September 20, 2021 • 34 mins
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Things Discussed on Episode:
- Winter is coming, again: What to expect from Covid-19 as the season looms
- What We Actually Know About Waning Immunity
- Indian study finds big drop in COVID antibodies within four months of vaccination
- Moderna’s Covid-19 Vaccine Best Prevents Hospitalization, CDC Study Indicates
- 5 reasons why FDA advisers did not recommend Covid-19 booster shots for everyone
- Israeli Study Finds Third Shot Provides Significant Boost in Covid-19 Immunity
- CDC Stands Up New Disease Forecasting Center
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Matt Boettger (00:00):
You're listening to the pandemic podcast.
We equip you to live the mostreal life possible in the face
today's crisis.
My name is Matt Boettger and I'mjoined with my one good friend,
Stephen Kissler, anepidemiologist at the Harvard
school of public health.
How are you doing buddy?
Stephen Kissler (00:13):
I'm doing all right.
How are
Matt Boettger (00:14):
you?
It's good.
You know, it's, you know, doingthis two week thing, it feels
like it feels a little bitlonger, you know?
So, it's good to see you again.
It's great to see ya.
And suddenly we got some stuffto chat about.
It's, it's kind of nice, youknow, to do every two weeks.
I know some of our listenersprobably would like to every
week, It gets a little more timeto breathe and kind of see
what's going on in the wholeCOVID spectrum, because now
(00:37):
somethings, sometimes thingschange really quickly and it's
in a week, but other times ittakes a couple of weeks to kind
of really see what's the wwhat's really, really making
headlines and what really needsto be talked about.
I think these two weeks havehelped to frame a couple of
things that I want to share.
With you to see what's going on,but first, just to hear what in
your neck of the woods, youknow, now that you were saying a
(01:00):
couple of things, what you'vebeen doing and the past two
weeks, what you've been workingon over there at at home.
Stephen Kissler (01:05):
Well, yeah, so we've been doing some you know,
a lot more modeling, so, youknow, different organizations
are really interested in justsort of how to keep their
clientele safe.
As we're going into the winter,as we're starting to think
about, you know, Yeah, just whatsorts of testing do we need?
It's, it's really interestingbecause I think that a lot of
these questions have become alot more nuanced.
Both as the technologies haveadvanced as our understanding of
(01:26):
the virus has advanced.
And I think a lot of thequestions have shifted from is
this safer?
Is it not?
Or Do we need to test or do weneed to not, and now it's more
like, so we have this manypeople who are vaccinated and
this many who aren't, but theywere vaccinated this many days
ago.
And these are the vaccines thatthey were vaccinated with.
And some people we know, andsome people we don't and there
the different types of teststhat we have available, and we
can do it this frequently withthis type of test.
But it, it, it keeps me.
(01:50):
Well employed for one and that'sgood.
And on my toes so it's been sortof fielding a lot of those kinds
of questions on differentlevels.
So it's been good, challengingman, busy, the
Matt Boettger (02:00):
same good, the same epidemiologists.
Stephen Kissler (02:03):
And so I'm pretty excited to be less
famous, but
Matt Boettger (02:06):
I I'm sure.
I know.
Well, you know, you mentionedwinter and so let's start with
this.
It's a bit on my mind.
Maybe only like may seven daysreally, because I think my wife
brought it, brought it up to me.
I'm like, oh yeah.
Like she was like, what do youexpect to winter to be, you
know, you know, she's asking meas if I'm a qualified person,
but she just says, I have, Ihave the gateway to asking these
questions to you and mark.
So, you know, so I'm gonna throwmy scenario and then I want the
(02:30):
actual informed person you toactually talk about.
What you might expect about theupcoming months.
I know we've done all thesecaveats of you are not a
magician.
You can't see the future.
And when it comes to viruses isway unknown.
But given what we know, so thisis what I'm thinking, Stephen
I'm.
Okay.
All right.
A couple of things have beenhappy in my mind.
I follow the news about everycouple of days or maybe about
(02:52):
every day, at least for five or10 minutes and clips some
articles, and I've seen apattern.
I haven't seen a lot ofinformation on headlines about
other variants.
Whereas say a month, six weeksago, eight weeks ago, there was
a number of headlines talkingabout other variants other than.
So I'm thinking, huh?
I wonder what that is.
(03:12):
We've talked about how Delta isjust way more intense it's, you
know, at least two times morecontagious.
And so it seems to be a strongforce among variants.
So, so I'm thinking, you know,is there going to be another
variance like, or, or as Deltagoing to keep things abate?
I have no clue, but it seems tobe right now holding strong,
which for me is a great news.
(03:33):
I mean, for a number of reasons,Yes, because there's not new new
variants, but because Delta isincredibly more contagious, but
not necessarily thatproportionate in how worse it
is.
Right.
It's so I would rather have asuper, highly contagious one,
roughly the same kind ofworseness whatever, you know
what I mean?
And so keeping those maybe moretraumatic mutations at bay,
(03:56):
right?
So the.
We're also seeing now in the U Sthat cases are starting to level
out to decline overall.
Right now we're seeing hotpockets here and there.
Someone at, oh my gosh, is thiswinter going to be like, just
like, as really slow burnanticlimactic in a good way.
Right.
As long as there's no variance.
So what are you thinking aboutwhat this winter might look like
(04:16):
in light of what we've seen sofar in the past two or three
weeks?
Stephen Kissler (04:20):
No, I'm, I'm glad you bring all of this up
because I think that You know,last year, last year, around
this time, or even a little bitearlier when we were talking
about the winter, you know, Iwas, I was pretty certain that
we were going to have a majorwinter search which we did end
up having.
And you know, that was based offof experience with previous
respiratory pandemics and someof the modeling that we had done
(04:41):
at the number of susceptiblepeople who were still in the
population.
We of course didn't havevaccines at that point.
And so, yeah, I, you know, the,the, the playing field has
changed.
And I am a lot less, I'm a lotless certain about what this
winter is going to look like asa result.
So one of the things and therewas a, there was a paper on this
(05:03):
by by some colleagues.
So I really highly respect lastyear.
But it also matches up with justsort of my own epidemiological
intuition, which is that the.
Sort of this, this seasonalvariation and transmission that
we see where we see these realspikes in the winter and troughs
in the summer.
Is, it depends a lot on reallyjust sort of the baseline
(05:23):
infectiousness of the virusitself.
W which is basically the, youknow, if you have this virus
that sort of just on the knifesurge of, of transmissibility,
where the reproduction number,once you factor in behavior and
immunity, and all of thesethings is right around.
Then these subtle changes in theweather and how frequently
people spend time indoors and soon is really enough to sort of
(05:45):
shift the virus on one side orthe other of that threshold.
And that's what gives us thisseasonal change in transmission,
but for something that's a lotmore infectious, you know, we
have this Delta.
Variant where you know, we thinkthe reproduction number is like
on the order of six to eight ina, you know, in a you know, in a
population with no immunity andwhere everybody's mixing at a
normal rate, but that's, youknow, that's, that's quite a bit
(06:07):
more infectious than, than wethink flu is.
And the result of that cansometimes be that these seasonal
variation in transit.
Sort of gets damped out.
It's sort of overwhelmed by justthe inherent contagiousness of
the virus.
And, and I think that's, that'spart of why we saw so much
spread this summer because theseasonal damping effect that we
normally see in the summer justwasn't strong enough to.
(06:31):
Really do much to suppresstransmission of this, of this
highly infectious variant.
And so then I think, you know,the question becomes, you know,
what do we expect to see thiswinter?
And it could very well be thatwith high vaccination rates with
lots of spread over the courseof this.
That we might actually not seeas much of a winter surge as we
might've expected with previousvariants.
(06:53):
I think that's possible now.
I, I do still expect to see abit of a surge, especially in
places that have colder weather,where people are going to spend
a lot more time indoors.
I do think that keeping controlof the virus this winter,
especially, you know, up here inthe Northeast is going to be a
lot harder this winter.
And I do expect to see spikes incases up here.
But I am hopeful that it's notgoing to be.
(07:13):
As disruptive as last winter'ssearch was in large part due to
vaccination and due to exposureand all of these different
factors playing into it.
So I don't think that we'll ableto be able to totally avoid this
kind of wintertime surge, butbut I, I know it's strange for
me, but I'm a little bithopeful.
You know, it the, that it mightIt might be a lot less
disruptive than it could havebeen otherwise.
(07:35):
So
Matt Boettger (07:38):
great.
You know?
Yeah.
Again, I mean, not that I wantto be thankful for the amount of
transmission in the summer andcases, that seems to be
potentially to our advantagethat Delta raised locally head
around, you know, April, may,June kind of, you know, again,
allowing it to be not quite asintense, right.
(07:59):
I, even though hospitals wereoverwhelmed still, if I'm not
trying to make light of somereally particular hard states.
Yes, but I could have onlyimagined if that was December or
January.
Now I get it.
Florida's a little bit differentif you were saying how you know,
they're kind of more in theinside during the summer months
because it's so just crazy hotand humid and maybe in the
(08:20):
winter they're more outside.
So that could, it could causeit, so, before we continue on, I
forgot to mention this becausewe always say a couple intro
things that love reviews.
We've got two that came in thisweek.
I'll read this.
This is from will 6, 1 9 6happened on Thursday.
Love the podcast.
Great way to stay up to date onthe, on the latest pandemic
(08:40):
info.
I'm an RT in this podcast is agreat way to keep up with the
newest variants treatment invaccine.
Thank you.
Will the 61 96 and thenSeptember 12th, squids 1, 1 12.
I love these.
Helpful and quick knowledge,love this podcast to get instant
info on the pandemic as we learnmore together, super helpful and
straight to the point.
Thank you.
(09:01):
All of you for leaving reviewshelps us and inspire.
Keeps us going.
So I want to do that.
If you wanna support us in anyway as little as$5 a month,
patrion.com/pandemic podcasts,or just a one-time gift PayPal,
then Mo all in the show notes.
Okay.
I got the other way we cancontinue to move forward as I
get back to my screen, it wentaway.
(09:22):
Okay.
So the next thing I want to talkabout is let's just go straight
to the vaccines.
Cause there's a lot ofinformation when talking about I
want to get to the boosts.
For sure.
And let's talk about, you saidthere's some news that dropped
to this morning that I wasn'taware of speaking of vaccine
with.
We want to share that.
Yeah.
Stephen Kissler (09:36):
So it seems like, what Pfizer has just
announced this morning is thatthey now have safety and
efficacy data for, I believeit's five to 11 year olds.
So this is sort of the next agegroup down from who the vaccine
is currently approved for.
I believe it's a smaller.
Then what's normally given toadults, which is pretty standard
for pediatric vaccines.
And yeah.
(09:58):
I haven't seen the data yet.
I don't think that they'veactually released those data
yet, but they say that it looksgood.
So I'm looking forward toreviewing it.
And and I imagine, you know, if,if it does bear out, then, then
we, we could start to see someregulatory changes relatively
quickly.
I wouldn't be surprised if westart to see vaccine approvals
for those age groups.
And the coming month or so, so
Matt Boettger (10:18):
great.
That's awesome.
And then let's just continue onthe heels of this.
You said there was a piece ofinformation as well.
New news that may drop later ontoday or tomorrow it's related
to kind of the vaccines, it'sall about safety and, and, and
reduce the level of mortality.
But you said there's kind of ainteresting statistic that might
be making headlines soon.
Stephen Kissler (10:37):
Yeah.
So, I was speaking with somejournalists over the weekend and
sort of talking about.
What's going to be coming up.
And there's, there's a reallysignificant threshold.
Unfortunately that we're aboutto cross.
And that is that the the numberof deaths in the United States
is about to pass 675,000.
The number of recorded deathsfrom COVID-19.
(10:57):
And that's significant becausethat is the same as the best
estimate of the number of deathsthat we suffered in the U S
during the 1918 flu pandemic.
So that's, you know, even justfrom a cultural and social
significance point of view, youknow, that's, that's, that's a
big deal.
Now of course, in in myconversations this weekend, I
was talking about a lot of thesethings too.
There are, there are a ton ofreasons why.
(11:21):
We need to interpret thesenumbers in context first and
foremost, of course, is that theUnited States is over three
times as big as it was in 1918.
So on a per capita basis theCOVID-19 pandemic still has not
been as deadly as the 1918 flupandemic.
And you know, furthermore, aswe've talked about in a number
of episodes since the questionof mortality data is, can be a
(11:43):
really sticky one in the sensethat you know, what, which,
which deaths do you actuallyattribute to COVID?
So there, there may be someundercounting, you know, or
there may be some over countingin some contexts, but there's
almost definitely a lot ofundercounting as well, because
we've seen these huge spikes inexcess mortality.
But really surpassed theofficial counselor COVID 19, but
(12:05):
also, you know, that wasprobably in play even more so
during the 1918 flu pandemic,because there really weren't
these national robustcrosschecked data streams for
mortality data.
Then either a lot of ourestimates come from sort of
these rough estimates that we'reextrapolating from certain
populations.
And certainly.
(12:26):
Minority populations at the timewere not counted in any sort of
rigorous way in the mortalitycounts either.
And we're doing better at thatnow, but still not perfect.
And you know, so, so therethey're all of these issues, but
but nevertheless, I think thatit's, it's a significant
threshold to cross.
And I think that we're probablygoing to be hearing a lot more
about that.
Matt Boettger (12:46):
Yeah.
Now, if you're new to our show,how do you know which episode
this was?
We've talked about a couple oftimes mark and Stephen, when
they were both on that, it wasnew to me.
Early on there was all of thiskind of misinformation about
like conspiracy is about overcounting deaths.
As COVID.
Now I'm not saying there's notabuse.
I w I'm sure there could be a,you know, I'm sure there's some
(13:08):
abuse in some level on COVIDdeaths, but in general, It just
really positing the difficultyin, you know, the nature of our
show.
It's okay.
It's, it's complicated.
The complexity of actuallydetermining the cause of death.
And this is not just strictly aCOVID issue.
You bring mark back on here andhe'll definitely tell you about
how it's just not straight orit's not like a little like know
(13:29):
algorithm you just put in and itjust tells you, there's just,
you know, there's narrative andthere's context.
And, and so it's a complicatedreality that, that, that this
makes things harder.
Not conspiracy, just part ofhumanity.
So the complexity of humanity,now let's get into this vaccine
and I'm trying to find a way tohow I could maybe weave this
(13:51):
into one discussion because wehave vaccine to discuss in
general, right?
Just Medina it's, you know, youknow, just hitting the topics
like its efficacy being strongerthan Pfizer.
We can talk about that, butmaybe the context, and then we
talked about immunity.
And how that works and thewaning immunity in light of when
(14:12):
you might need a booster andthese kinds of things.
So let's maybe let's make theanchor point, this Israel study.
So that might be a revolving wayfor us to see it everything.
So if you're not familiar, therewas a study done in Israel.
Credible about really suggestingthat there is a significant
Wayne and ethicacy inparticularly the Pfizer.
(14:33):
What kind of thing thatdominated Israel?
I mean, that's the one they usedthe Pfizer vaccine you know,
down to maybe even like 40 to50% effective when it comes to I
think hospitalization or the Iforgot what that was, but
something you can correct me onall these stats.
I'm just general.
But pretty significantly low 40,50, 60% on, on, on those kinds
(14:54):
of things.
So.
This has been circulating,suggesting that, oh, we should
really advance a cause of abooster, right?
Because if that's that dramaticnow, you know, Biden and the
administration advance for abooster for everyone, FDA just
came out, you know, kind ofcountering and say, no, that's
more nuanced.
Let's do that for 65 or older.
(15:15):
Those who are at severe risk.
And I heard, they just releaseda third tier that's basically
health workers that are likethat, that are in constant
contact.
Those kinds of three, threegroups.
So we're seeing this kind offight of what should we do?
Should we get a booster?
Is Pfizer really not effective?
Now we've got to pull inimmunity and waning and these
kinds of factors in this greatarticle I've put in the show
(15:37):
notes, please, please, pleaseread it as body Atlantic waning
immunity is not a crisis rightnow.
And to put it in there about howfi you know, Pfizer also had.
Really suggesting that there'swaning immunity, there's
antibody reduction significantlywithin the Pfizer vaccine, maybe
after six months, eight months,these kinds of things.
And maybe you can help us sortall this out when it comes to,
(16:02):
again, like last week,antibodies are not the sole
reason that w the solemeasurement of whether we have
strong immunity.
And, and really kind of helpedus go through the T-cells B
cells antibodies in what youthink in the end, let them all
this craziness.
What is your suggestion when itcomes to.
(16:23):
Efficacy
and
Stephen Kissler (16:24):
boosters.
Yeah.
Yeah.
So let's let's try to break thisdown.
You know, and this is somethingthat that's you know, as, as
this introduction or the eldestis complex and it's something
that, you know, even we,epidemiologists are trying to
wrap our heads around in there'sa lot of disagreement or at
least, you know, very vigorousdiscussion about, you know, sort
(16:44):
of what, what the right pathforward is because it does play
into, you know, there are these.
Biological physiological,epidemiological considerations,
but also social considerationsconsiderations to justice
considerations to equity safety,all of these things are really
factoring into this and thatthis is a pretty sticky
situation.
So right.
So we have the vaccines, we, youknow, some of the story that's
(17:05):
starting to emerge is all right.
So it seems like the efficacy ofthe modern vaccine seems to be
holding up a little bit morestrongly than.
Both of them seem to be holdingup more strongly than the
AstraZeneca and the Johnson andJohnson.
And so now there are a lot ofquestions as to what do we do in
this context.
So as you mentioned, this studyfrom Israel is one of the best
(17:26):
that we have to date on, youknow, clear.
Numbers regarding the sustainedefficacy of these vaccines in a
real setting, which is really,really what we're after.
You know, we can measureantibodies, we can measure sort
of, you know, levels of immunityin the blood.
But all of those things arereally just proxies for what we
(17:47):
care about, which is, am Iprotected from infection?
Am I protected from symptoms?
Am I protected fromhospitalization?
And am I protected from dying?
Given vaccinations.
And the study from Israel reallydid see a pretty clear evidence
of waning immunity.
The biggest declines in immunityyou know, looking at these
different tiers it was of coursein symptomatic disease of any
(18:09):
sort of showing any sort ofsymptoms.
And I think that's where we sawthe sharpest declines.
Efficacy against hospitalizationand deaths remained high, but
was definitely lower.
I think, I don't know if itquite reached down to that 40%,
but I, I think it was still, youknow, probably on the 60 to 80
level, which is, which is lower,you know, definitely lower than
we were seeing with early on in,in as these vaccines were first
(18:31):
being rolled out.
And so that's, you know, that'sthe first thing that sort of
perks up your ears and it makesyou want to learn more.
So what's going on here?
Well, you know, first of all, wewaning immunity whether to
natural infection or to avaccine is totally natural,
happens all the time.
Really?
The outlier is things that weget permanently immunized to.
(18:56):
So things like measles and tosome extent like varicella,
which causes chickenpox, youknow, Viruses in particular that
basically you get exposed tothem and by, cause you know,
they give us lifelong immunity.
Yeah, that's pretty rare.
You know, you can think aboutall sorts of other infections,
whether it be RSV or flu ortetanus you know, not naturally,
(19:16):
hopefully you're not beingnaturally infected with tetanus,
but, but we have to get boostersevery 10 years, right.
To keep up our immunity, totetanus for the same reason that
our immunity wanes it declinesover time.
And it seems like for thecoronavirus vaccine and for
natural infection, that seems tobe the case here as well.
As you mentioned this Atlanticarticle really you know,
describes this in a good way.
You know, w we can ask thequestion, like, why does our
(19:39):
immunity weigh in?
And part of that is because ifwe, if we kept these really high
levels of immunity to everythingall at once, there's just not
enough space in the body for allof those cells to keep
circulating.
And so, so it has to decline.
And so really what our body hasis this memory that allows us to
Mount a good response quickly.
But that response gets betterand better.
The more we get exposed to avirus.
(20:01):
And so, so the question thatwe're trying to answer now is
how many exposures do you needand how does that depend on the
vaccine that you've gotten andreally critically on how old you
are, so that it brings in anextra layer of complexity into
this study from Israel, which isthat the they really focused on
vaccinating the oldest membersof their society first and sort
of worked down the age group.
(20:23):
The people we have the mostinformation about right now on
waning immunity as for the mostelderly.
Now in this study, they didbreak down by age group and they
actually did show that inyounger age groups, it seems
like the immunity is bettersustained than an older age
groups.
That's also a very well knownphenomenon across epidemiology,
which is that frequently.
You know, we, we have just like,we have a physical age, we also
(20:45):
have an immunological age.
And that correlates with ourability to.
Mount a good and effective andsustained response to things
that we've been exposed to.
So oftentimes when people areolder, They need a higher dose
flu vaccine, for example, orthey need boosters more
frequently against thepneumococcal bacteria.
(21:05):
And so this is, this is alsovery consistent.
And I think that what we'rebeginning to learn now is, you
know, not only do we needboosters, but also who needs
boosters and why and howfrequently.
And so all of that is sort ofwhat the study from Israel is
starting to inform.
That then brings us to some ofthe FDA decisions that that we
heard over this past week.
So for a while the white househas been saying, you know, we
(21:29):
want to approve boosters acrossthe population, basically, as
soon as the FDA gives us thegreen light and seems to really
have been pushing for that.
So the FDA came back with reallyinteresting decision, which was
that?
Well, actually, actually, no,we're not, we're not going to
recommend boosters for.
Because the the data justdoesn't really suggest that for
(21:50):
people under the age of 65 whoare healthy and have no other
comorbidities and aren't exposedto high levels of the virus that
they're actually going to havemuch of a benefit right now from
a booster relative to theprotection that they already
have no getting a booster willactually provide, you know, it
will absolutely provide greaterprotection for those age groups.
But we have to remember thatthose age groups are on average.
(22:13):
Closer to their finishing theirvaccine.
So, so, people like me are morefreshly vaccinated, you know, my
I already have higher levels ofantibodies in my system than
people who were vaccinatedearlier and I'm younger.
I got walloped with the seconddose, you know, and so I don't
know if that actually correlatesto the level of protection that
I have, but I can guarantee yousomething happened and I, you
(22:35):
know, there's and so.
So I think that this, thisdecision is actually interesting
and based off of the data wehave available makes it makes a
lot of sense because those olderage groups are more likely to be
further away from their vaccine.
And they're more likely tosuffer the severe effects from
COVID-19 anyway, and they'remore likely to have less durable
immunity in the first place.
And so vaccinating those agegroups with a third dose makes
(22:56):
an awful lot of sense.
And I do think that we willprobably approve a third dose
for everyone at some point, but.
Necessarily think that the timeis now.
And I think it still makessense.
You know, we, we have a hugeabundance of vaccines in this
country, but.
The other thing that we'vetalked about in the last
episode, I think, and that hasbeen factoring into a lot of
(23:17):
these decisions is that, youknow, how do we balance giving
third doses to our own countryversus trying to provide
vaccines for the rest of theworld?
And I think that's reallycritically important too,
because.
Vaccination rates in a generallymore wealthy countries are much,
much, much higher than in othercountries who aren't able to
afford the doses or who weren'tas quick to the, you know,
(23:40):
securing the doses or whatever,where distribution is more
difficult.
And so I think that there's, youknow, we have to put in a really
big effort to make sure thatwe're providing doses to those
countries as well.
And that's even in our nationalinterests, you know, we, we
really.
Prevent the spread of COVIDacross the world because that's,
what's going to keep newvariants from emerging.
And that's, what's going to keepinfection from spilling back
(24:02):
over into the United States.
So from a humanitarianperspective, from a nationalist
perspective, from all of theseperspectives, that makes a lot
of sense to raise vaccinationrates around the world.
And so I think it's actually avery good choice to still
protect the people who we knowto be most vulnerable, but for
right now, to really focus ondistributing vaccines around the
world and to do those thingssimultaneously to really throw
(24:23):
our weight behind both.
And I think that's a reallyinteresting and seems to me like
a very good way forward to that.
Both the scientific data, butthen also sort of the social
responsibility and this longview forward for where do we
want to be in this pandemic inthe next six months?
It seems to really integrate allof those things in a good way.
So I was, I was pleasantlysurprised.
Matt Boettger (24:46):
Great.
Yeah.
Can you help make sense?
You know, you know, I wasthinking about, okay, the Biden
administration.
They advance boosters foreveryone, you know, to me, I
could, I could logically thinkthrough why Biden would want to,
and this administration wants toadvance the cause of that.
Right.
There's I won't get into that.
Right.
That's the gets into thepolitics.
Sure.
(25:07):
But what I want.
Fast adviser as Fowchee kind ofbacking Biden.
Who's he's, he's the scienceguy, right?
So he seems to be at odds withthe FDA.
And he still seems to be like,kind of answering the cause of
he still wants this to happen.
Can you help make sense of thisin light of it?
You know, it may be, it justreveals the fact that.
(25:28):
The data really is complicated,you know?
Cause I, you know, I see in thatAtlantic article, they read
about how we know one reason whynot to advance boosters for
everyone is because of aparticular demographic age
demographic.
Because when you look at theteenage people who, who they're
in very rare circumstances cansuffer from what like
(25:49):
myocarditus.
Here's pericarditis, which Ididn't know about.
I don't know the difference.
Maybe you can, if you know thedifference, you can talk about
those two.
I have no idea, but this toexist.
Yeah.
We need mark desperately.
So these, these two thingsexist.
So they're like, well, it maynot actually be worth the costs
given how little they'resusceptible already and they've
already been vaccinated twice.
So there is these kinds ofsituations.
(26:11):
So is that's where FDS reserved,but then here's Fowchee is still
really advancing.
Is there, what's the sciencebehind staying in that
direction.
Yeah.
So
Stephen Kissler (26:21):
I think in my mind, a lot of what's going on
here is really just a questionof time.
So I think the, you know, theagain, I, I imagine that
probably within the next sixmonths to a year, that third
doses will probably be approved.
Across age groups, because atthat point, you know, we'll have
had more time for those agegroups in their immunity to
(26:41):
weigh in and we'll have moredata and information.
We'll just have more informationavailable to make a really sound
decision about that.
I know that with Dr.
Fowchee, a lot of his sort of,Well, it seems like the reason
why he is throwing his weightbehind this idea of boosters for
all is because it really, thequestion there comes down to you
know, resources, like what, whatare the resources we have
(27:03):
available?
And he's very convinced thatthis both and approach of.
Providing third doses for peoplein the United States and
providing doses for peoplearound the world is feasible.
That, that we could enter intothis false narrative of
scarcity.
When in fact there is none andthat, you know, we can, we can
argue about, well, do we do oneor the other, you know, are we,
(27:26):
you know, stealing doses awayfrom the rest of the world?
If we vaccinate people here Andyou know, who better to know
what these numbers are then him,you know?
And he, he seems to believe thatlike, well, no, there's, there,
there is actually no narrativeof scarcity here that and, and
we can do, we can easily do bothat the same time.
We can throw our weight behind.
And I think that's a reallycompelling argument, you know?
(27:46):
But it also makes sense to methat an organization like the
FDA who is ultimately, you know,they're the ones with whom the
buck stops with these decisions.
They're ultimately responsibleand it would make sense to me
that they would want to treadslowly.
I think it's true that for thosewho are under 65 and don't have
co-morbidities and are notfrequently exposed to COVID-19
(28:08):
and already have, are fullyvaccinated against COVID-19 that
the risk of hospitalization anddeath from COVID is now.
Not that much different frommany other risks that we bear in
our day-to-day life.
And that's really what they'retrying to evaluate is like, how
does this risk stack up in otherrisks that we accept every day?
(28:29):
Yeah.
And so that seems sound to me.
And again, I think that therewill come a time when it makes
sense, you know, of course therisks that we face in our day to
day life compound.
So, you know, we might have.
Risk from flu and a risk fromCOVID on a risk from tetanus and
a risk from all these otherthings.
And we don't want those to addup too much.
So it makes sense to introduce athird dose at some point to
(28:51):
reduce that risk.
But right now I think that it'sa totally sensible choice to
say, like we've got plenty ofdata to know for sure that a
third dose for people over theage of 65 makes a lot of sense.
Absolutely.
I think we can wait a little biton, on, on approving it.
It's sort of, you know, justpushing the decision down the
road a little bit.
And again, I really want toemphasize that there is a lot of
(29:15):
room for reasonabledisagreements, amongst people
who are very well-informed onthis.
This is even putting me at oddswith some of my own very
well-respected colleagues whohave been really pushing for
either a third dose or who hadbeen pushing for it and not
giving third doses to anyoneuntil everyone in the world.
So.
So I'm sort of threading thismiddle ground, which it seems
(29:36):
like the FDA has chosen to aswell.
But I just also want toemphasize that this is, you
know, this is just one youngepidemiologists perspective and
there's a lot of there's a lotof room for discussion out
there.
Matt Boettger (29:47):
Yeah.
This is an insensitive probablykind of way to say things
because of when I was a child,when you mentioned Fowchee
saying maybe it's notnecessarily either or, but both
hand, it kind of reminds me oflike when I was a child, And
yeah, I definitely heard from mygrandma when I was eating dinner
and I didn't finish my plate andshe would always use the flame.
Well, they're starving people inAfrica.
Right.
(30:07):
And so somehow that's supposedto make me eat my plate because
you know, some of that, there'sa relationship between the two
and it's and it's really, it'snot a relationship directly
between whether I eat my peasand whether the somebody who's
fed, you know, it's just kind ofa way to, like, I think that's a
similar kind of reality withwith, without you saying, like
it's not necessarily.
By taking a mercy in an articleby this, by take, by receiving
the vaccine in the U S doesn'tdeprive someone in somebody
(30:32):
it's, it's much more complicatedscenario that you have to work
with in policy that actuallyneeds to be addressed to be able
to provide these.
So, you know, one thing I wantedto drop on.
Unless you have anything elsethat you want to share, that
that peaks your interest.
We didn't talk about this, but Ifigured this might be an
interesting topic if you knowanything about this, because
since right now, I feel as ifthe variants are kind of at bay
(30:54):
right now, there's not like, atleast, at least in the
mainstream.
We're not talking about, I'msure all you scientists are
studying all these littlevariants on a small level and
seeing where they're going andhow they're.
But I remember seeing thisarticle about three months ago,
maybe two months ago about us,isn't prepared to track COVID
variants as Delta mutationspreads.
Right?
(31:14):
So now it's all over this.
This was back in probably may.
Have you heard anything talkedabout your colleagues about what
the us has done or been tryingto cultivate to be maybe like a
front runner, kind of like theUK on really being able to see a
variance in the context of theus and, and it starts kind of
scoping them out before they gettoo large.
Stephen Kissler (31:36):
Yes, we're, we're making progress on it.
Slow and steady progress, butprogress, you know, that's I, in
many ways, you know, especiallyearly in the pandemic, you know,
frankly, the UK has run circlesaround us in terms of their
genomic surveillance for thisepidemic and, you know, kudos to
them for that they've and a bigpart of that is just you know,
there were some very clearpolicy and funding decisions
(31:58):
where.
They're public health regulatoryagencies decided that that was
actually an important thing todo.
And here, you know, some similarproposals were advanced and
ultimately decided, well, wedon't actually need those as
much.
And so now that led us to thesituation that we're in, where
we're kind of trying to catchup.
Now a lot of the sequencing anda lot of the genetic
surveillance that is being doneis still being done.
(32:18):
At universities and in localpublic health agencies.
So like for example, the NewYork city department of health
and different universities aresort of acting as the sequencing
hubs for their regions currentlyin doing a lot of the sequencing
and analysis and epidemiology totry to figure out what's
circulating and where and thatThat's fine, but definitely
(32:41):
having an integrated platformand, you know, agreement about,
you know, who's doing what alittle bit better distribution
of labor there makes a lot ofsense.
And so that's something thatwe're moving towards.
So that is going to be one ofthe key.
Goals.
I believe of this new nationalcenter for outbreak analytics
that's being started and isactually going to be led by mark
(33:03):
Who's one of my very closecolleagues and mentors here at
the school of public health atHarvard.
And so I think that's going tobe one of their first and
central efforts is, is trying tofigure out how they're going to
make a national responsiveplatform for Genetic outbreak
analytics in the United States.
So, but that's, you know, westill have some time it's going
(33:25):
to take a while to build thatinfrastructure, to build the
sort of organization that weneed for that kind of thing.
So it may still be some timebefore we build up that
capacity, but it's, it's movingin the right direction.
It's something that.
Just about every epidemiologistis thinking about right now.
And so, yeah, so we're, we're,we're racing to to get it to get
that sort of thing put together.
(33:45):
It'll come, it'll take sometime, but it'll, it'll get
there.
Matt Boettger (33:47):
Yeah.
And I didn't even know thisexisted, so I don't know if you
have any information you couldput in the show notes or links
to this new research or whateverwith mark at the head of it.
And just, if he wants to followup, see what's going on, see
their first kind of seeds ofmovement.
I'll try to put in the shownotes if Stephen can share.
Great.
I think that's it for, fortoday.
We're good.
I hope.
You guys have a wonderful week.
(34:09):
We'll see you guys yet.
Our Dar normal every two weeksuntil things change, you want to
leave a review, please do applepodcasts.
We love to see them.
It inspires us to want tosupport us patrion.com/pandemic
podcast for monthly donations orjust a one-time gift PayPal,
then know all you can find inthe show notes, as well as some
of the articles we discussed foryour reading.
(34:31):
Pleasure.
Have a wonderful time.
We'll see you guys in two weeks.
Take care and.
You're listening to the pandemic podcast.
We equip you to live the mostreal life possible in the face
today's crisis.
My name is Matt Boettger and I'mjoined with my one good friend,
Stephen Kissler, anepidemiologist at the Harvard
school of public health.
How are you doing buddy?
Stephen Kissler (00:13):
I'm doing all right.
How are
Matt Boettger (00:14):
you?
It's good.
You know, it's, you know, doingthis two week thing, it feels
like it feels a little bitlonger, you know?
So, it's good to see you again.
It's great to see ya.
And suddenly we got some stuffto chat about.
It's, it's kind of nice, youknow, to do every two weeks.
I know some of our listenersprobably would like to every
week, It gets a little more timeto breathe and kind of see
what's going on in the wholeCOVID spectrum, because now
(00:37):
somethings, sometimes thingschange really quickly and it's
in a week, but other times ittakes a couple of weeks to kind
of really see what's the wwhat's really, really making
headlines and what really needsto be talked about.
I think these two weeks havehelped to frame a couple of
things that I want to share.
With you to see what's going on,but first, just to hear what in
your neck of the woods, youknow, now that you were saying a
(01:00):
couple of things, what you'vebeen doing and the past two
weeks, what you've been workingon over there at at home.
Stephen Kissler (01:05):
Well, yeah, so we've been doing some you know,
a lot more modeling, so, youknow, different organizations
are really interested in justsort of how to keep their
clientele safe.
As we're going into the winter,as we're starting to think
about, you know, Yeah, just whatsorts of testing do we need?
It's, it's really interestingbecause I think that a lot of
these questions have become alot more nuanced.
Both as the technologies haveadvanced as our understanding of
(01:26):
the virus has advanced.
And I think a lot of thequestions have shifted from is
this safer?
Is it not?
Or Do we need to test or do weneed to not, and now it's more
like, so we have this manypeople who are vaccinated and
this many who aren't, but theywere vaccinated this many days
ago.
And these are the vaccines thatthey were vaccinated with.
And some people we know, andsome people we don't and there
the different types of teststhat we have available, and we
can do it this frequently withthis type of test.
But it, it, it keeps me.
(01:50):
Well employed for one and that'sgood.
And on my toes so it's been sortof fielding a lot of those kinds
of questions on differentlevels.
So it's been good, challengingman, busy, the
Matt Boettger (02:00):
same good, the same epidemiologists.
Stephen Kissler (02:03):
And so I'm pretty excited to be less
famous, but
Matt Boettger (02:06):
I I'm sure.
I know.
Well, you know, you mentionedwinter and so let's start with
this.
It's a bit on my mind.
Maybe only like may seven daysreally, because I think my wife
brought it, brought it up to me.
I'm like, oh yeah.
Like she was like, what do youexpect to winter to be, you
know, you know, she's asking meas if I'm a qualified person,
but she just says, I have, Ihave the gateway to asking these
questions to you and mark.
So, you know, so I'm gonna throwmy scenario and then I want the
(02:30):
actual informed person you toactually talk about.
What you might expect about theupcoming months.
I know we've done all thesecaveats of you are not a
magician.
You can't see the future.
And when it comes to viruses isway unknown.
But given what we know, so thisis what I'm thinking, Stephen
I'm.
Okay.
All right.
A couple of things have beenhappy in my mind.
I follow the news about everycouple of days or maybe about
(02:52):
every day, at least for five or10 minutes and clips some
articles, and I've seen apattern.
I haven't seen a lot ofinformation on headlines about
other variants.
Whereas say a month, six weeksago, eight weeks ago, there was
a number of headlines talkingabout other variants other than.
So I'm thinking, huh?
I wonder what that is.
(03:12):
We've talked about how Delta isjust way more intense it's, you
know, at least two times morecontagious.
And so it seems to be a strongforce among variants.
So, so I'm thinking, you know,is there going to be another
variance like, or, or as Deltagoing to keep things abate?
I have no clue, but it seems tobe right now holding strong,
which for me is a great news.
(03:33):
I mean, for a number of reasons,Yes, because there's not new new
variants, but because Delta isincredibly more contagious, but
not necessarily thatproportionate in how worse it
is.
Right.
It's so I would rather have asuper, highly contagious one,
roughly the same kind ofworseness whatever, you know
what I mean?
And so keeping those maybe moretraumatic mutations at bay,
(03:56):
right?
So the.
We're also seeing now in the U Sthat cases are starting to level
out to decline overall.
Right now we're seeing hotpockets here and there.
Someone at, oh my gosh, is thiswinter going to be like, just
like, as really slow burnanticlimactic in a good way.
Right.
As long as there's no variance.
So what are you thinking aboutwhat this winter might look like
(04:16):
in light of what we've seen sofar in the past two or three
weeks?
Stephen Kissler (04:20):
No, I'm, I'm glad you bring all of this up
because I think that You know,last year, last year, around
this time, or even a little bitearlier when we were talking
about the winter, you know, Iwas, I was pretty certain that
we were going to have a majorwinter search which we did end
up having.
And you know, that was based offof experience with previous
respiratory pandemics and someof the modeling that we had done
(04:41):
at the number of susceptiblepeople who were still in the
population.
We of course didn't havevaccines at that point.
And so, yeah, I, you know, the,the, the playing field has
changed.
And I am a lot less, I'm a lotless certain about what this
winter is going to look like asa result.
So one of the things and therewas a, there was a paper on this
(05:03):
by by some colleagues.
So I really highly respect lastyear.
But it also matches up with justsort of my own epidemiological
intuition, which is that the.
Sort of this, this seasonalvariation and transmission that
we see where we see these realspikes in the winter and troughs
in the summer.
Is, it depends a lot on reallyjust sort of the baseline
(05:23):
infectiousness of the virusitself.
W which is basically the, youknow, if you have this virus
that sort of just on the knifesurge of, of transmissibility,
where the reproduction number,once you factor in behavior and
immunity, and all of thesethings is right around.
Then these subtle changes in theweather and how frequently
people spend time indoors and soon is really enough to sort of
(05:45):
shift the virus on one side orthe other of that threshold.
And that's what gives us thisseasonal change in transmission,
but for something that's a lotmore infectious, you know, we
have this Delta.
Variant where you know, we thinkthe reproduction number is like
on the order of six to eight ina, you know, in a you know, in a
population with no immunity andwhere everybody's mixing at a
normal rate, but that's, youknow, that's, that's quite a bit
(06:07):
more infectious than, than wethink flu is.
And the result of that cansometimes be that these seasonal
variation in transit.
Sort of gets damped out.
It's sort of overwhelmed by justthe inherent contagiousness of
the virus.
And, and I think that's, that'spart of why we saw so much
spread this summer because theseasonal damping effect that we
normally see in the summer justwasn't strong enough to.
(06:31):
Really do much to suppresstransmission of this, of this
highly infectious variant.
And so then I think, you know,the question becomes, you know,
what do we expect to see thiswinter?
And it could very well be thatwith high vaccination rates with
lots of spread over the courseof this.
That we might actually not seeas much of a winter surge as we
might've expected with previousvariants.
(06:53):
I think that's possible now.
I, I do still expect to see abit of a surge, especially in
places that have colder weather,where people are going to spend
a lot more time indoors.
I do think that keeping controlof the virus this winter,
especially, you know, up here inthe Northeast is going to be a
lot harder this winter.
And I do expect to see spikes incases up here.
But I am hopeful that it's notgoing to be.
(07:13):
As disruptive as last winter'ssearch was in large part due to
vaccination and due to exposureand all of these different
factors playing into it.
So I don't think that we'll ableto be able to totally avoid this
kind of wintertime surge, butbut I, I know it's strange for
me, but I'm a little bithopeful.
You know, it the, that it mightIt might be a lot less
disruptive than it could havebeen otherwise.
(07:35):
So
Matt Boettger (07:38):
great.
You know?
Yeah.
Again, I mean, not that I wantto be thankful for the amount of
transmission in the summer andcases, that seems to be
potentially to our advantagethat Delta raised locally head
around, you know, April, may,June kind of, you know, again,
allowing it to be not quite asintense, right.
(07:59):
I, even though hospitals wereoverwhelmed still, if I'm not
trying to make light of somereally particular hard states.
Yes, but I could have onlyimagined if that was December or
January.
Now I get it.
Florida's a little bit differentif you were saying how you know,
they're kind of more in theinside during the summer months
because it's so just crazy hotand humid and maybe in the
(08:20):
winter they're more outside.
So that could, it could causeit, so, before we continue on, I
forgot to mention this becausewe always say a couple intro
things that love reviews.
We've got two that came in thisweek.
I'll read this.
This is from will 6, 1 9 6happened on Thursday.
Love the podcast.
Great way to stay up to date onthe, on the latest pandemic
(08:40):
info.
I'm an RT in this podcast is agreat way to keep up with the
newest variants treatment invaccine.
Thank you.
Will the 61 96 and thenSeptember 12th, squids 1, 1 12.
I love these.
Helpful and quick knowledge,love this podcast to get instant
info on the pandemic as we learnmore together, super helpful and
straight to the point.
Thank you.
(09:01):
All of you for leaving reviewshelps us and inspire.
Keeps us going.
So I want to do that.
If you wanna support us in anyway as little as$5 a month,
patrion.com/pandemic podcasts,or just a one-time gift PayPal,
then Mo all in the show notes.
Okay.
I got the other way we cancontinue to move forward as I
get back to my screen, it wentaway.
(09:22):
Okay.
So the next thing I want to talkabout is let's just go straight
to the vaccines.
Cause there's a lot ofinformation when talking about I
want to get to the boosts.
For sure.
And let's talk about, you saidthere's some news that dropped
to this morning that I wasn'taware of speaking of vaccine
with.
We want to share that.
Yeah.
Stephen Kissler (09:36):
So it seems like, what Pfizer has just
announced this morning is thatthey now have safety and
efficacy data for, I believeit's five to 11 year olds.
So this is sort of the next agegroup down from who the vaccine
is currently approved for.
I believe it's a smaller.
Then what's normally given toadults, which is pretty standard
for pediatric vaccines.
And yeah.
(09:58):
I haven't seen the data yet.
I don't think that they'veactually released those data
yet, but they say that it looksgood.
So I'm looking forward toreviewing it.
And and I imagine, you know, if,if it does bear out, then, then
we, we could start to see someregulatory changes relatively
quickly.
I wouldn't be surprised if westart to see vaccine approvals
for those age groups.
And the coming month or so, so
Matt Boettger (10:18):
great.
That's awesome.
And then let's just continue onthe heels of this.
You said there was a piece ofinformation as well.
New news that may drop later ontoday or tomorrow it's related
to kind of the vaccines, it'sall about safety and, and, and
reduce the level of mortality.
But you said there's kind of ainteresting statistic that might
be making headlines soon.
Stephen Kissler (10:37):
Yeah.
So, I was speaking with somejournalists over the weekend and
sort of talking about.
What's going to be coming up.
And there's, there's a reallysignificant threshold.
Unfortunately that we're aboutto cross.
And that is that the the numberof deaths in the United States
is about to pass 675,000.
The number of recorded deathsfrom COVID-19.
(10:57):
And that's significant becausethat is the same as the best
estimate of the number of deathsthat we suffered in the U S
during the 1918 flu pandemic.
So that's, you know, even justfrom a cultural and social
significance point of view, youknow, that's, that's, that's a
big deal.
Now of course, in in myconversations this weekend, I
was talking about a lot of thesethings too.
There are, there are a ton ofreasons why.
(11:21):
We need to interpret thesenumbers in context first and
foremost, of course, is that theUnited States is over three
times as big as it was in 1918.
So on a per capita basis theCOVID-19 pandemic still has not
been as deadly as the 1918 flupandemic.
And you know, furthermore, aswe've talked about in a number
of episodes since the questionof mortality data is, can be a
(11:43):
really sticky one in the sensethat you know, what, which,
which deaths do you actuallyattribute to COVID?
So there, there may be someundercounting, you know, or
there may be some over countingin some contexts, but there's
almost definitely a lot ofundercounting as well, because
we've seen these huge spikes inexcess mortality.
But really surpassed theofficial counselor COVID 19, but
(12:05):
also, you know, that wasprobably in play even more so
during the 1918 flu pandemic,because there really weren't
these national robustcrosschecked data streams for
mortality data.
Then either a lot of ourestimates come from sort of
these rough estimates that we'reextrapolating from certain
populations.
And certainly.
(12:26):
Minority populations at the timewere not counted in any sort of
rigorous way in the mortalitycounts either.
And we're doing better at thatnow, but still not perfect.
And you know, so, so therethey're all of these issues, but
but nevertheless, I think thatit's, it's a significant
threshold to cross.
And I think that we're probablygoing to be hearing a lot more
about that.
Matt Boettger (12:46):
Yeah.
Now, if you're new to our show,how do you know which episode
this was?
We've talked about a couple oftimes mark and Stephen, when
they were both on that, it wasnew to me.
Early on there was all of thiskind of misinformation about
like conspiracy is about overcounting deaths.
As COVID.
Now I'm not saying there's notabuse.
I w I'm sure there could be a,you know, I'm sure there's some
(13:08):
abuse in some level on COVIDdeaths, but in general, It just
really positing the difficultyin, you know, the nature of our
show.
It's okay.
It's, it's complicated.
The complexity of actuallydetermining the cause of death.
And this is not just strictly aCOVID issue.
You bring mark back on here andhe'll definitely tell you about
how it's just not straight orit's not like a little like know
(13:29):
algorithm you just put in and itjust tells you, there's just,
you know, there's narrative andthere's context.
And, and so it's a complicatedreality that, that, that this
makes things harder.
Not conspiracy, just part ofhumanity.
So the complexity of humanity,now let's get into this vaccine
and I'm trying to find a way tohow I could maybe weave this
(13:51):
into one discussion because wehave vaccine to discuss in
general, right?
Just Medina it's, you know, youknow, just hitting the topics
like its efficacy being strongerthan Pfizer.
We can talk about that, butmaybe the context, and then we
talked about immunity.
And how that works and thewaning immunity in light of when
(14:12):
you might need a booster andthese kinds of things.
So let's maybe let's make theanchor point, this Israel study.
So that might be a revolving wayfor us to see it everything.
So if you're not familiar, therewas a study done in Israel.
Credible about really suggestingthat there is a significant
Wayne and ethicacy inparticularly the Pfizer.
(14:33):
What kind of thing thatdominated Israel?
I mean, that's the one they usedthe Pfizer vaccine you know,
down to maybe even like 40 to50% effective when it comes to I
think hospitalization or the Iforgot what that was, but
something you can correct me onall these stats.
I'm just general.
But pretty significantly low 40,50, 60% on, on, on those kinds
(14:54):
of things.
So.
This has been circulating,suggesting that, oh, we should
really advance a cause of abooster, right?
Because if that's that dramaticnow, you know, Biden and the
administration advance for abooster for everyone, FDA just
came out, you know, kind ofcountering and say, no, that's
more nuanced.
Let's do that for 65 or older.
(15:15):
Those who are at severe risk.
And I heard, they just releaseda third tier that's basically
health workers that are likethat, that are in constant
contact.
Those kinds of three, threegroups.
So we're seeing this kind offight of what should we do?
Should we get a booster?
Is Pfizer really not effective?
Now we've got to pull inimmunity and waning and these
kinds of factors in this greatarticle I've put in the show
(15:37):
notes, please, please, pleaseread it as body Atlantic waning
immunity is not a crisis rightnow.
And to put it in there about howfi you know, Pfizer also had.
Really suggesting that there'swaning immunity, there's
antibody reduction significantlywithin the Pfizer vaccine, maybe
after six months, eight months,these kinds of things.
And maybe you can help us sortall this out when it comes to,
(16:02):
again, like last week,antibodies are not the sole
reason that w the solemeasurement of whether we have
strong immunity.
And, and really kind of helpedus go through the T-cells B
cells antibodies in what youthink in the end, let them all
this craziness.
What is your suggestion when itcomes to.
(16:23):
Efficacy
and
Stephen Kissler (16:24):
boosters.
Yeah.
Yeah.
So let's let's try to break thisdown.
You know, and this is somethingthat that's you know, as, as
this introduction or the eldestis complex and it's something
that, you know, even we,epidemiologists are trying to
wrap our heads around in there'sa lot of disagreement or at
least, you know, very vigorousdiscussion about, you know, sort
(16:44):
of what, what the right pathforward is because it does play
into, you know, there are these.
Biological physiological,epidemiological considerations,
but also social considerationsconsiderations to justice
considerations to equity safety,all of these things are really
factoring into this and thatthis is a pretty sticky
situation.
So right.
So we have the vaccines, we, youknow, some of the story that's
(17:05):
starting to emerge is all right.
So it seems like the efficacy ofthe modern vaccine seems to be
holding up a little bit morestrongly than.
Both of them seem to be holdingup more strongly than the
AstraZeneca and the Johnson andJohnson.
And so now there are a lot ofquestions as to what do we do in
this context.
So as you mentioned, this studyfrom Israel is one of the best
(17:26):
that we have to date on, youknow, clear.
Numbers regarding the sustainedefficacy of these vaccines in a
real setting, which is really,really what we're after.
You know, we can measureantibodies, we can measure sort
of, you know, levels of immunityin the blood.
But all of those things arereally just proxies for what we
(17:47):
care about, which is, am Iprotected from infection?
Am I protected from symptoms?
Am I protected fromhospitalization?
And am I protected from dying?
Given vaccinations.
And the study from Israel reallydid see a pretty clear evidence
of waning immunity.
The biggest declines in immunityyou know, looking at these
different tiers it was of coursein symptomatic disease of any
(18:09):
sort of showing any sort ofsymptoms.
And I think that's where we sawthe sharpest declines.
Efficacy against hospitalizationand deaths remained high, but
was definitely lower.
I think, I don't know if itquite reached down to that 40%,
but I, I think it was still, youknow, probably on the 60 to 80
level, which is, which is lower,you know, definitely lower than
we were seeing with early on in,in as these vaccines were first
(18:31):
being rolled out.
And so that's, you know, that'sthe first thing that sort of
perks up your ears and it makesyou want to learn more.
So what's going on here?
Well, you know, first of all, wewaning immunity whether to
natural infection or to avaccine is totally natural,
happens all the time.
Really?
The outlier is things that weget permanently immunized to.
(18:56):
So things like measles and tosome extent like varicella,
which causes chickenpox, youknow, Viruses in particular that
basically you get exposed tothem and by, cause you know,
they give us lifelong immunity.
Yeah, that's pretty rare.
You know, you can think aboutall sorts of other infections,
whether it be RSV or flu ortetanus you know, not naturally,
(19:16):
hopefully you're not beingnaturally infected with tetanus,
but, but we have to get boostersevery 10 years, right.
To keep up our immunity, totetanus for the same reason that
our immunity wanes it declinesover time.
And it seems like for thecoronavirus vaccine and for
natural infection, that seems tobe the case here as well.
As you mentioned this Atlanticarticle really you know,
describes this in a good way.
You know, w we can ask thequestion, like, why does our
(19:39):
immunity weigh in?
And part of that is because ifwe, if we kept these really high
levels of immunity to everythingall at once, there's just not
enough space in the body for allof those cells to keep
circulating.
And so, so it has to decline.
And so really what our body hasis this memory that allows us to
Mount a good response quickly.
But that response gets betterand better.
The more we get exposed to avirus.
(20:01):
And so, so the question thatwe're trying to answer now is
how many exposures do you needand how does that depend on the
vaccine that you've gotten andreally critically on how old you
are, so that it brings in anextra layer of complexity into
this study from Israel, which isthat the they really focused on
vaccinating the oldest membersof their society first and sort
of worked down the age group.
(20:23):
The people we have the mostinformation about right now on
waning immunity as for the mostelderly.
Now in this study, they didbreak down by age group and they
actually did show that inyounger age groups, it seems
like the immunity is bettersustained than an older age
groups.
That's also a very well knownphenomenon across epidemiology,
which is that frequently.
You know, we, we have just like,we have a physical age, we also
(20:45):
have an immunological age.
And that correlates with ourability to.
Mount a good and effective andsustained response to things
that we've been exposed to.
So oftentimes when people areolder, They need a higher dose
flu vaccine, for example, orthey need boosters more
frequently against thepneumococcal bacteria.
(21:05):
And so this is, this is alsovery consistent.
And I think that what we'rebeginning to learn now is, you
know, not only do we needboosters, but also who needs
boosters and why and howfrequently.
And so all of that is sort ofwhat the study from Israel is
starting to inform.
That then brings us to some ofthe FDA decisions that that we
heard over this past week.
So for a while the white househas been saying, you know, we
(21:29):
want to approve boosters acrossthe population, basically, as
soon as the FDA gives us thegreen light and seems to really
have been pushing for that.
So the FDA came back with reallyinteresting decision, which was
that?
Well, actually, actually, no,we're not, we're not going to
recommend boosters for.
Because the the data justdoesn't really suggest that for
(21:50):
people under the age of 65 whoare healthy and have no other
comorbidities and aren't exposedto high levels of the virus that
they're actually going to havemuch of a benefit right now from
a booster relative to theprotection that they already
have no getting a booster willactually provide, you know, it
will absolutely provide greaterprotection for those age groups.
But we have to remember thatthose age groups are on average.
(22:13):
Closer to their finishing theirvaccine.
So, so, people like me are morefreshly vaccinated, you know, my
I already have higher levels ofantibodies in my system than
people who were vaccinatedearlier and I'm younger.
I got walloped with the seconddose, you know, and so I don't
know if that actually correlatesto the level of protection that
I have, but I can guarantee yousomething happened and I, you
(22:35):
know, there's and so.
So I think that this, thisdecision is actually interesting
and based off of the data wehave available makes it makes a
lot of sense because those olderage groups are more likely to be
further away from their vaccine.
And they're more likely tosuffer the severe effects from
COVID-19 anyway, and they'remore likely to have less durable
immunity in the first place.
And so vaccinating those agegroups with a third dose makes
(22:56):
an awful lot of sense.
And I do think that we willprobably approve a third dose
for everyone at some point, but.
Necessarily think that the timeis now.
And I think it still makessense.
You know, we, we have a hugeabundance of vaccines in this
country, but.
The other thing that we'vetalked about in the last
episode, I think, and that hasbeen factoring into a lot of
(23:17):
these decisions is that, youknow, how do we balance giving
third doses to our own countryversus trying to provide
vaccines for the rest of theworld?
And I think that's reallycritically important too,
because.
Vaccination rates in a generallymore wealthy countries are much,
much, much higher than in othercountries who aren't able to
afford the doses or who weren'tas quick to the, you know,
(23:40):
securing the doses or whatever,where distribution is more
difficult.
And so I think that there's, youknow, we have to put in a really
big effort to make sure thatwe're providing doses to those
countries as well.
And that's even in our nationalinterests, you know, we, we
really.
Prevent the spread of COVIDacross the world because that's,
what's going to keep newvariants from emerging.
And that's, what's going to keepinfection from spilling back
(24:02):
over into the United States.
So from a humanitarianperspective, from a nationalist
perspective, from all of theseperspectives, that makes a lot
of sense to raise vaccinationrates around the world.
And so I think it's actually avery good choice to still
protect the people who we knowto be most vulnerable, but for
right now, to really focus ondistributing vaccines around the
world and to do those thingssimultaneously to really throw
(24:23):
our weight behind both.
And I think that's a reallyinteresting and seems to me like
a very good way forward to that.
Both the scientific data, butthen also sort of the social
responsibility and this longview forward for where do we
want to be in this pandemic inthe next six months?
It seems to really integrate allof those things in a good way.
So I was, I was pleasantlysurprised.
Matt Boettger (24:46):
Great.
Yeah.
Can you help make sense?
You know, you know, I wasthinking about, okay, the Biden
administration.
They advance boosters foreveryone, you know, to me, I
could, I could logically thinkthrough why Biden would want to,
and this administration wants toadvance the cause of that.
Right.
There's I won't get into that.
Right.
That's the gets into thepolitics.
Sure.
(25:07):
But what I want.
Fast adviser as Fowchee kind ofbacking Biden.
Who's he's, he's the scienceguy, right?
So he seems to be at odds withthe FDA.
And he still seems to be like,kind of answering the cause of
he still wants this to happen.
Can you help make sense of thisin light of it?
You know, it may be, it justreveals the fact that.
(25:28):
The data really is complicated,you know?
Cause I, you know, I see in thatAtlantic article, they read
about how we know one reason whynot to advance boosters for
everyone is because of aparticular demographic age
demographic.
Because when you look at theteenage people who, who they're
in very rare circumstances cansuffer from what like
(25:49):
myocarditus.
Here's pericarditis, which Ididn't know about.
I don't know the difference.
Maybe you can, if you know thedifference, you can talk about
those two.
I have no idea, but this toexist.
Yeah.
We need mark desperately.
So these, these two thingsexist.
So they're like, well, it maynot actually be worth the costs
given how little they'resusceptible already and they've
already been vaccinated twice.
So there is these kinds ofsituations.
(26:11):
So is that's where FDS reserved,but then here's Fowchee is still
really advancing.
Is there, what's the sciencebehind staying in that
direction.
Yeah.
So
Stephen Kissler (26:21):
I think in my mind, a lot of what's going on
here is really just a questionof time.
So I think the, you know, theagain, I, I imagine that
probably within the next sixmonths to a year, that third
doses will probably be approved.
Across age groups, because atthat point, you know, we'll have
had more time for those agegroups in their immunity to
(26:41):
weigh in and we'll have moredata and information.
We'll just have more informationavailable to make a really sound
decision about that.
I know that with Dr.
Fowchee, a lot of his sort of,Well, it seems like the reason
why he is throwing his weightbehind this idea of boosters for
all is because it really, thequestion there comes down to you
know, resources, like what, whatare the resources we have
(27:03):
available?
And he's very convinced thatthis both and approach of.
Providing third doses for peoplein the United States and
providing doses for peoplearound the world is feasible.
That, that we could enter intothis false narrative of
scarcity.
When in fact there is none andthat, you know, we can, we can
argue about, well, do we do oneor the other, you know, are we,
(27:26):
you know, stealing doses awayfrom the rest of the world?
If we vaccinate people here Andyou know, who better to know
what these numbers are then him,you know?
And he, he seems to believe thatlike, well, no, there's, there,
there is actually no narrativeof scarcity here that and, and
we can do, we can easily do bothat the same time.
We can throw our weight behind.
And I think that's a reallycompelling argument, you know?
(27:46):
But it also makes sense to methat an organization like the
FDA who is ultimately, you know,they're the ones with whom the
buck stops with these decisions.
They're ultimately responsibleand it would make sense to me
that they would want to treadslowly.
I think it's true that for thosewho are under 65 and don't have
co-morbidities and are notfrequently exposed to COVID-19
(28:08):
and already have, are fullyvaccinated against COVID-19 that
the risk of hospitalization anddeath from COVID is now.
Not that much different frommany other risks that we bear in
our day-to-day life.
And that's really what they'retrying to evaluate is like, how
does this risk stack up in otherrisks that we accept every day?
(28:29):
Yeah.
And so that seems sound to me.
And again, I think that therewill come a time when it makes
sense, you know, of course therisks that we face in our day to
day life compound.
So, you know, we might have.
Risk from flu and a risk fromCOVID on a risk from tetanus and
a risk from all these otherthings.
And we don't want those to addup too much.
So it makes sense to introduce athird dose at some point to
(28:51):
reduce that risk.
But right now I think that it'sa totally sensible choice to
say, like we've got plenty ofdata to know for sure that a
third dose for people over theage of 65 makes a lot of sense.
Absolutely.
I think we can wait a little biton, on, on approving it.
It's sort of, you know, justpushing the decision down the
road a little bit.
And again, I really want toemphasize that there is a lot of
(29:15):
room for reasonabledisagreements, amongst people
who are very well-informed onthis.
This is even putting me at oddswith some of my own very
well-respected colleagues whohave been really pushing for
either a third dose or who hadbeen pushing for it and not
giving third doses to anyoneuntil everyone in the world.
So.
So I'm sort of threading thismiddle ground, which it seems
(29:36):
like the FDA has chosen to aswell.
But I just also want toemphasize that this is, you
know, this is just one youngepidemiologists perspective and
there's a lot of there's a lotof room for discussion out
there.
Matt Boettger (29:47):
Yeah.
This is an insensitive probablykind of way to say things
because of when I was a child,when you mentioned Fowchee
saying maybe it's notnecessarily either or, but both
hand, it kind of reminds me oflike when I was a child, And
yeah, I definitely heard from mygrandma when I was eating dinner
and I didn't finish my plate andshe would always use the flame.
Well, they're starving people inAfrica.
Right.
(30:07):
And so somehow that's supposedto make me eat my plate because
you know, some of that, there'sa relationship between the two
and it's and it's really, it'snot a relationship directly
between whether I eat my peasand whether the somebody who's
fed, you know, it's just kind ofa way to, like, I think that's a
similar kind of reality withwith, without you saying, like
it's not necessarily.
By taking a mercy in an articleby this, by take, by receiving
the vaccine in the U S doesn'tdeprive someone in somebody
(30:32):
it's, it's much more complicatedscenario that you have to work
with in policy that actuallyneeds to be addressed to be able
to provide these.
So, you know, one thing I wantedto drop on.
Unless you have anything elsethat you want to share, that
that peaks your interest.
We didn't talk about this, but Ifigured this might be an
interesting topic if you knowanything about this, because
since right now, I feel as ifthe variants are kind of at bay
(30:54):
right now, there's not like, atleast, at least in the
mainstream.
We're not talking about, I'msure all you scientists are
studying all these littlevariants on a small level and
seeing where they're going andhow they're.
But I remember seeing thisarticle about three months ago,
maybe two months ago about us,isn't prepared to track COVID
variants as Delta mutationspreads.
Right?
(31:14):
So now it's all over this.
This was back in probably may.
Have you heard anything talkedabout your colleagues about what
the us has done or been tryingto cultivate to be maybe like a
front runner, kind of like theUK on really being able to see a
variance in the context of theus and, and it starts kind of
scoping them out before they gettoo large.
Stephen Kissler (31:36):
Yes, we're, we're making progress on it.
Slow and steady progress, butprogress, you know, that's I, in
many ways, you know, especiallyearly in the pandemic, you know,
frankly, the UK has run circlesaround us in terms of their
genomic surveillance for thisepidemic and, you know, kudos to
them for that they've and a bigpart of that is just you know,
there were some very clearpolicy and funding decisions
(31:58):
where.
They're public health regulatoryagencies decided that that was
actually an important thing todo.
And here, you know, some similarproposals were advanced and
ultimately decided, well, wedon't actually need those as
much.
And so now that led us to thesituation that we're in, where
we're kind of trying to catchup.
Now a lot of the sequencing anda lot of the genetic
surveillance that is being doneis still being done.
(32:18):
At universities and in localpublic health agencies.
So like for example, the NewYork city department of health
and different universities aresort of acting as the sequencing
hubs for their regions currentlyin doing a lot of the sequencing
and analysis and epidemiology totry to figure out what's
circulating and where and thatThat's fine, but definitely
(32:41):
having an integrated platformand, you know, agreement about,
you know, who's doing what alittle bit better distribution
of labor there makes a lot ofsense.
And so that's something thatwe're moving towards.
So that is going to be one ofthe key.
Goals.
I believe of this new nationalcenter for outbreak analytics
that's being started and isactually going to be led by mark
(33:03):
Who's one of my very closecolleagues and mentors here at
the school of public health atHarvard.
And so I think that's going tobe one of their first and
central efforts is, is trying tofigure out how they're going to
make a national responsiveplatform for Genetic outbreak
analytics in the United States.
So, but that's, you know, westill have some time it's going
(33:25):
to take a while to build thatinfrastructure, to build the
sort of organization that weneed for that kind of thing.
So it may still be some timebefore we build up that
capacity, but it's, it's movingin the right direction.
It's something that.
Just about every epidemiologistis thinking about right now.
And so, yeah, so we're, we're,we're racing to to get it to get
that sort of thing put together.
(33:45):
It'll come, it'll take sometime, but it'll, it'll get
there.
Matt Boettger (33:47):
Yeah.
And I didn't even know thisexisted, so I don't know if you
have any information you couldput in the show notes or links
to this new research or whateverwith mark at the head of it.
And just, if he wants to followup, see what's going on, see
their first kind of seeds ofmovement.
I'll try to put in the shownotes if Stephen can share.
Great.
I think that's it for, fortoday.
We're good.
I hope.
You guys have a wonderful week.
(34:09):
We'll see you guys yet.
Our Dar normal every two weeksuntil things change, you want to
leave a review, please do applepodcasts.
We love to see them.
It inspires us to want tosupport us patrion.com/pandemic
podcast for monthly donations orjust a one-time gift PayPal,
then know all you can find inthe show notes, as well as some
of the articles we discussed foryour reading.
(34:31):
Pleasure.
Have a wonderful time.
We'll see you guys in two weeks.
Take care and.
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