best access to high quality masks. At a time, I might add, when there is great access to these masks. In the beginning of the pandemic, we were protecting the health care providers and the workforce by saying don't use their masks, the N95s, etc., even the surgical masks, and everybody had their own showy cloth masks that they developed for themselves. But the reality is now that doesn't cut it. So we need to make sure everybody has access to these higher quality masks, which are very accessible, whether somebody gives them to everybody, whether somebody purchases them or what, they're all over the place. So they're not a scarce resource like so many other things have been during the pandemic. Dr, do you have a follow-up? I do not have a follow-up, not in the chair. Thank you so much, Dr. Levine. Dr. Levine, we have a bunch of questions. I'm going to interject a question because it's sort of Can I, I'm going to stay on with you, but I just need to tell my administrative assistant that this is going a little longer so she can tell the next meeting when I'll show up. I'm sorry, I forgot that you had the timeframe. No, but it's okay. Hang on. Okay. And I apologize. I perhaps I selectively forgot that there was the timeframe. So we will be expeditious. Following on the theme of sort of availability of what has now been identified as the things to be focused on, and you responded to representatives' smallest question about masks, I'm and in general you have, you talked about the antigen tests. I'm thinking about the community, I want to say the new American and refugee community who one might have more of a challenge of actually getting a test. And two, at least the several tests that I have seen and used, they do come in two languages, but they don't necessarily come in the, and I have to say, I had a little trouble with the picture, but that's me. So how are we working with those populations for whom access to and following through on these new protocols are something very new and different? Yes, important question. You know, we continue to learn every day in the pandemic, and I think we've learned a lot about health equity and how to do it well. We have a health equity community engagement team, the HIST team that continues to have meetings across the state with advocacy groups, with groups of leaders in our new American and other diverse communities. And the bottom line is we sort of have to respond real time whenever something new happens. So everybody understood how to register for a test in the past, everybody understood what tests they were registering for and how it was done and how to find the result, all of that. And now suddenly we're putting everybody in the population in a whole new world of do it at home antigen testing. So that's going to require just as much attention in terms of proper dialect and interpretive materials, as you point out, proper hands-on kind of instructions so people understand exactly the methodology and the interpretation of the test result. And again, Omicron appeared literally weeks ago, and our pivot to antigen test has just been possible in the last few weeks. So this is all happening real time, and we're trying to do it as quickly as possible. But we share the concerns that you raised and we know from our experience throughout the pandemic that these are areas we need to work with people on closely. Thank you. Thank you. We've got a question from Representative Rosenquist. Thank you, Madam Chair. Dr. Levine, I know maybe six months ago, one of the big buzz things going around was, let's get to herd immunity. And there were numbers of percentages of the population that would need to be vaccinated to start approaching those numbers. My recollection is that number was lower than currently our vaccination rate in the state. So is there still a goal or a theory or where are we approaching that point of herd immunity? Thank you. Yeah, I've always tried to shy away from a number because I gave a range which was really broad like 65 to 95 percent because nobody knew the answer. And all we know is the further we go in the pandemic, the higher the number has to be because we're still seeing the entire swath of the population get COVID at high rates. So clearly what we're really trying to let people to know is herd immunity is a little bit of a fleeting phenomenon when you have a virus that started as virus A and then it's mutated to virus B, C, D, and who knows what. You're always dealing with a slightly different virus than you started with. There are some viruses like the measles. That's not what we deal with. We know what it takes to get herd immunity for the measles virus. But this is a little bit different. It's like the influenza virus in some ways where moment to moment, year to year, you're not dealing with the exact same virus you started with. And so the vaccine induced immunity you gave people isn't adequate to the test the next time around. But the number is certainly higher than 90 percent for short. Thank you. Representative Whitman. Thank you, Madam Chair. And thank you, Commissioner Levine, for all of your work and all of the Department of Health's work coming on two years. Really appreciate you being here today. My question is about metrics, I guess. And you know, you've we've heard a lot of people say that case rates aren't necessarily a good metric right now, and we're focusing more on hospitalization, ICU cases. But you know, when we look at that flat in the curve graph that we start with, a lot of it's about that gap in what's the available healthcare system capacity. And so my question is how do, you know, we assess that and are we able to communicate that? Because you know, when we hear like 100 plus hospitalizations, you know, I don't really have a reference for how much more wiggle room is left. And I imagine that's probably changing over time as well. So I was wondering if that's a metric that the Department of Health works on and if that's something that could be communicated. Yeah, so you're right. We're shying away from cases being the end all but the reality is, we won't even know the number of cases because of so many people doing at home testing, they're not all reporting it to the health department. So we don't have as much of a window into that number of cases. Hospitalization numbers are still critical numbers. As you're learning probably day to day, not everyone hospitalized as a COVID patient was hospitalized because of their COVID. They were often hospitalized because of the severe illness they had that brought them into the hospital. And then while they were getting tested in the emergency room, they were learned to have COVID, whether that was exacerbating their illness or not as difficult to say, but often it was just because of the fact that there's a high rate of transmission of COVID now. And so we're trying to get a better handle on that. But when we say 90, our average lately has been 90 hospitalizations a day. Think about the number of hospital beds in the state being well over 1200. When we talk about an average of 20-ish ICU patients a day, there's over 100 ICU beds in the state. So they're not all being occupied by COVID patients. And that's the important finding there. But let's say the assumption we make and the conclusion from what I just said is our healthcare system is not being stressed by COVID. Well, that's completely untrue. COVID is sort of the icing on the cake. That's really, you know, the straw that broke the camel's back. But COVID is also responsible for all those medical admissions that represent people who never got evaluated because they were afraid to go to the healthcare system because they thought they'd get COVID by doing that. People whose chronic diseases weren't managed well during the pandemic and have gotten out of control. People who didn't have all the usual preventive screenings that they would have had in normal or normal or times. So there's still tremendous stress on the healthcare system because of all the business they're getting. And then today, the newest wrinkle, which is not anything that should be startling to anyone, is that the healthcare workforce, tired as it was before Omicron, is now tired and actually acquiring Omicron at higher rates. So our hospitals are incredibly stressed by the fact that their workforce capacity is challenged. They have people on sick leave, absenteeism rates are up. And that's just a fact of life. So add the stress of that to the whole equation. And that's what we're really working on the most right now. And that's in the front of our radar screen. So a lot of factors going in, but we kind of have a handle on all of them in terms of the data and the metrics you're talking about. So we know what to watch for. Excuse me. It sounds like you have responded to that question. And I really appreciate it. I also am appreciative of you spending the extra time with us and answering our questions and putting your next meeting a little bit later. Another time, another time I would love us to have a conversation. And whether you're the right person or whether you could direct us to the right person, you talk about how this may be an ongoing, maybe not, you know, at the same level, but for a public health agency to be nimble enough to respond to ongoing what may be serial pandemics and things and not have to give up the rest of what their jobs, their responsibilities are. What does the, you know, what does the fit up look like? What do, what's the structure that maybe needs to be that we've learned now maybe wasn't in place before that we should have in place for the future because we know the future is going to continue with this. But that's a question for another time, but as a heads up, and if you tell me there's a national public health person, it's more because you can't answer that. All of us public health and state health officials are meeting on this all the time. So this is very relevant. Okay. Well, that's wonderful. Happy to come back. Great. Well, thank you. And as everyone who asked a question and everyone then who did not, we all sincerely appreciate what you and your staff have done and the balancing act. And as Representative Wood said, your ability to do that with also with humor and to be very forthright about the balancing that you are doing. So thank you. Thank you very much. And please pass on our appreciation. Thank you all. Great to see you all again. Great to see you. Bye bye. Thank you, Dr. Levine. I feel like I've gone to med school or public health school. This has been very, very helpful and very, but I do think that's part of what our role is is to sort of think about what we need to do differently, whether it is systemically or whether it is in preparation for other pieces. As we begin to look at and explore what other kinds of questions might you have for if not Dr. Levine or someone else in terms of constituencies or whatever in terms of the pandemic and what we should or could be doing. Representative Wood. Thank you, Madam Chair. I would like to hear from DCF more about the testing for tots. Tots or whatever they're calling it. I think it's been a significant concern and it feels like we need to know a little bit more about that. I don't think we need a big long time, but I think it would be helpful for us to or maybe it could be written. It would be helpful for us to have information from them directly about what they're doing and what childcare programs need to do in order to access that. We heard that the area agencies and aging, for instance, were targeted for supplies and about 40% or so of those supplies didn't make it to their intended locations. I think we just need to be aware of those supply chain issues and distribution issues and the kind of guidance that might be given to those childcare providers. So, to put sort of broadly and maybe some I see some other hands going up as well. We need some more, you would find it helpful to have some more information on what actually is happening. What is the experience of, for instance, of the childcare centers with this testing for tots and stuff like that? Okay. Yes. Representative Small. Building on a question that you asked, Anne, is really bringing the Vermont Health Equity Initiative or someone from the Vermont Health Equity Team at the Department of Health and understanding how marginalized populations are being impacted by this ever-changing landscape and just getting that kind of on the ground information as to what supports are needed or what's working really well. I'm writing this down. Do you want me to just jump in then? Yes. So, I also, building on your question, I mean, I'm sort of balancing in my head, though, our need to have, we have so much work to do and this is one of those things that's part of our charge and might not be something we can fix immediately, but we should all know about in case we want to learn, I mean, I don't know what the future holds. But is the whole idea of the long haulers and respiratory illness and mental health like what does, once we get through this, what does the future hold? And do we have the things we need in place in order to assist the public with those sort of things? I mean, I, and I know that there is people working on some of this looking to the future on the long long haulers, for example, is there, are we learning anything by what happened a year and a half ago when this all started, those folks who are still struggling with issues? And what does that mean for public health and expense and all of those things, I think? Yeah. So, I mean, what does it mean and what if anything can we do? We meeting government and that kind of thing. Representative McFawn and then Representative Whitman. I have a concern with the immunity that the vaccination program provided, especially to the elderly and those people with underlying conditions early on. And then the booster, they were up first to get those boosters. Now that protection is waning. And I'm wondering what the plan, if there's anybody that we could bring in to find out what's the plan for that? Because I am sure that the Council on Aging and others like that would like to know what's going to happen there. Maybe has that ever brought up in the older workers' caucus? Representative Noyes, has that been brought up in the older Americans' caucus? So we just had our first meeting of the session yesterday and it was not, but we will be continuing to talk about the issues that affect older Vermonters and I'm sure that will be coming up. I don't particularly have, sorry, go ahead. No, no, I thought you were done, sorry. No, I don't have the commissioner scheduled to come, but in the past he has been to our caucus. But yeah, he's on my list. I was just going to say, Tupper, that you should know, I think that this is something that worries me because so many people in my family are in health care and the health care workers were boosted a lot before many of us. I think maybe my daughter was vaccinated, boosted three months before me for my booster. So they're looking into it. It's, I mean, as we know from the newspapers, over 450 health care workers right now have Omicron or whatever in just one hospital. Never mind the others. So that immunity is starting to wear off too. Yeah. I do want to make sure we don't get confused. Getting a vaccine does not promise that we'll never get it. The immunity may wane, but just, I mean, which is what we're seeing. But getting a vaccine has never, of any, you know, has never been the promise of you'll never get it. It is, if you happen to contract it, you'll be less sick. That's exactly what I'm talking about. Okay, I just want to, I wasn't sure. Immunity is wearing off and you get sick. You may get sicker than you would. You are not only would that immunity and that having been vaccinated doesn't, doesn't go on forever. So if somebody's near the end of that immunity, they get sick, they may get sick. I don't know. That's why I was asking the question. Is that something that people have worried about? You know, the doctor talked about the hospitalization rate and the death rate. Well, now, you know, that immunity that we had is, we still have a lot of it, but as we go back out into this thing, that's going to wane. Is that going to make a difference in terms of whether you get sick or not? Anyway, it's a question. Good question. And my guess is that there's doctors and scientists and researchers looking at this every day. Dane. Yeah, thank you. I think I am interested in hearing from somebody who can kind of speak on how hospitals are doing statewide. I figure it's kind of very region to region, but just sort of somebody who can, yeah, remark on where our current capacity is. You know, have we, have we exceeded that? Or what, what can we do about it? And Dane, I will take that question under advisement. And I might in fact, I will have a conversation with Representative Lippert, who was chair of the health care committee, and he might be able to direct you either to a, they're going to be talking about it at some time, and you can go there or something like that. And I am bringing that up right now, because one of the things that the house health care is looking at right now is what are those temporary measures and temporary flexibility and changes in law and policy that we made that are set to expire, I think in March. And that committee has been got some updates earlier. And they're in the midst of discussing, discussing it as we, as we were talking about this. And there's an act, there's a section six. Oh, no. I need to do a little research. We all can do some research. There's some sections of act six, which was passed before that really relate to us and whether or not we would support making them more permanent. And we have even less time than we did for the budget adjustment, because they would like to vote the bill out on Wednesday. But so, but one of them has, I mean, for instance, one of them has to do with prescribing a buprenorphine. And I think what we've heard some stuff about that, you know, whether it can be telemedicine or those kinds of things. And so we need to, we will be looking at that on Tuesday afternoon. We may actually figure out if we can get Jen on tomorrow while we are also doing some bill introductions after we get off the floor. She can tell us what sections they are, and we can all have homework and talk about this on Tuesday. You're going to have lots of homework over the weekend, just thought I'd tell you, because, you know, it will be one to sort of get our arms around the flexibility kind of thing. And the other is to identify, I'm going back and forth between your three, between three and five priorities, or for our work going forward. Now we know we're going to do something. We're not sure what it is, but we know we're going to do something around adult individuals or with with disabilities, and the whole or the disability. So I'm going to call that the topper, the topper Teresa and Carl thing. We know we're going to do that. Number one, we know we're going to do prop five. And we know, well, and I believe we could do in about 15 minutes, because I haven't heard anything, to build the miscellaneous amendments to the health department statute. They have sent us answers for some of the questions, and I can make sure that you all have them in terms of there's a list of where to there's a list of who they consulted with. Then there is a whole that there's a link to the website on the department of health. There's a link to a page on the department health website that has where all of the prescription kiosk drop offs are. So there's a map so we can see where are the prescription, the unused prescription kiosk, deserts are in the state, and all those things. So I mean, I would say the person that we need to hear from is someone from the pharmacists. Other than that, I didn't hear from individuals that they I believe what I heard, for instance, in response and Teresa, let me know if I'm wrong, that you got the answer that you needed, or do you still want to hear from someone? No, I got the answer that I needed from what Mr. Englanger said. Okay, okay, and that was about who in fact they consulted with to make sure that they consulted with actual consumers, and as well as others, I think that was related to the name change. Yes, yes, yes. So so we know we're going to do all the we know that so those won't be on the sort of list per se. My thought was we have a boatload of bills as they relate to COVID. We have a boatload of bills as they relate to setting some legal limitations, or outlawing certain part, certain procedures as it relates to abortion. And then we had, and I think there's another grouping as well, then there's a grouping around substance use. Those those three rather than people having to pick which one of the five, if that is a category, and Carl I'm in one sense thinking of you, if that is a category of bills you're interested in that you only have to put one there, as opposed to the others, that's my thought. So to group some of them and then some of them they're not, they don't, and they're for instance, they're two, they're two bills around reach up. So we'll put those together whether we do both of them or or any of them. But when we take it up, since we have two bills, we would undoubtedly comment on on both of them. And so that kind of thing. Teresa I thought I saw your hand maybe or no. So that's sort of my my idea. So there'll be like, there'll be some some of them will be groups, and some of them will be a list of individual bills. And you wanted the bills from last year as well, that were introduced last year as well. So they will be on the list. Not the bills that we passed. There are a couple of bills that were introduced last year that relate to we passed the Senate version. So we don't need to be looking at that. So I've removed, I'm in the process of removing those. But so that will be that will be all ready for your weekend enjoyment. To go back on a different point, very appreciative of the spreadsheet. Mr. Englander's response was that sent to the committee or can I find that on the website? Around who they let's make sure that I will make sure that everyone gets that response. It may not have been sent to the whole committee. It may have been sent to Teresa. Yeah, I think I don't, as I recall, I think it was just sent to you and I, Madam Chair. But yeah, that'd be, we should put that up on our website. Okay. Can you take care of that? Yes, ma'am. Finding it. Thank you. Thank you very much. I appreciate it. And whether or not we can, I think we tasked David Englander from the health department to reach out to the pharmacists. Will that be sufficient or should we, or do you want to hear? Carl, I'm directing this to you because this was an issue of a question that you had. Is a letter from them all right? A letter from who? The large chains. Yeah, I assume so. Okay. We'll sort of figure it out. And Julie, who is already posted the response and was under yesterday's date. Okay. So I'm looking forward to seeing you and we're still, I think that we, are we finished the discussion and represent Bromstead? Sorry, I just have a couple of questions while we talk about, because we're talking about sort of the future. Okay. I'm curious if during the budget, when we start working on our budget pieces, will we hear more about the ARPA dollars and what's left and what kind, will we get any input into that and how things are going with what they have allocated? Is it being sent? That's a question. Do you have a suggestion? Okay. I guess my suggestion would be that I know that they're really busy, but it seems like in between when they put in, when I'm talking about house appropriations, when they put in the adjustment and then, but before they really kind of sink their teeth into the budget, maybe there's a little bit of time there that the people that we work with from appropriations might be willing to give us some sense of that or maybe it's joint fiscal that could come in and talk to us about that. Just so, I think that constituents still hear out there that there's all this money and it would be really nice to know how is it really going? Where are we in the allocation? And, and I'm not exactly sure who the right people are, but maybe joint fiscal and or maybe somebody. I think we have two sets of questions embedded, two issues embedded in where I'm making up one issue that maybe wasn't in there for you. One is where are the, is what dollars have been allocated and actually sent out because we allocated and hasn't always, they haven't always, so like what's happened? I'm assuming that you want more, sorry. I'm assuming you want more than just dollars and cents. Right. It's not really about the, as much about the dollars and cents as it is just the macro though, you know, like, oh, there's, you know, honestly, I guess that goes back to my other, my second question, which is of Kelly, which is how did, what are they saying about the IT project and how that fits in because that was money that was associated with what we're talking about and if it's not happening and there's not the staff to make it happen, then there must be money sitting around. Do you want me to do a quick rundown of what I heard yesterday? Sure, everybody. Super. So they're still moving forward with getting a final product out. What they, they scaled things back so they could try to have something to go live in October, which we know didn't happen and that still hasn't happened because they ran into the glitch about being able to backdate things. The federal deadline that they were up against has now been pushed out to June. So that's, you know, we're getting some more leeway in terms of coming into compliance and not getting penalized by the feds for, for that. But they're not stopping the, getting the whole module done. It's just taking longer than they thought. And so far, the vendor that is, is building this module has not, so this is some, there's some IT stuff that is really like above my pay grade, but I'll do my best to try to relay what I heard. So there was a fixed price that the vendor was going to get for building this IT system. They have not put in a change order for any increase in costs to get to a final product as of yet. There were no sort of hard and fast assurances that that wouldn't happen, but it hasn't happened yet. So they're still working on getting to a complete and final product. Getting the initial scaled back version rolled out is still hung up, but it's almost there. But then they'll continue to build in all of those pieces to the system that they talked about from the very beginning. There was something, hold on, I'm going to just look at my notes extremely quickly and there was something else I wanted to make sure that I mentioned. The unspent CCFAP money because of this delay in being able to do the flip and get more money to families, which we talked about in the BAA, is the money that they're planning on using to get more money out to families with this temporary rate change thing that they think that they're going to be able to do within the old system. And from what Sean said, they're not planning on backdating that temporary rate. They're just going to look at the unspent money that they have, the remaining time period that they have in this budget year and make a calculation for how much money will go out to families to try to at least spend what they had to spend. But I didn't feel like that is what I heard when we were hearing testimony on that unspent subsidy money. But that's when I asked him in energy and technology, that's what he said. So there's not unspent money on the IT system. That money is still going to be spent. It was funded. The system is still supposed to come to fruition. It's not unspent. It's just not finished yet. There is a chance they will come back and need more money. But there's no official request for an increase at this point either. So that's the sort of long and short of what I heard. There may be some other costs that come up in terms of DCF rolling out the new system to providers and families. I didn't hear any numbers for cost of those things thrown around at this point. I assume that's something we can ask about when we start talking about the budget. And there was not a go live date at this point for the new module. Did they talk about user testing, Kelly? So they talked about the user testing that happened with the first scale down model, which was where they discovered that there was this glitch about back dating and that's when they hit pause. So right now, there's nothing completed that's functioning for users to test. That's my understanding. Was users, was that inclusive of the community or, you know, like providers and families or was that users just defined internally? I'm not sure that I know the answer to that. So when I was doing research on the budget adjustment, I did ask about that. And the user group that we asked them to put together was used throughout the summer. And that is when they discovered the problem. The glitch. Yeah. But they haven't since. Right. Because there's nothing for them to test yet. They haven't worked out the glitch that they discovered. But they're still working on it. And so they're planning on using the 814,000 to help to fund that temporary second rate thing within the old system. And there was also like a, well, we think we can do it. And we hope that when we do it, that we don't break the old system. Yeah, it's just so interesting because they didn't do that. That's not what their budget adjustment said. It said that it was dropping to the bottom line in the agency of human services. Right. But I asked because that's what I had heard in our committee. And Sean said they were planning on using that unspent subsidy money to fund this temporary increase in this budget year. But he also said that they hadn't made the decision yet. And it's, you know, it will happen very quickly. I think that's consistent with Kelly saying I think it's consistent with I had gotten just before the session started, I had gotten an email about this issue from well, a source, let's just say. And so Ann and I had a meeting with them, a brief meeting with them. And they, the BAA had already been submitted. But and so somehow this fix and using this money that as that solution came up after the BAA had been submitted. But I mean, he didn't say that in testimony to us. And I'm not sure if he said that in testimony to the Appropriations Committee either, but because they just struggled about approving it. I got an emergency email this morning, a text from them. Yeah. Yeah. So that we had heard that as we had heard that well as well. When Ann and I met with them. But yeah, it, it felt a little bit like I wasn't, you know, wasn't quite sure. It sounds like a plan in evolution or a plan. Yes, it did definitely sound like that for sure. And Representative Sims asked what their plan was for getting information out to providers once they made a decision about this temporary short term increase to families. And he said that they would be having forums with providers as well as other outreach. But that what's that? I was just having forums forums forums with providers with providers to to let and and families, I think, to let them know about this short term help that they are maybe going to offer. Because Representative Sims, as a parent with children in childcare, she was like, you know, I keep hearing about this, but I don't hear about this from my provider and my provider doesn't know about this. So that was and and this and this is still a something in some something in our our Royal are our something in the department's thinking and thought and hope bubble. It is not a reality. Correct. That is. So that's why we can no one knows anything or no one's right. Right. Right. They don't they don't have any information to share yet. So they haven't. But that was they plan on sharing it via forums and, you know, email and written communications as well, but forums. So it's yeah, it was it was. Well, thank you. Thank you for the update. It's 10 of three and we need to be on the floor at three and chopper just will. So this ends our meeting.