WHO press conference 20 November 2020

Good morning to to our Geneva based correspondence and welcome to this WHO press briefing this morning.

As as you have seen in the, in the media advisory that we have sent to you yesterday, we will be speaking today about COVID-19 therapeutics and treatments where we are, what's the way forward.

Last night you have all received a press release from BMJ and, and you've seen the, the, the, the guideline development group has issued its advice.

So today we will discuss on that, but we will also discuss broadly on, on treatment options.

So with us, we have today Doctor Janet Diaz who is the Head of Clinical Care here at at WHO you have talked to her already, you have seen her at WH regular press conferences.

So she will try to give you this update and to answer some of your questions.

We also have with us Graham Rochework, who is based at Master University in Canada in Hamilton, and he was one of the chairs regarding Remdesivir and regarding the advice that has been issued last night.

So he may jump in as necessary to answer your questions.

If you look at the participants who are with us today, you may see some names that you are not familiar with.

These are WHO colleagues who are interested to hear also from Doctor Diaz.

So, so we felt free to invite few, a few colleagues of Doctor Diaz, but these are all WHO people.

So we will start immediately.

I will hand over to to Janet, Doctor Diaz to to give us a little bit broad overview of where we are, what happened with Solidarity trial, what happened with remdesivir, but also what is the what is the way forward?

[Other language spoken]

Thank you, Tarek and it's a pleasure to be here and good morning to all the colleagues and thank you for this opportunity to brief you on the on where we are in the state of affairs for therapeutics and COVID-19.

So as discussed, I'm the clinical lead here in the health emergency programme for emerging infectious diseases and that includes the COVID-19 pandemic.

And and I want to frame the picture for you right now about, you know the focus right now is on therapeutics.

But again, obviously the clinical care of patients with COVID-19 is more than just therapeutics.

It includes supportive care, good screening, good triage, a good COVID care pathway and and then the administration of life saving therapeutics as they become available.

So, and I want to maybe always put that into the context that it's not one magic bullet that will save lives, but it's a good comprehensive care plan that will take care of patients with COVID-19.

And the most important thing with the public health interventions to reduce the transmission of COVID-19, so our hospitals don't get overloaded with patients.

But let's go focus on the therapeutics.

As you know, we issued our guidance overnight on the living guideline on therapeutics in COVID-19.

[Other language spoken]

And I and I want to take you back as to how do we make any recommendation from WHO and especially in this time of the pandemic, how do we do this quickly and how do we do this in a trustworthy and transparent manner?

And, and I'm really thrilled that Bram, our Co chair was able to join us this morning.

Our other Co chair, Mike Jacobs was not able to be here due to scheduling complex, but I do think we can.

We'll be able to answer questions on some of the methodological issues on how we make recommendations in a bit.

But in the big picture, everything starts with an evidence generation.

That means those that are doing clinical trials, robust **** quality randomised control trials, which we believe provide the best evidence for safety and efficacy for interventions.

We have to really thank those people.

And for this Remdesivir, it includes many global collaborators.

It includes the investigators from Solidarity, which was done in over 400 countries around the world.

It includes the investigators from Act One, from the NIH and all the centres that participated in that study in the United States.

It includes investigators from simple, moderate and from the Wang study in China.

Those are the four studies that contributed into the meta analysis that was done in order to inform this guideline.

So those are the investigators who seem to be thankful for at the global level, at the country level, at the facility level, the manufacturers such as Gilead that have produced the drugs in order to conduct the trials, the donors, the funding agencies and most importantly the patients in the families that agreed to enrol in these clinical trials.

So one of the most important lessons learned from this pandemic is that we must conduct **** quality trials.

And that means having all this in place with good studies, good methods and get patients enrolled so we can find an answer faster.

And I think this pandemic really shows what global solidarity in this work can can be done.

The achievements made by these large platform trials, solidarity being one of them, as well as recovery as you are also familiar with from before.

So I, I want to just say thank you to those people that have made this possible and to the journals and the editors and the peer reviewers that have looked at all the results of these studies as they come through and have made them available to us over time.

And everyone I know is working nonstop to find a therapeutic, either a repurposed therapeutic like the ones that we're talking about right now or a new therapeutic like many of the pipeline monoclonal antibodies or small antivirals that are being tested now in early phase trials.

And that we are indeed talking a lot about these days in the media, etcetera.

So we have evidence generation, we have publications and what triggered this update and what happens next?

Is that the guideline that we have to develop, how do we take one study or two or a big study or a small study and then bring together that data in an evidence synthesis.

And the best way to do that is something called a meta analysis.

And of course, maybe we can ask Bran to describe what that meta analysis means, but it really means we bring together the data in order to see what is the truth behind this data.

You know, what is how strong is the effect of the intervention?

[Other language spoken]

And how certain are we about that benefit?

And so there is a process that exists and this is a methodological process.

[Other language spoken]

It's called the grade process, if those of you that are interested.

And So what we do at WHO for to write a guideline is that we thank all the investigators for doing their trials.

We take that data and an independent group that analyses that data in a meta analysis.

And that independent group, we are lucky because we then there's another Many thanks to the collaborators who did our meta analysis, which are collaborators from the McMaster University, a big team that is publishing a living network meta analysis in collaboration for us in order to keep up with our living guidelines.

And then they take that data, do an analysis.

So this is separate than the trial analysis to find the summary of fund findings table.

And then they grade the evidence.

So then they say, are we certain that this is **** certainty evidence, we believe it 100% or is there potential that maybe we're not so certain moderate certainty or is a certainty low and there is a strict criteria on how you do this.

And again, so this is something again, maybe we can bring to Bram a little bit later.

And so for this work, it's not like it can be done, you know, so easy.

So there is a a lot of people behind the scenes working to analyse grade and that this I actually want to thank the method support team that we're working with, which is the Magic Ecosystem Foundation.

And they've been giving us a tremendous amount of support in order to ensure that the methodological approach to looking at this data has been good.

Then what we have the evidence synthesis, we've graded the data.

We WHO then convenes an expert panel that's also independent from WHO, It's the guideline development group panel.

And I want to really say thank you to the 33 members of that panel, which include 28 clinical experts of varying specialties from intensive care to infectious disease to primary care to biology to paediatrics and obstetrics.

They come from all over the world, so regional representation.

They also included one expert in ethics and actually one one of the most important things is we also include patients, so patients who have had COVID to get their perspectives about how we write the guideline.

So this is the standard practise of writing the guidelines.

So I want to thank all those that participated with us.

And then our Co chairs, which is Bram, who's on this call with me and Mike Jacobs, who helps lead this, the discussions and the deliberations around writing the recommendation.

We met five times, looked at data on five different days in order to write this recommendation, to carefully look at the meta analysis, the subgroup analysis, in order to write the best guidance we could.

We looked at the outcomes that were important to patients and the values and the preferences what, what patients would want in this guideline.

So here is where we finally get to to the recommendation.

So the recommendation is clear and I'm just going to read from my papers because it's easier.

We recommend a conditional recommendation.

So I want to highlight that it's a conditional recommendation against the use of remdesivir in hospitalised patients with COVID-19, regardless of disease severity.

And this is based on the fact that the evidence summaries that are in our annex.

So you can clearly see this in the WTO guideline in the BMJ publication.

And then the full meta analysis is actually in the WTO publication that remdesivir has possibly no effect on mortality with an odds ratio that's 0.90 and a confidence interval of 0.70 to 1.12, which means that possibly remdesivir can lead to 29 fewer deaths per 1000 patient or up to 11 more deaths per 1000 patients.

So you can see that this is the the confidence interval is a little bit large, either reducing mortality or increasing mortality.

And so that was the evidence at the end, the big summary evidence that the panel had, and with that wrote a conditional recommendation against the use because it was not clear that there was no evidence that there was any important effect on mortality, on the need for mechanical ventilation or the time to clinical improvement.

Now, this did not prove that remdesivir does not have a benefit at all.

And that's why it's a conditional recommendation that can still be potential small benefit maybe in a subgroup, which is why the panel also recommended continued trials, continued enrollment into clinical trials, which is why Solidarity also continues to enrol into remdesivir.

And to focus perhaps better on the subgroups, you know, is there a subgroup that may benefit more, such as severe patients versus critical patients?

Is there a timing and disease that may benefit more, such as early versus late?

And those are all considerations that are in the guideline.

[Other language spoken]

Care of COVID-19 patients is a multidisciplinary, comprehensive approach.

It starts not just with one therapeutic.

It starts with a package of care, the COVID care pathway screening, triage, IPC, find out whose risk for severe disease, look for signs of complications and treat those complications.

Right now we have one life saving therapy and that's for that recommendation.

We have a strong recommendation for corticosteroids and severe and critical illness, the use of oxygen for patients who have severe and critical illness, and then advanced respiratory therapies.

We are looking at other things all the time.

The living guideline process is something which is not new.

I think it's something that has been discussed before, but we're actually enacting it, which means as trials read out or publish or make their data available, we can then take it in to the network meta analysis that our colleagues and our collaborators are doing, aggregate the data and then update the estimated effects and see does that change our recommendation.

And so we have to be flexible, we have to be agile, we have to be open, but we also have to provide some guidelines for policy makers in this time of uncertainty.

And we believe this methodological approach that is transparent, vigorous is a good approach in order to provide those guidelines in a rapid way.

And there are other drugs that we will be looking at.

You know, there's early phase drugs that that are in pipeline that we're monitoring such as the monoclonal antibodies, the small molecule antivirals.

There are other immunomodulators such as IO6 receptor antagonists such as Sosumusamab and other agents on the horizon.

And we are, I have to just say, with the big collaborations that we have with many partners around the world trying and working hard to keep up and ensure that our guidelines stay practical and useful.

And so before I finish, there was one thing I wanted to stress.

What is a conditional recommendations?

There's a definition for this.

It means for patients, the majority of individuals would want the suggested course of action, but some may not.

It means for clinicians that there may be different choices that are likely to be appropriate for different patients.

So maybe clinicians may tailor solutions for their patients and for policy makers.

There may be debate about this recommendation in your countries.

And so there may be very variability in the application of this conditional recommendation and I think that is important.

So with that, I want to I want to finish my commentary and and thank you for your attention.

Thank you very much, Doctor Diaz for this opening remarks.

Let's and thanks Bram for being with us.

And he may he may also be be able to answer some questions.

So I can see that we have one question so far.

And I'm sure you know, you should just click raise hands.

So let's go to Emma Farce from from Reuters.

[Other language spoken]

I'm not sure if I'm allowed A2 part question, but can I try?

The first part is just a clarification.

Has The Who also then moved to suspend remdesivir from its pre qualification list?

And what might that mean?

That's the first one.

And the second one, if I May, is there's a meeting at the WTO today on IP waivers for COVID drugs and treatments.

I was just wondering, what are you doing at The Who as part of this process?

Are you working with them on this or independently on a different track?

Thank you very much.

[Other language spoken]

Obviously, if, if, if you are not the right person, we can look for for, for answer somewhere else.

[Other language spoken]

I think it's best, you know, the, the colleagues at the in the pre qualification team are, are working on this line of work.

So we would have to reach out to them and unfortunately they're not on, they're not on this, on this panel with us this morning.

So Tarek, I suggest we just reach out to them to answer specifically where we are in the process.

And, and I guess they're also done a question on the World Trade Organisation discussions.

Yes, sorry, Emma, because, you know, it's, we always have to see what, what is the really area of expertise of, of people we are putting forward.

So, so really Janet Diaz is, is, is in charge of anything that comes to clinical care on COVID-19 patients and maybe not be too much into into processes.

So we will look for that.

Emma, I suggest that you send send me an e-mail with those questions and I will, I will.

[Other language spoken]

Jeremy, yes, thank you.

Hi to everyone.

I would like to know surprisingly, it seems like we will get the vaccine way before we ever find an effective treatment against COVID-19.

I was wondering if is this the 1st and do you think that manufacturers will still be willing to put their strength in finding a treatment if they might not be able to sell it compared to to the COVID vaccine?

[Other language spoken]

Sure, thanks Jeremy for the question.

No, I think I think all hands on deck has to be done for for both interventions.

Of course, the vaccination inter looking for, you know, an effective vaccine is, is a hugely important public health intervention and as well for patients who who do get sick, you know, that percentage that do also to provide them with an effective life saving treatment.

[Other language spoken]

I think we're all working towards the same goals to to do both.

[Other language spoken]

Now Lisa Schlein from Voice of America.

Lisa, good morning, Tariq and hello, good morning to you.

Could could you clarify what you're talking about the conditional use of remdesivir?

I didn't frankly understand you were talking about subgroups using it, that in some situations it might be possible that it might have, I don't know, perhaps a minimal impact to ease the problem of COVID-19.

If you could elucidate that, please.

[Other language spoken]

I'm going to start and then I'm going to hand it over to Bram.

So, so just to be clear, this is a conditional recommendation against the use of remdesivir.

So not to use remdesivir in all in in patients hospitalised with COVID, regardless of the severity of disease.

Now, the conditional nature is a little bit of a nuance.

So I'm going to give it to Bram because maybe Bram could be able to to speak of that a little bit differently the way I did.

So maybe it's more clear.

So thank you, Bram to you.

Thanks, Janet, and good morning, everyone.

As as mentioned, my name is Bram Rosberg.

I'm was the methods Co chair for this panel.

I'm also a practising ICU doctor in Canada, based in in Hamilton, ON Canada and.

Lisa, thank you for the question.

It is a bit nuanced and the epitome of conditional or weak recommendation are are considered synonymous.

And it, it basically recognises the idea that the majority of well informed patients.

So the majority of well informed patients, if they knew the data that was out there would choose not to receive remdesivir and similar for well informed clinicians and other stakeholders.

But there's going to be variation in, in values and preferences and, and variation in regions, variations in how people interpret the data.

And the conditional nature recognises that there might be a minority of people that that would still choose looking at the totality of the data to, to receive it.

So certainly agree that the against conditional against recognise the majority of people would would not choose but but the panel did not feel like there was enough to make strong guidance and strong guidance is more dogmatic and we didn't feel like there was enough for that strong guidance.

And I think this ties into what Janet was saying as well is that the panel felt strongly research needs to continue.

We did not see subgroups based on the data that we had that deserved specific recommendations for those subgroups.

We didn't think that there is an identifiable subgroup that said, you know, we think that you should give remdesivir in these situations, but there may be groups and the data was a bit more of a close call.

So that's why we felt strongly that trials need to continue using remdesivir and studying remdesivir and looking to see if there are specific groups that might, that might benefit.

And, and as she said, we were very explicit that that we do believe these studies need to continue.

Solidarity is continuing.

So hopefully that helps get in a little bit more of the nuance of of a conditional recommendation versus a strong recommendation, which is meant to to more certainly apply to to all.

[Other language spoken]

Thank you very much.

Bram and Janet, we have more questions coming in Logan Ciero from Swiss News.

[Other language spoken]

So you said that trials have to go on with these subgroups to see whether there there are some benefits.

Has the the group already agreed on when he it's plan, it's planning to gather gain to assess potential benefits.

Thank you, Laurent for the question.

So, so, again, so, so with this, this process with a living guideline, we actually have a standing guideline development panel and we actually do meet on a regular basis.

But the triggers to look at the, to look at the new evidence depends on what's, what's published, you know, what becomes available.

So we are monitoring how studies are progressing and, but when that study start to, you know, to analyse their own data and then then that becomes publicly available for us, then to take into the meta analysis, then we would convene the next panel.

But they're always ready to go.

It's a wonderful group of experts that are really dedicated to to convening when called upon and to look at data and to help draught these recommendations.

[Other language spoken]

Unless Brown wants to add something, we will go to Gabriela Sotomayor from Proceso.

[Other language spoken]

Thank you for taking my question.

[Other language spoken]

1 is like a follow up of my colleague, why there is no treatment and there's five vaccines right now.

I mean, what, what is the reason that we don't have a treatment?

I mean, I don't know if the, the, the sense is that the, the scientific community is, is very focused on, on the, on the vaccine, but not on treatment.

[Other language spoken]

And also for, for I, I heard about some aerosols that you can put in your nose and that can prevent of having COVID.

Have you heard of something about these kind of treatments?

[Other language spoken]

I don't know if it's that true and also what is happening with the people that are surviving.

I mean it's because they are lucky because they had oxygen and that but it's it's why I mean they are surviving is because of that.

They are they were lucky.

They had oxygen treatment, you know, on on time in the IC US, but not because of any therapeutics.

Is that Well, thank you, thank you, thank you, Gabriella.

These are I think really questions that many people asking themselves.

So Janet, would you like to take a few of them?

[Other language spoken]

Thank you, Gabriella, for the for the interesting important questions.

Why are there no treatments?

I'm not sure why.

I do think there's a tremendous global effort to to investigate treatments.

You know, I think a lot of interest was done up front with the repurposed of drugs, repurposed antivirals.

You know, we saw that with or other repurposed drugs such as hydroxychloroquine, lopinavir.

And, and there was a big push to try to test these and they've, they've been tested.

And unfortunately we just haven't, you know, the, the, the results haven't been as promising as we had hoped.

But I don't want to, I don't want to forget that we do have one life saving drug.

And even though it's a repurposed old, old drug, dexamethasone and corticosteroids, we do know that that does reduce mortality, save lives in patients with severe and critical.

So, so there is something there is, there is hope out there.

And then I also have to acknowledge that, you know, the many groups that are working on developing the monoclonal antibodies and testing those and the small molecule antivirals and the immunomodulators.

I still think there's a lot of stuff in these big trials are all on, you know, ongoing such as Solidarity, such as the the the platform trials in the US and in the UK that are enrolling and Remap CAT that are enrolling patients on different therapeutics arms looking for an answer.

So I think there's still things on the horizon.

So we should not lose hope and I think many investigators are working in this space as well.

I'm not familiar with the aerosol intervention.

So, so that would be interesting if you can share with us what that what that is potentially.

And then surviving, I think what we have been, I think the numbers that seem to be clear in different cohorts that have had COVID around the world since the beginning is that about 80% of people have, you know, mild disease, a proportion, maybe moderate disease and then only a small proportion, a smaller proportion, 20% go on to develop severe or critical disease and critical diseases.

There's a small, small portion, it's 5% or less and that is, and that seems to be kind of consistent, I think through the literature.

So, so most patients do have, if they have mild disease, have self limiting disease, they get better on their own, their immune system kicks in and and they get better.

We do know that even patients with mild disease may have persistent longer term symptoms and that has been now described.

So even though they don't get severe disease, there can be some persistent symptoms that last longer than one would have hoped for.

But we do know some people develop severe and critical disease.

And now that we have corticosteroids, that is 1 intervention they can receive.

And then good standard oxygen care, supportive care, safe ventilation, advanced respiratory support, good ICU care, all those things when bundled together, we have seen mortality and, and mortality, you know, is a hard number to say, but we have seen it range over the pandemic with multiple factors taken into place.

And we do know certain patients, certain subgroups are at higher risk for death, such as patients with comorbid chronic diseases, such as patients who are older, likely because their immune system isn't able to fight strongly against the the virus the way someone who may be younger may be able to do so.

So there's a lot of things there.

But I do think, you know, good health systems, strong, good clinicians that are trained in caring for patients who are sick, such as intensivists and nurses and respiratory therapists and rehab therapists, all working together has been able to save lives from patients who are suffering from patients, patients who are suffering from COVID-19.

[Other language spoken]

She has a follow up question.

And then then we will take a question from Nick from New York Times.

[Other language spoken]

Yeah, Now you, you say not to use remdesivir cause the benefits are really not there.

But I'm wondering, could the use of remdesivir actually be harmful in some cases?

I mean, maybe there aren't benefits, but perhaps there there's harm.

And then on the issue of steroids, President Trump was pumped with up with all kinds of stuff and and one of the things that went into his body was this experimental steroid drug, I believe is, has that been approved?

Is, is that actually efficacious?

And I'm wondering, in the case of Trump, how did he, I mean, he got the best care possible.

Is that what made him survive?

Because he's, he's got a lot of things going against him.

[Other language spoken]

And yet he seems to be pretty, you know, energetic.

How do you explain that?

Is it because he's the president and he got this fantastic care?

[Other language spoken]

Thank you, Lisa, for this.

You know that we are not commenting on particular cases, but maybe Janet can.

Yeah, but I keep that severe Thanks, Lisa, for the for the question.

And so I'm going to actually hand it to Bram.

Maybe Bram can walk us through the, the, the potential harms benefits versus harm analysis from the guideline.

[Other language spoken]

And, and I think Lisa, it is an important point is that there is ongoing uncertainty about the effect of remdesivir on important outcomes and mortality or, or survival is one of those where there's ongoing uncertainty.

So I, I think that when we look at the Janet very nicely describe the evidence synthesis that was performed to support this guideline.

And when we look at the results of that evidence synthesis, which is is found within The Who guideline, is it certainly it's still possible that remdesivir, our best guess is that there's no effect on survival.

Is it possible that it might still positively impact survival?

[Other language spoken]

Is it possible that it might still cause harm in terms of increased mortality?

Looking at our summary, it's possible.

And this is what influenced the conditional recommendation against.

We're not saying that there's evidence that remdesivir doesn't work, but there's there's evidence, there's not good evidence that it does work and there's not good evidence that harm is off the table.

And so it was these considerations that the panel looked at and they felt that the majority of people would not ascribe to a new therapy when the benefit was not there.

And that there was still a potential for for worsening outcomes and, and not and leading to increasing death.

And that was a lot of what influenced the recommendation, but again, a lot of what fed into the idea that that trials need to continue moving forward.

[Other language spoken]

Bruce from New York Times.

[Other language spoken]

Thanks for the briefing.

I just had a question on whether you have much clarity on how widely remdesivir is still being used.

And then there was reports of United States buying a very **** percentage of of the world's stock.

So again, is is there much regional variation in the usage of of remdesivir?

Is there much regional variation around the world about the effect?

Thank you Nick for that important question.

There is a, you know every the policy makers in each countries are making their decisions about, you know, authorization of drugs early.

Also many countries are are used are enrolled in the Solidarity trial or other large or other clinical trials.

So they are using these drugs in clinical trials and what we have seen not just in Remdesivir but in other drugs as well that there has been tremendous variability and usage of interventions, especially a lot of these, some of the therapeutics that were unproven.

So early on we saw a lot of off label use of of the repurposed drugs without the evidence behind it or without a recommendation behind it.

So right now, I actually am not aware of the global variability of use with the use of Remdesivir in different countries, but we know some countries obviously have put it on their on in their guidelines.

And So what we, what we hope is now we have, you know, we just released our guideline, you know, overnight, there's a lot of information in there, there's a lot of analysis in there.

And I think now that needs to be reviewed by the policy makers and the clinicians and see how that gets adopted or integrated and their guidelines.

Again, this is a, it's a living approach, right?

Everyone's trying to make the best decisions with the evidence they have at the time that they have it.

So now we have, you know, another piece to the puzzle with this, with this guideline that was just published in this analysis.

[Other language spoken]

I see that please I would like to take one more one more try.

Well, it's it's difficult to this virtual world to follow up quickly.

Yeah, sorry to forgot.

[Other language spoken]

I, I'll, I'm taking my political question off the table, but I would like you did not answer my question regarding steroids.

So my question is whether the experimental steroid that was given to President Trump and presumably has might have been given to other people is actually efficacious and whether steroids in general are are beneficial.

Whether whether this is is something that should be more widely used.

If you could elaborate upon that because I don't really get a sense of how valuable, how beneficial it is.

Thank you and now I'll shut up.

[Other language spoken]

So on on steroids in general and I don't know if we know what particular steroid was was used in this particular case, but maybe maybe Janet can can can do something answer on on on steroids in general.

[Other language spoken]

And and Lisa, I am not aware of the specific experimental steroid that was used in in in treatment that you're describing.

[Other language spoken]

But I can say that WTO did issue its clinical guideline for corticosteroids of which the, you know, the most common one being dexamethasone, but also applies to the other steroids in the class that are not that are that it was shown in the analysis that we that we have that was based largely on the recovery trial, the recovery platform trial that it does reduce mortality and so improves patient outcomes in patients with severe and critical disease.

So that was a clear recommendation.

So that we do recommend that that gets and it was a strong recommendation.

So that just to be clear, and I did, I do think many countries have have since, you know, included that in their standard of care and in their revised their guidelines.

It is not to be used in patients with mild disease.

And that also needs to be clear because we had a conditional recommendation against the use in mild disease because of the potential that it could increase harm in those patients.

So it shouldn't be widespread use for all COVID.

That that's not the answer.

It's it's only for the subgroup of patients with severe critical disease.

[Other language spoken]

Let's go to body hugger from from Chinese media buddy.

[Other language spoken]

Thank you for taking my question.

[Other language spoken]

Firstly, before yesterday we or yesterday we interviewed the IRU International Roads Union who said WHO have neglected to attach importance of this industry and the safety of practitions partitioners.

I'm sorry, could you could you give us more details that do you have any ignore some part of the word or another question is about the vaccine and the treatment.

Is that possible that miming to reasonable distribution the vaccines and the treatment for miming April for everyone.

[Other language spoken]

Well, this is this is a a press conference not on vaccines and Janet is I know, I know, but also treatment.

So can you just repeat your first question because I don't know Janet, if you got it, but I didn't understand what what industry you are you are referring to the industry industry of transport.

Transport yeah, IRU recommend that WHO have ignored this industry has no reaction from your side about guideline about how to treat the workers.

Well again, this is this is not really something for for Janet and for Bram.

I'm really not aware of those.

All right, yeah, please to the next question and the next question.

OK, If we if we if we can reformulate maybe Janet, like once we have some promising treatment or the one that we have, how to ensure the the equal access and equity?

[Other language spoken]

So I think implementation of guidelines and recommendations is an important aspect.

So how do we disseminate the information?

How do And so from the WTO perspective, we're using different dissemination techniques.

So that's the first thing, right.

We publish our guidelines on the WTO website.

We also made it available with our collaborators on the BMJ that also published our our guidelines.

It's also going to be available on the Magic app, which is also a another dissemination tool.

So, so one is dissemination and getting the public visibility and like this right now, this is an important venue as well and the D GS press conference.

So, so we first share the information and then we make tools at the country level or regional level to implement the recommendations and that could be working with ministries of health.

To adapt their guidelines if requested, giving information or educational materials on how to use the life saving for the therapeutics, what are the doses, those sorts of things.

So the practical implementation aspects at regional level and then a country level in our country offices support the implementation there with the national ministry and all the national experts that are involved.

So there's a dissemination implementation aspect and and of course dexamethasone which are corticosteroids, which is the one life, the one therapy right now that we have a strong recommendation.

[Other language spoken]

So access to that therapy is not an issue.

[Other language spoken]

Janet, we have 3 minutes left and we have two follow up questions.

So we will do a super, super fast log on 1st and then Gabriella and then we will close log on.

Yeah, I'll try to be to be fast first.

Could you elaborate on, on for, for which subgroups you think the trials should continue?

And then you answer to Nick's question by saying that there might be some countries part of Solidarity that still use remdesivir.

But I thought that after the interim results that were announced by Doctor Swaminathan, there was a strong recommendation to stop the use of remdesivir in the in the trials of Solidarity.

So is it still used by some partner countries?

[Other language spoken]

Janette, would you like to to try, I think for the for the subgroups of I'm going to pass off to Bram.

Maybe Bram can just reiterate what's what are they continued research subgroups that should be considered?

Yeah, I can, I can be brief.

I know time is of the essence.

But you know, as I said, the panel looking at what we did have, we did not feel like that there was identifiable subgroups, that there was enough to make specific recommendations.

But if you look at the end of The Who guidance, there is a section on ongoing uncertainty and some of the subgroups that are mentioned around different severities of illness.

And there's maybe some signal that, that those that are less sick or earlier in their course of illness might benefit or might be an area to focus on.

Again, not enough to, to change our recommendation in that group, but, but might be an area to, to encourage further work in.

[Other language spoken]

This would certainly be an area that I think would benefit from further investigation and around duration of therapy were some of the areas that we highlighted.

So I, I, I think it's still worthwhile exploring in these groups and, and even further data in general would be warranted.

Thank you very much, Bram and Janet.

And let's take the last question we have.

That's, that's again Gabriella Sotomayor from Proceso.

[Other language spoken]

Thank you very much.

Well, first, thank you for this briefing.

We, we appreciate a lot this kind of briefings.

And the question is on antibiotics, I mean people who are developing pneumonia with COVID, but they are not in need of hospitalisation.

They are giving some anti antibiotics for the pneumonia.

Three day antibiotics is a very strong one.

I don't know the name, but is that effective?

Do you think that it works?

[Other language spoken]

Basic, very thank you, Gabrielle.

[Other language spoken]

So, so currently in our clinical guidelines, we don't recommend for patients with mild disease like you're discussing or those that are treated as outpatients with COVID-19.

So, and, and those that we do not suspect have a bacterial pneumonia that we would not, we would recommend not to use antibiotics in those cases.

So antibiotics obviously are are indicated if you suspect A bacterial infection and then you would use a antibiotic appropriate for that bacteria.

There could be cases potentially where you may not be sure and perhaps a small child that uses has pneumonia that can also have a bacterial pneumonia that we're giving an antibiotic may be indicated because you're just not sure if it's just COVID, there could be a bacteria.

But in general, for outpatients with COVID-19, we do not recommend antibiotics since antibiotics are not effective for, for COVID-19.

Thank you very much, Doctor Diaz.

Thank you very much Graham as well.

And thanks to all journalists who were with us this morning.

We will continue to, to try to get you WHO experts on, on, on various issues, not only COVID-19, but obviously including on, on COVID-19 pandemic.

With that, I'll just remind you that we will have a press conference today at 3 O clock.

You have received the the media advisory and we are looking forward to seeing you there.

Wish you all the best and have a nice weekend.

[Other language spoken]