July 21, 2021 • 45 mins
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Things Discussed on Episode:
- Delta Covid-19 Variant Is Dominant U.S. Strain, CDC Data Show
- House Speaker Pelosi rejects two GOP selections tapped to serve on committee investigating the Capitol riot. Watch CNN
- Fauci Casts Doubt on Study Suggesting Delta Variant Hit Pfizer COVID Vaccine's Efficacy
- Top health expert says vaccinated people are spreading delta variant
- CDC warns Covid-19 vaccines might not protect people who are immunocompromised
- Going further than CDC, pediatricians group recommends masks in schools even for the vaccinated
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 mostlife possible Caymus hill
anymore.
It's been too long, likeliterally the faced with this
crisis.
That's out of my name is, butcouldn't join with not one, but
finally, two of my good friends,Dr.
Stephen Kissler andepidemiologist, the Harvard
(00:21):
school of public health.
Drum roll, please.
He came out of his cave at Dr.
Mark Kissler, a doctor at theuniversity of Colorado hospital.
That was phenomenal.
How's it going guys, guys.
Stephen Kissler (00:32):
It's great to see you.
It's been a long time.
Matt Boettger (00:34):
It's been for ever a mark.
What the heck have you been
Stephen Kissler (00:37):
doing?
I asked myself that too.
I think, I think it's it feelslike life has just accelerated
in in all sorts of domains.
And so a lot of work I've beenat the hospital a lot which has
been good.
And and then a lot of home stufftoo.
So it's just, yeah.
Yeah.
All
Matt Boettger (00:55):
over the place.
Yeah.
Stephen, your neck of the woods,like what's been going on with
you.
Stephen Kissler (01:00):
Alright.
Yeah.
Slowly transitioning back intosome of the work that I was
doing pre pandemic.
So I'm starting to think aboutthings other than COVID.
Even though we still have someCOVID related projects going.
So, but I like, it kind of feelslike in many ways, the summer
has been a bit of a reprieve inthat cases are a lot lower here.
I've gotten to just see morepeople even do a little bit of
traveling some good friends gotmarried this past weekend when
(01:22):
we got to go to the wedding.
And so it was just, takingadvantage of some of these
things that it's been a reallylong time since we've been able
to do so.
I'm grateful for that.
Yeah, that's still a strangeworld out there, but just trying
to transition back intosomething that reflects a little
bit closer to what what lifelooked like before.
Matt Boettger (01:40):
Yeah.
And I'm, I think this is goingto be the theme of today's, mark
was talking about this, he wastalking about it before we
started recording.
It's been a while for, it's beentwo weeks.
I think we just lost mark there.
So when he gets back, we'llwe'll chime him back in but it's
been two full episodes thatwe've been away from the
pandemic.
And we, we want to kind of checkin, talk about how things are
(02:00):
going for us.
And it's been just unusualbecause it's the summer and.
A sense of feeling like thingsare meant to be normal, but then
we have Delta and gamma andLambda and Epsilon.
I'm like the good news is I'mbeing reacquainted with my Greek
alphabet, which is, I think ifthere's going to be a win,
that's a win right.
For anyone.
(02:20):
So, I there's so that's, that'sbeen a really big, I guess, good
thing going on, but behind thatis a lot of questions of like,
what does normalcy look like?
Should we be doing.
And then there's like the, Ithink the sub narrative of like,
okay, well there's people whoare single and adults and some
are vaccine and some areun-vaccinated.
And then for me, thecomplication is when you have a
family and it's summertime and,under half of us are vaccinated
(02:43):
and the other half are stillwaiting to be vaccinated.
And what does it mean to live anormal life?
And so I just want to chat aboutthis for you guys.
Like, what does it mean for youguys to, because in my mind, as
we were kind of going from mayto June in the summer, sorry to
rev.
We were kind of asking ourselvesas a family, what do we do this
summer?
What do we want to do thissummer?
(03:03):
And we didn't, it was hard toknow what to do because there
was a sense of like, well, let'sjust wait.
I want to start with thisbecause that was a hard
question.
I'm like, well, if we'rewaiting, what are we waiting
for?
Because I'll have Stephen, Imight have you just chime in for
a second year, starting withthis because.
If we're looking for an intoCOVID, as we've been saying for
(03:24):
months now, I don't think that'sgoing to happen.
So that kind of wait, I thinkyou're stuck in your house
forever, right?
On the cover.
It's always going to be at somelevel part of the population.
And so this idea of moving tonormalcy needs a different kind
of measurement.
And so in light of what what'sgoing on with your discussion,
Stephen, what you guys have beentalking about, what does that
look like?
What he has been talking aboutthis idea of like moving towards
(03:46):
a sense of normalcy in the.
Of this kind of unknown of thesenew variants now with Delta kind
of dominate in the U S
Stephen Kissler (03:52):
yeah.
It's really tricky.
And I think we can, and I'm surewe will, over the course of this
episode, tackle it from, anepidemiological and a clinical.
And then also just like apersonal perspective, like what
all of this means, it's, it'sreally tricky because.
So one of the ways that I'vebeen thinking about this, right,
is that early on in thepandemic, one of the big reasons
why we were really emphasizingphysical distancing, flattening
(04:14):
the curve was the big thing.
And, and there were two reasonsfor that.
One of them was just to reducethe strain on hospitals.
The flatter, the curve, thefewer people get infected
overall.
And, you, you prevent, hugesurges from going to the house.
And we were trying to delay asmany cases as we could until we
had a vaccine.
And until we had effectivetherapeutics, right?
Like we're, as you really gain alot by pushing off infections to
(04:37):
a later date the landscape haschanged a lot and that's not to
say that, physical distancing,flattening the curve is no
longer important, but you know,we, we now have a vaccine we've
gotten a lot better at dealingwith COVID in the clinical
perspective.
And so, and so you're right.
We're transitioning.
A period where there was thisvery clear sense of a finite
waiting period to a sense where,COVID will be here with us for
(05:02):
the foreseeable future.
And that's, that's a reallytricky reality.
I know it's one that we've beentalking about throughout the
entire time we've been talkingabout this But that, that's
almost certainly the case atthis point and we can talk more
about epidemiologically, whythat's true.
But yeah, we're transitioninginto a time when, when we, as
individuals, we as societies,we, as epidemiologists, as
doctors, as teachers, as whoeverwe happen to be are thinking
(05:25):
about, what, what is our lifegoing to look like now that
SARS, cov two is going tocontinue spreading.
It's going to be with us.
It will probably be a wintertimerespiratory virus.
And that's going to meandifferent things for different
communities.
It's going to mean differentthings for different people.
And for those of us who arethinking about the epidemiology
and the clinical side of things,we're going to have to keep
innovating, trying to figure outhow to make this less and less
(05:45):
of a burden, but then also forindividuals, just like, how do
we navigate this?
As people, how do we renegotiateour risk of going out into the
world?
That was a very intuitive thingand the pre COVID era, but now
there's this new risk that sortof layered on top of everything
else.
How, how do we.
That we haven't really developedthe intuition to have a feel for
what that means.
And I think the story of thisnext year or two is going to be
(06:07):
reintegrating this new risk intoour intuitive sense of, of, of
what we're able to, to manage aspeople.
And that's going to be a reallydifficult thing to do cause
we're all going to go about itat a different way and in a
different speed.
Matt Boettger (06:21):
Yeah.
That's great.
Mark.
How about you?
Like w.
Dealing with idea trans she's anormalcy in the context of your
clinical work, but also as afamily man and working with
kiddos and that kind of stuff.
How's that been for you?
What's that look like?
Has Delta change anything what'sgoing on in your neck of the
woods?
Stephen Kissler (06:37):
Yeah.
It's kinda I just want to echo alot of what Stephen said.
I had a funny conversation witha colleague of mine, just as a
sidebar outside the elevatorsthe other day, who has been
really involved in our COVIDresponse.
Essentially what he, here we arehere we are, we're starting to
see this kind of cyclical thing.
That, that old article, the roadwas right.
And he was kind of bummed aboutit and we bonded for a moment a
(06:57):
bit like neither of us arereally all that happy to admit
that Stephen's right.
And, and yet I think there'sthis sense of amongst clinicians
is what does this mean?
Do we integrate COVID into ourregular medicine teams, just as
we take care of all sorts ofrespiratory viruses at the time.
And how do we, how do we startto think about COVID now that we
(07:20):
know a lot about it and we knowmore or less that it's probably
going to be here to stay?
Yeah.
Was there anything from apersonal standpoint, tricky one.
We've been doing a lot more,we've been out some traveling,
we'd go out, I've been, goingthrough our local stores rec
(07:41):
center and all these things andfeeling pretty good about it.
I think post vaccine with sortof a sense of how do we keep
each other in general?
And not being overly cautious.
I feel like there's a reallygood return to a certain what I
call maybe a local normalcy,certain ways.
And so that's, also there's,taking the kids out and they're
(08:06):
doing things and they've beengoing to school even during
parts of the pandemic, just maskup.
And and that seemed to go prettywell too.
We were fortunate that eventhough we all got COVID at one
point.
I think we we've been kind of ina, in a fortunate state where
we've been sheltered from someof the severe complications, at
least as a family.
I think it's tough.
I think for me the, as we figureout what, what do we do and how
(08:27):
do we get back into things?
There's this combination ofwhat's our ideal state.
And then what's kind of thereality that we face, and we,
we, we just have to kind of flexand know that sometimes we have
to do things just because we.
We need to do them, we need toget out, we need to reconnect
with family and, and thosethings.
So there's, this they're verymuch sort of a reality check in
the midst of all of this that'sthat's just constantly going,
(08:49):
the back of my mind.
Matt Boettger (08:51):
I've been in the same way.
Like, just kind oftransitioning, talking as a
family of what, which we shouldbe doing hesitancy because all
this, this E over a year of likesecluding ourselves in a house
and then the light switch comeson at summer.
And it's just, what I was hopingfor is just like black and
white, we're switched on.
We're ready to go.
And just not that way, we'retrying to transition back into
(09:11):
normal, seen what that lookslike.
And it's been, it's been kindof, it's been harder just to,
in, try and encourage our familyand my wife to be like, if
there's one time to begintransition.
It is now, right?
Because if you're looking for ameasurement, if you're looking
for some kind of quantifiablemetric to make you feel as if
this is a safest time for me totry to like get back in the
normalcy now is the time we'retalking.
(09:33):
I think off the, off the airthough, waiting until November,
if your skin is not going to beprobably the ideal situation,
because come November, there'sprobably going to be some kind
of resurgence of COVID nothinglike last year and that's going
to probably.
Raise some hair in the back ofyour neck and re you know, the
trauma of the year before andthe summer is a great time to be
in the transition.
So for us, it's been as ofrecently of slowly getting back
(09:55):
into the pool and go into thepool.
And it's been amazing.
We, one time we went to thepool, we got ice cream, like, oh
my gosh, this field.
Amazing.
I, I it's just to be with myfamily outside, going to a
store, getting ice cream, gointo a pool relaxing last week
we went to a restaurant grantedwe were outside and it was just
really wonderful to just kind ofbegin the transition.
(10:16):
I know it's hard for the familyand wife.
Cause right now we're, thelittle ones are unvaccinated.
I want to throw it back to you,mark, of just like, about
dealing with your kiddos and thefuture and with a Delta variant.
Is there any concern for you, inlight of that and when it comes
to the fall and the winter inlight of what you see with the
vaccine, the vaccines and itsefficacy, and some of them may
(10:37):
be the rare responses of heartinflammation with kids and that
kind of stuff.
Where are you landing right nowin the process come fall or
winter with the kids aboutgetting them vaccinated or not
vaccinated?
Where are you at on that?
Stephen Kissler (10:51):
Yeah, I I think there's a couple of things.
So, one of them is that it'sreally helpful for me to keep in
mind what Stephen was mentioningat the beginning, which is
what's our, what's our bigpicture goal here.
And really, yeah.
Hopefully we've stressed thisthroughout that of course, part
of the goal is to avoidourselves from getting COVID, as
much as possible, but reallythere's this secondary goal,
(11:12):
which is a bigger picture and alittle harder to grasp
intuitively, which is we'retrying to avoid being major
vectors in a dangerous andvulnerable time period, because.
As the evidence has shown timeand time again, that there
though there are very severeinsignificant manifestations in
kids in general, compared to allcomer respiratory viruses, this
(11:34):
is a little bit less of athere's less morbidity amongst
the younger population.
And I think that's important toremember because, what's, what's
our goal here.
And so as we're thinking about.
I think relative risk ofreentering life and, having our
kids be able to do the thingsthat are important for their
development.
Not just like recreation, butjust like be involved in, in our
(11:54):
community, in important ways.
I think that that's helpful forme.
Does that make sense?
think it, because again, I thinkthat we can get into it replace.
If the number one goal is alwaysjust to avoid like me getting
infected and it's a little bitfreeing in certain ways as we
kind of think like, okay, what'sthe, what are we trying to do
here?
And where are we at in theoverall pandemic in terms of our
(12:16):
need to flatten the curve?
Our concern for these vulnerablepopulations to, to what degree
are they being protected by?
The things that have been putinto place up until now.
So as I think about, I, I thinkthat I'm going to make the same,
use the same kind of paradigmaround decision for vaccinating,
my kids as I did, with myselfand as I recommend with my
patients, which is, we're gonnalook at the evidence which.
(12:39):
So far to date has not shown atremendous downside to vaccine.
And in younger people, therehave been, there have been a lot
of reports and a lot of certainmedia coverage of like a
myocarditis or vaccine relatedmy carditis and younger people
in particular.
And I think that's probably dueto the robust immune response
that young people have.
And anytime we see things likethat, we always always have to.
(13:04):
Hold that up against, what's therisk with infection, natural
infection too, and there's,there can be I think a false
sense where, oh, it's better toget, like, if you're going to
get myocarditus, it's better toget it from the natural
infection.
Cause it's not.
Yeah, sure.
And then like this artificialvaccine or whatever, and a lot
of suspicion around that.
I, I'm more of a mind of let'sjust look at overall what's our
(13:26):
relative risk relative risk ofserious complications and
morbidity, and also bearing inmind that there's still this
component.
With COVID of asymptomaticspread and presymptomatic
spread, which has always beenone of the distinguishing
factors and made this kind of atougher thing to get
epidemiologic hold on.
And so there's this benefit tohaving more people vaccinated
(13:47):
because of that that component,that that's going to continue to
help to protect our communities.
It's a long winded way ofsaying, I think I, I don't.
Severe, significant reservationsabout getting my kids
vaccinated.
And I think globally, as westart to think about, is this a
good thing?
Epidemiologically.
It's probably a good thing forthe vaccine age to March down a
(14:07):
little bit.
And again, I think we just haveto be really conscious of our
messaging around that.
And the way that we talk aboutit, both in our families and
communities, and thenprofessionally, because this is
just such a highly charged issueand it has been for years and
it's just going to continue todo.
Yeah.
Super, super supercharged goingforward.
Matt Boettger (14:24):
Yeah.
No.
Great.
Thanks mark.
Yeah, let's get into this alittle bit about the variants,
because I think this is on a lotof people's minds.
We see, we saw, we're seeing alittle bit of resurgence of the
spread in the U S Dow.
Particularly like you just said,mark and unvaccinated areas is
where we see the highest, whichkind of goes back to this idea
of like really trying to.
Do our best to talk about itwith our friends and our family
(14:46):
who aren't vaccinated to helpencourage them to be able to get
facts.
And if they're not vaccinealready, because yeah.
It prevents yourself, but alsothe community at large to have a
resurgence and those kinds ofthings.
Steve, I want to go back to youand just looking at the Delta
variant, where we've seen itright now in light of its it's
spread it's a couple of thingsthat come to mind when I saw
(15:07):
here with the Delta.
There were some questions aboutparents and unvaccinated kid at
the Delta variant.
If there's anything that we knowabout, if there's any difference
when it comes to kiddos.
And the biggest thing I sawhere, we talked about this off
the before we started recordingis an interesting, Israel had a
resurgence and and so there wasthis one study, small study.
Presuming that maybe Pfizer orthe, the, the vaccine doesn't
(15:29):
work as well against the Deltavariant.
So like only like a 64%protection against infection.
That's different though, ofcourse, against
hospitalizations, still on theupper nineties, those kinds of
things, the dangerous parts of,of COVID that kind of stuff.
Also Fowchee re said that, that.
That's really true.
So in light of what you'reseeing, where are we seeing with
a Delta variant right now?
(15:49):
And it's spread in the us and inanything that's looks more
dangerous for us whatsoever.
Stephen Kissler (15:55):
Yeah.
So the, the Delta variant inmany ways is kind of changed the
game.
Not, It's not, we're stilldealing with COVID, it's still
the same virus that we'redealing with, but it, it really
has affected how we're going tolive with it in, in the next
months, two years.
And so, The Delta variant rightnow makes up the majority of
(16:15):
cases in the United States.
I think it's now over 80% of allnew cases are associated with
the Delta variant.
And so it swept the the viralpopulation pretty quickly.
And we saw this with the alphavariant to the The one was
originally detected in the UK.
That also happened where it veryquickly made up the majority of.
(16:36):
New COVID cases.
And as soon as it started to dothat, then we started to see
cases rise again.
And that was because it was moreinfectious.
And so the things that we weredoing that were able to suppress
the previous variants of thevirus were no longer effective
and know no longer as effective.
And so the alpha variant startedto rise and now the Delta
variant has replaced that one.
And so we're starting to seecases of that go up again, too.
(16:56):
So there's, there's a lot ofdifferent things going on here.
So first.
So we have the Delta variant,which is more infectious that
starting to cause rises incases, especially in communities
where vaccination rates are low,but it's also spreading in
locations where vaccinationrates are high.
Why?
Okay.
So, we ask ourselves, we got, wegot the vaccine to prevent
(17:18):
clinical illness for sure, butalso to prevent the spread of
disease.
And there are some places thatare verging on the, the
thresholds that we were talkingabout for her to immunity.
Why are we.
See the spread of Delta, even inplaces that should ostensibly
have gotten some degree of herdimmunity and that that can be
largely traced back to the factthat the Delta is so much more
infectious.
Right?
When we were talking about SARScov two originally back in
(17:41):
beginning of 2020, we weretalking about reproduction
numbers on the order of threewhereabouts, one infected person
would infect three others, allth all of the things being
equal.
By the time it jumps to thealpha and the Delta variant, the
Delta variant now has a closerto a reproduction number of
around six.
Right.
And that's a huge, hugedifference.
It's like twice as infectious aswhat we'd been dealing with
before.
And some simple calculationssuggest that with It's that
(18:04):
infectious you need about 85% ofpeople protected from infection
to get herd immunity.
Now, the, the vaccines areprobably only on the order of 70
to 80% optimistically effectiveagainst infection.
So even if you have the entirepopulation back, You would still
be able to see the spread of theDelta Varian.
So that's one big reason, thisthere's been a lot of suggestion
(18:26):
that like, well, why are wegetting vaccinated in the first
place?
They clearly don't work becausethe Delta variant is spreading
in highly vaccinatedpopulations.
And to some extent, that's true,but that's just because this
virus is such a formidable foein terms of its
transmissibility.
The good thing about thevaccines is they are preventing
people from getting symptomaticillness that preventing people
from going to the hospital andpreventing people from dying.
(18:46):
And that's true for the Deltavariant as well.
Even if the Delta variant isactually more severe as well,
which it seems to be thevaccines still do a very good
job of preventing against thesymptomatic illness and the
onward, hospitalization anddeath.
So that's all good news.
But again, it's not, as we'vebeen saying.
For a very long time to thesevaccines are not the magic
bullet that we hope for them tobe always, they're not a hundred
(19:08):
percent effective.
They don't protect everyone.
And even vaccinated peoplesometimes do get hospitalized
and some of them die too.
And we, we don't want that.
We don't want that.
But that's happening in, in muchsmaller numbers amongst the
vaccinated population.
It's really complex.
Right.
And and it's difficult and thevoltage Delta variant will
continue to spread.
And so, and so that's kind ofthe situation that we're in
(19:28):
right now where it's spreading,it's spreading mostly and
unvaccinated populations are lowvaccination populations, but
it's continuing to in highlyvaccinated populations too.
And so that's where we're at.
Matt Boettger (19:39):
Okay.
Kind of reminds me of like,Groundhog's day for us.
Like it's like kind of dealingwith the same questions in the
same concerns, over differentcycles of different variants.
Kind of like when the verybeginning, when we were doing
unlocked down and we were doingsocial distancing and there was
accusations, see, it's notworking, it's not working.
It's not working.
They're still infected stillgrowing because it's, it's, it's
so hard when you don't haveanything to compare it to.
(20:00):
Right.
You can't compare the same thingto the same stand in the same
way, because you're actuallydealing with that variable.
And it wasn't until, for us, atleast for me, maybe not for
everybody, but it wasn't untilwe saw, oh my gosh, flu cases
are non-existent this year.
That comparison help me realize,oh, could you, so if that
affected the flu thatdramatically, could you imagine
if we wouldn't have done what wedid?
(20:21):
What if COVID would have donethe same thing now?
It's like, oh, vaccines, aren'tworking.
Lord help us if we didn't have avaccine right now and what it
might look like, and like on ageographical scale with a Delta
variant going crazy, right.
That it's so effective.
And the fact that we're stillseeing a rise in cases, we
should just be counting ourlittle blessings that we have
it, that it could be so muchworse, right.
(20:41):
So much worse.
So, no, thanks for thatcomparison.
There really appreciate that.
That helps make sensitive,these, these articles that I
read that it's kind of hard,cause I'm not.
This niche, this area ofexpertise.
So when they start with titles,like called a top health expert,
and like, I have no idea whetherthere's actually really is a top
health expert, that's the title.
So that's the magistarium,that's the must be the truth.
Right?
(21:02):
So top health expert saysvaccinated, people are spreading
Delta variant, and that helpsnow you put everything into
restaurant.
Of course, it's going to at somelevel, because of the extremity
of, of the spread.
Of the virus.
Mark, do you wanna add anythingto this conversation?
Stephen Kissler (21:21):
W I love that.
I just think not to put too fineof a point on it.
I think you guys said itexactly, but that's the sense of
anytime we resort then to,jumping to this conclusion, Oh,
the vaccines don't work or thisabsolutism around that.
Especially when, with, whenthat's kind of retreating into a
sense of kind of fatalism about,it's like, well, nothing that we
do matters.
Yeah.
(21:41):
Let's just go back to doingwhatever we feel like, I think
there's a, there's just thisreal draw sometimes to say, I
just want my intuitions to bevalidated and I'm going to kind
of follow the evidence until thepoint in which my intuitions are
validated.
And then I'm going to stop.
And that's just it's so hard andI feel like that's, those are
some of the conversations, thatwe ha have been having and are
(22:02):
having continually about some ofthese things, because we've got
to push through to that level alittle higher resolution and
it's helpful.
I find that just really helpfulto situate what is really going
on with vaccines, Delta spread,and then, and then that makes a
material difference in what Ifeel comfortable doing.
With me and my family, so Iappreciate it.
Great to kind of, oh yeah, no, Iwas just one of the things that
(22:24):
I've been thinking about linkingall of these things together.
I really appreciate that, thatpoint, mark.
And is that like, like how, howI feel myself tempted towards a
sort of fatalism in the otherdirection that like, we're never
going to be able to understand.
To, to, to accept the sort ofbehavioral changes, the sorts of
acknowledgement of thecomplexity of the world that
(22:45):
will allow us to engage with theworld in the way that it exists,
as opposed to the way that wewish it would be.
But then again, I think thatthere's when, when I'm tempted
towards those moments of sort offatalism on, on the other side
of the spectrum I think it'slike, it's always helpful for me
to remember that.
Then times when actually ourcollective behavior has changed
profoundly in response todifferent risks or different
(23:08):
threats that we've faced on apopulation scale.
For example, putting on aseatbelt when I go into a car,
right?
Like I, I never drive without myseatbelt on.
And when seatbelts were firstintroduced, there was a lot of
rules.
Against them.
People actually thought theywould be harmful.
And it took a long time to youknow, for, for that to integrate
now, it's, it's second nature.
I don't even think about it whenI get into a car.
More to the point of infectiousdisease, as we think about
(23:30):
navigating this transition Ithink a lot about the experience
we had an actually especiallythe gay community had with HIV
in the 1980s, going into thenineties and two thousands,
right?
Like HIV is still spreading.
Right.
And it's still a threat to Twopeople and it's it causes
disease.
And there had to be some vest,behavioral changes different
(23:52):
ways that people thought aboutthe risks of certain activities,
different ways about the risk ofinteracting with other people.
And yeah.
A lot had to change.
And in many ways, a lot haschanged and that's been
integrated into culture.
It's been integrated into theways that people lead their
lives.
And so I think in some ways,what COVID is forcing us to do
is to do those same sorts ofthings on a more mainstream,
broad scale population level.
(24:13):
But there are things that we, orat least different parts of.
Society have done before.
And so I do think that there ishope and there's actually even
like roadmaps that others havegone through previously that we
can look to and draw forinspiration for very clear
practical guidance on how to dothis.
And I think that that'ssomething we're going to have to
really, we rely on in the comingmonths and years to.
(24:35):
Navigate this, this ongoing sortof simmering crisis.
Yeah, I think and just, maybe itwas kind of my, my last
contribution to this particularpoint to bring it back to our
conversation at the beginningof, what do we do now and how.
Think about recalibrating ourrisk.
It feels to me that one of thebig conversations that's going
on amongst different differentpeople in different communities
(24:58):
is the sense of, to what degreedo we value safety in
relationship to other goods.
To what degree do we value ourprotection against infectious
disease in relationship to otherthings that are also important.
And good.
And I think there's, there is away there's of course there's,
absolutisms on every side, andthere is potentially a way to
(25:21):
prevent, a huge amount ofinfectious disease by never,
ever seeing anybody again.
And, by doing all these thingsthat are otherwise damaging.
To, to other human goods.
And so I think there's, wedon't, I don't know if we always
have that conversation on thatlevel about like, okay, what are
the, what are the underlyingthings that I'm wanting?
That I'm shooting forward for myself and my community.
And how do we talk about the,just real granular details about
(25:45):
how, how the, our numberaffects?
Yeah.
My sense of, whatever, communalintegration and, and, social
justice or whatever, likethat's, that's a complicated
calculus, but there is a sense,I think that we're transitioning
into a period where making thatconversation a little bit more
explicit, could be useful.
And and I think could alsobridge a little bit of these
(26:05):
different communities where thathave reacted to COVID.
Different ways, if that makessense that there's the, I think
that lots and lots of thesedifferent reactions have been
deeply motivated by somedifferent underlying assumptions
about what is important and whatis worth protecting.
And And I think if we can startto think about that a little bit
(26:28):
and and recognize that we're ina different phase right now, in
which some of those otherconcerns may be rising a little
bit on the priority list, how dowe then react?
You know our conversation sothat we're not quite so siloed
and just continue to be siloedand moving in the opposite
directions from here on out.
Matt Boettger (26:46):
Yeah.
I don't want to make this soundlike exaggeration, but you know,
up until this point, I feltlike, fundamentally we were.
Rational animals.
I think we're kind offundamentally irrational animals
and like, everyone, like, Ithink, I think we, because I
think there is stuff beyondrationality that we consider as
part of our importance and thatkind of stuff.
And it's it's, and I've learnedthis the hard way of like, I
(27:07):
have things in my own life thatI put prioritize.
I prioritize in my life.
That anybody on the outsidelook, that's fundamentally
irrational.
It doesn't make any sense whyyou'd prioritize that over this
statistically, that kind ofstuff.
But helping people guidance intonormalcy through statistics,
I've learned that does notreally work that well.
Like, just constantly hammeringthe idea that, oh, now the
summer it's June, it's July,it's going to be August and
(27:28):
statistically, you have 103chance, one a hundred, three
chance to get in a car accidentand have some failures and
versus one in a million chancetoo, die of COVID and you're
like solved.
It didn't really solve anyproblems.
Statistic doesn't really matterright now because I feel scared
and it's a bit of a big hardyear and there's been a lot of
things that's happened and theyhave a narrative and I've got to
find my way and my way totransition into it.
(27:49):
So combining rationality andirrationally as a hard quest to
move forward in normalcy.
But my biggest, my biggest PSA.
Now is the time to do thattransition because it's a time,
at least in the U S where it'sone of the safest times to be
able to, Hey, and if you're in,yeah, you can be outside, you
(28:09):
can go to the pool, you can doall those kinds of things begin
to, to reintegrate those thingsthat you value that you've
sacrificed for over a year now.
But you know, in relationship toother things like, so now
there's other variants there'sLambda there's Absalon as well,
any contributions to that,Stephen on this stuff.
Besides.
Alphabet I know Landa looks likethat's hitting south America
(28:30):
pretty intensely.
And it seems to be prettyaggressive, I guess Peru was hit
and they have one of thebiggest, mortality rates per
capita.
So I'm not sure what Lambda isin relationship to Delta.
We have Epsilon, which I guessis a California variant.
Right.
And so I have a couple ofquestions.
So just these two ones.
So if you can maybe get us up tospeed on these two, where, where
(28:50):
they were in a relationship.
And then my other question, justto throw out you and your you're
at Harvard, you can hold theseintention.
Right?
So, in that is the other one ishow has variants in general
changed over the course ofvaccines?
So, before the vaccine, this wasspreading all over.
Is there a, has there been likea change of rate in it that's
been noticeable in the amount ofvariance because of vaccinated
(29:14):
people?
Is it, is, has that changed orare we seeing them still come on
the scene roughly at the samerate as before the backseat?
Stephen Kissler (29:23):
Yeah.
So, first the overview of thevariants that we have so far,
right?
They, we do have a number ofdifferent variants and it's been
interesting as time has gone on,they've shifted between their
different classifications of howconcerning they are, how
interesting they are, or, howsuddenly they are, right.
The classification.
And so, So it's hard to keeptrack of.
Even, even as an epidemiologist,who's looking at these things
(29:44):
all the time, but I think theupshot of all of this is that
there are multiple variantsspreading.
In addition to the Delta, thereare others.
And even within those, there aredifferent, different subjects.
Sub lineages within thosevariants that have different
attributes.
And so, but really the broadpicture is that, the key three
things that we're interested inwhen we're looking at the
variance is theirtransmissibility.
(30:06):
So their ability to spread theirability to evade our immunity
and their severity.
And those are the three axesthat the virus.
Moving around the evolutionaryspace and and trying to figure
it out now, now the only onethat the, that it's really being
well.
So, so the virus will naturally.
(30:27):
Evolve to be both be moretransmissible.
And when it's spreading incommunities where immunity is
high, if a variant emergencethat is able to get around that
immunity, it will naturallyspread more easily too.
And so we'll start to see moreof that variant as well.
It doesn't necessarily try tobecome more severe.
In fact, sometimes it tries tobecome less severe.
It just depends on sort of theseother axes and how they're all
linked together.
(30:48):
So each of these variants thatyou just listed off kind of
differ in how far along they areon each of these axes.
The big concern with the Deltais just how much more
transmissible it is.
And that's usually the realconcern, because if you're more
transmissible, you can justinfect way, way, way more, many
more people.
And so you get sort of the, theeffect becomes much larger.
So that's the issue there, butyeah.
(31:08):
The variants of different, someof them are able to get around
to some amount of naturalimmunity as well.
And so they make both immunityfrom previous infection and
immunity from vaccination alittle bit less strong when,
when faced with that variant.
So there's the question of, howdoes vaccination play into all
of this?
Well, it's pretty wellestablished now that on average,
the immunity that you get fromvaccination is stronger than the
(31:31):
immunity that you get fromnatural infant.
And so, it seems to last longer,it seems to be more durable.
It seems to be, more effectiveon a, on a challenge by
challenge basis when you'reexposed to the virus.
As far as we can tell there's ofcourse, we have a lot of
vaccines too, so it depends onwhich vaccine we're talking
about here March.
That seems to be the case.
So that's all good.
And so there's, there's been alot of speculation, like.
(31:54):
So we, we now have vaccines andnow we're hearing a lot about
these variants.
It's very easy to say.
Okay, well, let's draw a causallink between the two vaccines,
therefore variants vaccines, ormaybe the reason why we're
seeing more and more variants.
I'm not going to be able tosatisfyingly say that.
Absolutely.
No, that's not the case, but Idon't think that it's nearly
that simple.
And I think that we would becontinuing to see new variants
(32:14):
emerging regardless of whetheror not the vaccines were there.
And in fact, I think that thevaccines are probably helping to
suppress the development andspread of variants rather than
to encourage them.
Why is that?
When we're thinking about theevolution of a virus the the,
the, the sweet spot for evolvingsomething that is a worst
(32:34):
variant in terms of eithergetting around immunity or being
able to spread more easily isthese intermediate levels that
we can get into.
So I'm thinking about likeintermediate immunity where
either, yeah.
Only small fractions of thepopulation are protected, or the
people who are protected areonly protected at a middling
level.
So one of the good things aboutvaccinating with a very good
vaccine and vaccinating veryhard really getting the vaccine
(32:57):
distributed to many people isthat it moves you from that
middle area where protection ison the on the middle scale to
very high levels of protection,where many people are highly
protected.
And what that does is that thatdrives cases down.
It prevents the amount of itkeeps the amount of virus that's
spreading in the population low.
And that just gives usstatistically fewer chances to
(33:17):
develop new variants in thefirst.
So really the worst scenariothat we can be in is when we
have half of people beingnaturally infected with this
infection that sort of gives youa middle level of immunity.
And that really allows the virusto to explore the space of
possibilities and be.
It's come up against people whoare partially protected, but not
fully protected.
(33:37):
And so it can get around theseevolutionary barriers a little
bit more easily.
So of course, in places thathave a very good vaccine, that
sort of middling vaccination.
That can contribute to someamount of the evolution of
variants, but that's not to say,that the vaccines are causing
the evolution of the variants.
This, this is the virus doingwhat viruses do, and all viruses
(33:59):
do this to some degree.
All biological organisms do thisto some degree they're following
the same rules and the samepatterns.
And so we would be seeing.
Whether or not the vaccines arehere and I'm, and based off of
all the evidence that I see, Ithink the vaccines have actually
probably helped us keep somevariants from spreading that
would have spread otherwise.
That's my rough take on, on, on,on the interplay between all of
(34:20):
these different complex
Matt Boettger (34:21):
factors.
So you were talking about howthere is speculation that
somehow vaccines could actuallybring about more variants in
what situation could have, coulda vaccine actually bring about
more variants?
Is it that somehow people arecarrying it?
There's the assumption thatpeople are carrying it.
It's stain in the body.
And then, and then, or thevaccine itself is making it,
(34:42):
what's the name?
Contributes to that theory.
Stephen Kissler (34:44):
So it would be really it's.
If the vaccine provides, maybeonly partial protection, like
very low degrees of protection,basically the more the vaccine
resembles natural infection, themore likely it is for it to to
contribute to the development ofvariants, basically.
And so, So, yeah, roughlyspeaking, that, that seems to be
the case.
Yeah.
(35:04):
We were predicting, predictingevolution is as just an
incredibly difficult thing.
And it's something that we'restill scientifically very in the
early stages of doing so.
So that's why I'm hedging somuch about these things.
But you know, it really, really,it is that like, If you one sort
of general rule in the evolutionof anything, but especially, do
variants of a virus and theevolution of resistance or the
(35:25):
evolution of greatertransmissibility is that if you
give the virus sort of a lowhurdle to clear, if, if you give
it many low hurdles to clear,it's able to evolve new variants
more easily than if you give ita very high wall.
And so the vaccines are our highwall and natural infection these
low hurdles in, in some sense,roughly speaking.
(35:46):
And so that's why that's myintuition behind why the
vaccines helping prevent thesevariants from spreading.
We want, we want to present itwith high walls as frequently as
we can because the low hurdlesare what allows it to
incrementally change.
And then eventually, we, we getsomething that's really new and
is able to spread through thepopulation.
Matt Boettger (36:02):
Great.
Awesome.
One of the things hitting thevaccine Pfizer, we've been
hearing about booster shotscoming up like boosters or B.
I think Pfizer has got onecoming up and it's been
available.
And I don't know if he has noinformation about this.
To what extent are we going toneed a booster?
I saw an article here, a veryexciting study indicates MRN
vaccines could provide here as aprotection.
(36:22):
Against COVID-19 they'll haveany clue where this is true, but
is there at this point in time,is there any indicator by which
we might need a booster in ayear or so?
Or is this looking like theevidence is showing that, Hey,
we could be rocking it for like2, 3, 4, 5 years with the, with,
with, with, with one goodvaccine.
Stephen Kissler (36:41):
Yeah.
We have no idea.
As far as I should.
Check that off.
Yeah.
I mean, it's one of those thingswhere right where you, you only
know, well, how long immunitylasts by following people until
the immunity fails.
Yeah.
That's the only way to know forsure.
The immune system is so complexthat we won't know for certain,
until we start seeing people whogot vaccinated early on and
(37:02):
start to get reinfected.
And hopefully that doesn'thappen for a very long time.
And, and that's something we'reabsolutely watching closely, but
it's unfortunately, one of the.
You can't really know untiluntil after you would want to
have known it until after, afteryou're able to really do
something about it.
That's not entirely true,they're working on boosters so
that if, and when it becomesclear that boosters are needed,
we can just deploy themimmediately.
(37:22):
And, and that's a very goodthing, but there's been a lot of
speculation of how long immunitylasts and if we're going to need
booster shots, and frankly,there's just.
Not only does the evidence notexist, but it couldn't exist at
this point to know thatquestion.
The answer to that question, forsure.
Matt Boettger (37:37):
Yeah.
Yep.
Okay, great.
I saw a couple of things here.
I'm trying to look it up here.
CDC warns COVID 19 vaccines maynot protect people who are
immune compromised there.
So there's been a little bit ofa guidance on that quick
question though.
What does it mean to be immunecompromised?
Because I get the.
And there's no.
And I'll get to like, well,maybe I'm immune compromised who
knows maybe have it, like, I'mguessing this is like, I'm gonna
(37:58):
throw this to you, mark.
I'm guessing this has like areal.
Definition.
It's not like, oh, I haveallergies.
And so I might be immunecompromised.
Stephen Kissler (38:06):
Yeah.
I think that's that's exactlyit, that I would not worry about
somebody with seasonal allergiesor general kind of general
medical conditions as being inthat category.
That means a very specific setof things.
And it's true.
We have seen.
Where I've cared for patients,or I know people who have really
good example of this is maybesomebody has rheumatoid
arthritis and is on animmunosuppressive medication,
(38:29):
which part of the role of thatmedication is to tamp down the
immune system.
So you're not creating theseauto Antabuse.
To make your arthritis worse.
Well that also works with thesame processes that your immune
system needs to do to respond toa vaccine.
And so, there have even been,folks who've been fully
vaccinated and then checked afew months later to see if the
antibody response and it's beenthere.
(38:50):
Largely as a result becausetheir therapeutic is working as
it should.
And so then there's a few,they're typically more rare
conditions when there's, isn'tmedication-related it's more
rare for someone to have animmune deficiency to the degree,
to which they're not going torespond to the vaccine, but that
also happens.
And we do see folks like that inthe hospital as well.
We have some differentconsiderations.
(39:11):
In terms of our therapeuticapproach to those patients.
And so things that we might doto help support them in the case
of an infection.
And I think that typicallythat's more often than not,
that's going to be somethingthat you know about.
It's not going to be somethingthat you just discover as a
result of getting COVID afterthe vaccine.
(39:32):
So it's definitely not somethingI would incur, encourage people
to really worry about if it'snot something you already know.
I do think if you are, what, onone of these, these
immunosuppressive medicationsare not necessarily rare.
There's some of the conditionsthat they treat or have a
reasonable prevalence in thecommunity.
And so I think if that's thecase for you, then having some
(39:52):
conversations with your doctoror being really thoughtful about
what additional.
Risk reduction, methods.
Should I take in the, and sodoes that mean that I'm one of
the people who, even though I'mvaccinated, I'm still wearing a
mask in public or, beingthoughtful about the time when I
go to the store or things likethat, just knowing that my own
personal risk is still a littlebit elevated compared to other
(40:14):
vaccinated folks.
Yeah.
Matt Boettger (40:16):
Okay.
T and a to advance a cause forpeople getting vaccinated to
help those people who can'tquite get the full benefits of
vaccination as well we'll landon this.
I read this article.
There's a lot more stuff.
A lot of talk about this ourfirst and back in weeks, we'll
catch up over the coming weeks.
Hopefully we'll have mark back alittle more often.
I saw this a guideline kind of,it kind of surprised me, mark.
I don't know if you've read orsaw this America American
(40:38):
academy of pediatrics recommendsmasks in schools, even for
vaccinated going further thanthe CDC.
Any, any reason for that?
Or is this just over caution or.
Did you have you
Stephen Kissler (40:50):
any, I haven't, I'll have to read it, then see
what their what the evidencebase is that they're using for
that?
I don't know, Stephen, if that'ssomething you're familiar with,
I actually just, there's been aconversation at my kids' school
about mask or no mask in thefall.
And they've gone actually backand forth.
On this.
And so it's going to beinteresting to see where this
lands.
I suspect personally that a lotof it's going to have to do with
(41:11):
where we're at on that saw toothcurve of up and down infection.
And and again, kind of treatingthis in a more chronic season.
And almost, the metaphor thatStephen used, it's like the
weather report, there's like aweather report and then there's
kind of a COVID infectivityreport.
And we may have to ma minorlyalter our behaviors as a result
of where we're at on that curve.
(41:31):
And then we can relax them intimes when that's less less of
an issue I'm interested to see.
I'll have to, I don't want tocome in yet, but I'll have to
take a look and see what theAmerican academy of pediatrics
is drawing that recommendation.
I think it's interesting.
I think it's interesting too.
Cause it just highlights yetagain, this complex interaction
between based statistics, expertopinion and our social response
(41:55):
to expert opinion, each of whichhas a lot wiggle room.
So somebody interesting to seebut I'll take a look.
Good.
Matt Boettger (42:02):
My last thought here, before we go on, as I keep
going back to what you said, thevery beginning mark, about how
am I, right?
You said you guys were thinkingas a hospital, but how to
thinking about how taking theCOVID war to the patients and
basically integrating them intothe whole normal respiratory
illness, basically wing or area.
So think of it, not as siloedreality, but it's just.
(42:24):
One piece of a bigger puzzle ofrespiratory viruses.
So that's part of theconversation right now.
Mark.
I want
Stephen Kissler (42:30):
to make it clear.
That's not I'm not involvedright now in any of the
operations conversations aroundthat.
So it's not as if we're havingat least that I'm privy to.
Conversations about physicallymoving patients or
re-integrating on the teams,different hospitals manage this
in different ways.
So far, we have siloed our COVIDpatients on a particular one,
too many COVID teams over thecourse of the pandemic,
(42:54):
depending on how many folks wehave at at the time.
But what I do know what more I'msaying.
From a conversation standpoint,as we're thinking about it, just
as physicians caring for thesepatients.
I do think there's a sense thatat a certain point, there, there
may be, there's just maybe atipping point at which that
makes a lot of sense.
And so we have had some of thoseinformal conversations, but
(43:15):
nothing that I know of in termsof like formal operational
changes, Sure.
Matt Boettger (43:20):
Well, I'm just thinking of landing the plane
with this kind of metaphor ofjust seeing that, how our lives
are, trying to work that, thatstring of COVID and refabricate
it into our life versus seeingit as a siloed reality.
And to seeing that hospital'slike as a metaphor of like,
we're all working with takingthis siloed reality for a good
point.
And how do we.
The string and now fabricate it.
(43:41):
So now, instead of looking atseparately, it's part of the
life that we live with.
Right.
And that is the hard, but Ijust, that imagery that you said
early on, just maybe like thatstruck me.
Yeah,
Stephen Kissler (43:51):
absolutely.
I think re-integration orintegrating any illness
experience into the story thatproceeded it and follows it is a
major part of how humans copewith disease.
And so I think that asabsolutely we're at this funny,
we've talked about some of the,the narrative structure of life
and disease over the course ofthis pandemic and talking a lot
about illnesses is aninterruption illnesses causing
(44:13):
chaos or an UN UN narrator.
Sort of state, and that at acertain point, there's an
opportunity, I think.
And of course we don't want toforce this and we don't want to
be too prescriptive about it,but there's a certain point at
which a type of integrationbecomes appropriate or possible.
And I think we're starting tomaybe turn the corner into that
(44:34):
phase with COVID.
Matt Boettger (44:35):
Yep.
Yeah, I agree.
Well, this is great.
Great to end on that thought.
And I just hope that we all cantry to begin to kind of take
that metaphor and how we beginto make those steps of
refabricating that, that bigpart of a siloed life into the
normal part of our life which isfor the overall wellbeing of all
of us.
Well, thanks so much guys forcoming back.
It's great to have both of youSteve and mark on it.
(44:57):
Good to see your faces.
Can we see in person we'll bedone.
Regularly as best as we canweekly bi-weekly, we're striving
for weekly until we feel like wemight provide more value
bi-weekly so, we're here.
I got a couple of emails, like,did you guys leave?
Do you guys drop off?
Please come back, but we're thatwas just a little break.
We'll be back for theforeseeable future.
Thanks so much for Katina.
(45:17):
Listen to us and subscribe tous.
You can always do that to giveus a rating.
Give us a review, keeps usinspired.
Keeps us going.
Do you want to support us?
patrion.com/bending podcast.
One time a gift of Venmo peopleall in the show notes.
Thank you again.
Have a wonderful week.
We'll see you guys all nextMonday.
Take care and bye-bye.
You're listening to the pandemic podcast.
We equip you to live the mostlife possible Caymus hill
anymore.
It's been too long, likeliterally the faced with this
crisis.
That's out of my name is, butcouldn't join with not one, but
finally, two of my good friends,Dr.
Stephen Kissler andepidemiologist, the Harvard
(00:21):
school of public health.
Drum roll, please.
He came out of his cave at Dr.
Mark Kissler, a doctor at theuniversity of Colorado hospital.
That was phenomenal.
How's it going guys, guys.
Stephen Kissler (00:32):
It's great to see you.
It's been a long time.
Matt Boettger (00:34):
It's been for ever a mark.
What the heck have you been
Stephen Kissler (00:37):
doing?
I asked myself that too.
I think, I think it's it feelslike life has just accelerated
in in all sorts of domains.
And so a lot of work I've beenat the hospital a lot which has
been good.
And and then a lot of home stufftoo.
So it's just, yeah.
Yeah.
All
Matt Boettger (00:55):
over the place.
Yeah.
Stephen, your neck of the woods,like what's been going on with
you.
Stephen Kissler (01:00):
Alright.
Yeah.
Slowly transitioning back intosome of the work that I was
doing pre pandemic.
So I'm starting to think aboutthings other than COVID.
Even though we still have someCOVID related projects going.
So, but I like, it kind of feelslike in many ways, the summer
has been a bit of a reprieve inthat cases are a lot lower here.
I've gotten to just see morepeople even do a little bit of
traveling some good friends gotmarried this past weekend when
(01:22):
we got to go to the wedding.
And so it was just, takingadvantage of some of these
things that it's been a reallylong time since we've been able
to do so.
I'm grateful for that.
Yeah, that's still a strangeworld out there, but just trying
to transition back intosomething that reflects a little
bit closer to what what lifelooked like before.
Matt Boettger (01:40):
Yeah.
And I'm, I think this is goingto be the theme of today's, mark
was talking about this, he wastalking about it before we
started recording.
It's been a while for, it's beentwo weeks.
I think we just lost mark there.
So when he gets back, we'llwe'll chime him back in but it's
been two full episodes thatwe've been away from the
pandemic.
And we, we want to kind of checkin, talk about how things are
(02:00):
going for us.
And it's been just unusualbecause it's the summer and.
A sense of feeling like thingsare meant to be normal, but then
we have Delta and gamma andLambda and Epsilon.
I'm like the good news is I'mbeing reacquainted with my Greek
alphabet, which is, I think ifthere's going to be a win,
that's a win right.
For anyone.
(02:20):
So, I there's so that's, that'sbeen a really big, I guess, good
thing going on, but behind thatis a lot of questions of like,
what does normalcy look like?
Should we be doing.
And then there's like the, Ithink the sub narrative of like,
okay, well there's people whoare single and adults and some
are vaccine and some areun-vaccinated.
And then for me, thecomplication is when you have a
family and it's summertime and,under half of us are vaccinated
(02:43):
and the other half are stillwaiting to be vaccinated.
And what does it mean to live anormal life?
And so I just want to chat aboutthis for you guys.
Like, what does it mean for youguys to, because in my mind, as
we were kind of going from mayto June in the summer, sorry to
rev.
We were kind of asking ourselvesas a family, what do we do this
summer?
What do we want to do thissummer?
(03:03):
And we didn't, it was hard toknow what to do because there
was a sense of like, well, let'sjust wait.
I want to start with thisbecause that was a hard
question.
I'm like, well, if we'rewaiting, what are we waiting
for?
Because I'll have Stephen, Imight have you just chime in for
a second year, starting withthis because.
If we're looking for an intoCOVID, as we've been saying for
(03:24):
months now, I don't think that'sgoing to happen.
So that kind of wait, I thinkyou're stuck in your house
forever, right?
On the cover.
It's always going to be at somelevel part of the population.
And so this idea of moving tonormalcy needs a different kind
of measurement.
And so in light of what what'sgoing on with your discussion,
Stephen, what you guys have beentalking about, what does that
look like?
What he has been talking aboutthis idea of like moving towards
(03:46):
a sense of normalcy in the.
Of this kind of unknown of thesenew variants now with Delta kind
of dominate in the U S
Stephen Kissler (03:52):
yeah.
It's really tricky.
And I think we can, and I'm surewe will, over the course of this
episode, tackle it from, anepidemiological and a clinical.
And then also just like apersonal perspective, like what
all of this means, it's, it'sreally tricky because.
So one of the ways that I'vebeen thinking about this, right,
is that early on in thepandemic, one of the big reasons
why we were really emphasizingphysical distancing, flattening
(04:14):
the curve was the big thing.
And, and there were two reasonsfor that.
One of them was just to reducethe strain on hospitals.
The flatter, the curve, thefewer people get infected
overall.
And, you, you prevent, hugesurges from going to the house.
And we were trying to delay asmany cases as we could until we
had a vaccine.
And until we had effectivetherapeutics, right?
Like we're, as you really gain alot by pushing off infections to
(04:37):
a later date the landscape haschanged a lot and that's not to
say that, physical distancing,flattening the curve is no
longer important, but you know,we, we now have a vaccine we've
gotten a lot better at dealingwith COVID in the clinical
perspective.
And so, and so you're right.
We're transitioning.
A period where there was thisvery clear sense of a finite
waiting period to a sense where,COVID will be here with us for
(05:02):
the foreseeable future.
And that's, that's a reallytricky reality.
I know it's one that we've beentalking about throughout the
entire time we've been talkingabout this But that, that's
almost certainly the case atthis point and we can talk more
about epidemiologically, whythat's true.
But yeah, we're transitioninginto a time when, when we, as
individuals, we as societies,we, as epidemiologists, as
doctors, as teachers, as whoeverwe happen to be are thinking
(05:25):
about, what, what is our lifegoing to look like now that
SARS, cov two is going tocontinue spreading.
It's going to be with us.
It will probably be a wintertimerespiratory virus.
And that's going to meandifferent things for different
communities.
It's going to mean differentthings for different people.
And for those of us who arethinking about the epidemiology
and the clinical side of things,we're going to have to keep
innovating, trying to figure outhow to make this less and less
(05:45):
of a burden, but then also forindividuals, just like, how do
we navigate this?
As people, how do we renegotiateour risk of going out into the
world?
That was a very intuitive thingand the pre COVID era, but now
there's this new risk that sortof layered on top of everything
else.
How, how do we.
That we haven't really developedthe intuition to have a feel for
what that means.
And I think the story of thisnext year or two is going to be
(06:07):
reintegrating this new risk intoour intuitive sense of, of, of
what we're able to, to manage aspeople.
And that's going to be a reallydifficult thing to do cause
we're all going to go about itat a different way and in a
different speed.
Matt Boettger (06:21):
Yeah.
That's great.
Mark.
How about you?
Like w.
Dealing with idea trans she's anormalcy in the context of your
clinical work, but also as afamily man and working with
kiddos and that kind of stuff.
How's that been for you?
What's that look like?
Has Delta change anything what'sgoing on in your neck of the
woods?
Stephen Kissler (06:37):
Yeah.
It's kinda I just want to echo alot of what Stephen said.
I had a funny conversation witha colleague of mine, just as a
sidebar outside the elevatorsthe other day, who has been
really involved in our COVIDresponse.
Essentially what he, here we arehere we are, we're starting to
see this kind of cyclical thing.
That, that old article, the roadwas right.
And he was kind of bummed aboutit and we bonded for a moment a
(06:57):
bit like neither of us arereally all that happy to admit
that Stephen's right.
And, and yet I think there'sthis sense of amongst clinicians
is what does this mean?
Do we integrate COVID into ourregular medicine teams, just as
we take care of all sorts ofrespiratory viruses at the time.
And how do we, how do we startto think about COVID now that we
(07:20):
know a lot about it and we knowmore or less that it's probably
going to be here to stay?
Yeah.
Was there anything from apersonal standpoint, tricky one.
We've been doing a lot more,we've been out some traveling,
we'd go out, I've been, goingthrough our local stores rec
(07:41):
center and all these things andfeeling pretty good about it.
I think post vaccine with sortof a sense of how do we keep
each other in general?
And not being overly cautious.
I feel like there's a reallygood return to a certain what I
call maybe a local normalcy,certain ways.
And so that's, also there's,taking the kids out and they're
(08:06):
doing things and they've beengoing to school even during
parts of the pandemic, just maskup.
And and that seemed to go prettywell too.
We were fortunate that eventhough we all got COVID at one
point.
I think we we've been kind of ina, in a fortunate state where
we've been sheltered from someof the severe complications, at
least as a family.
I think it's tough.
I think for me the, as we figureout what, what do we do and how
(08:27):
do we get back into things?
There's this combination ofwhat's our ideal state.
And then what's kind of thereality that we face, and we,
we, we just have to kind of flexand know that sometimes we have
to do things just because we.
We need to do them, we need toget out, we need to reconnect
with family and, and thosethings.
So there's, this they're verymuch sort of a reality check in
the midst of all of this that'sthat's just constantly going,
(08:49):
the back of my mind.
Matt Boettger (08:51):
I've been in the same way.
Like, just kind oftransitioning, talking as a
family of what, which we shouldbe doing hesitancy because all
this, this E over a year of likesecluding ourselves in a house
and then the light switch comeson at summer.
And it's just, what I was hopingfor is just like black and
white, we're switched on.
We're ready to go.
And just not that way, we'retrying to transition back into
(09:11):
normal, seen what that lookslike.
And it's been, it's been kindof, it's been harder just to,
in, try and encourage our familyand my wife to be like, if
there's one time to begintransition.
It is now, right?
Because if you're looking for ameasurement, if you're looking
for some kind of quantifiablemetric to make you feel as if
this is a safest time for me totry to like get back in the
normalcy now is the time we'retalking.
(09:33):
I think off the, off the airthough, waiting until November,
if your skin is not going to beprobably the ideal situation,
because come November, there'sprobably going to be some kind
of resurgence of COVID nothinglike last year and that's going
to probably.
Raise some hair in the back ofyour neck and re you know, the
trauma of the year before andthe summer is a great time to be
in the transition.
So for us, it's been as ofrecently of slowly getting back
(09:55):
into the pool and go into thepool.
And it's been amazing.
We, one time we went to thepool, we got ice cream, like, oh
my gosh, this field.
Amazing.
I, I it's just to be with myfamily outside, going to a
store, getting ice cream, gointo a pool relaxing last week
we went to a restaurant grantedwe were outside and it was just
really wonderful to just kind ofbegin the transition.
(10:16):
I know it's hard for the familyand wife.
Cause right now we're, thelittle ones are unvaccinated.
I want to throw it back to you,mark, of just like, about
dealing with your kiddos and thefuture and with a Delta variant.
Is there any concern for you, inlight of that and when it comes
to the fall and the winter inlight of what you see with the
vaccine, the vaccines and itsefficacy, and some of them may
(10:37):
be the rare responses of heartinflammation with kids and that
kind of stuff.
Where are you landing right nowin the process come fall or
winter with the kids aboutgetting them vaccinated or not
vaccinated?
Where are you at on that?
Stephen Kissler (10:51):
Yeah, I I think there's a couple of things.
So, one of them is that it'sreally helpful for me to keep in
mind what Stephen was mentioningat the beginning, which is
what's our, what's our bigpicture goal here.
And really, yeah.
Hopefully we've stressed thisthroughout that of course, part
of the goal is to avoidourselves from getting COVID, as
much as possible, but reallythere's this secondary goal,
(11:12):
which is a bigger picture and alittle harder to grasp
intuitively, which is we'retrying to avoid being major
vectors in a dangerous andvulnerable time period, because.
As the evidence has shown timeand time again, that there
though there are very severeinsignificant manifestations in
kids in general, compared to allcomer respiratory viruses, this
(11:34):
is a little bit less of athere's less morbidity amongst
the younger population.
And I think that's important toremember because, what's, what's
our goal here.
And so as we're thinking about.
I think relative risk ofreentering life and, having our
kids be able to do the thingsthat are important for their
development.
Not just like recreation, butjust like be involved in, in our
(11:54):
community, in important ways.
I think that that's helpful forme.
Does that make sense?
think it, because again, I thinkthat we can get into it replace.
If the number one goal is alwaysjust to avoid like me getting
infected and it's a little bitfreeing in certain ways as we
kind of think like, okay, what'sthe, what are we trying to do
here?
And where are we at in theoverall pandemic in terms of our
(12:16):
need to flatten the curve?
Our concern for these vulnerablepopulations to, to what degree
are they being protected by?
The things that have been putinto place up until now.
So as I think about, I, I thinkthat I'm going to make the same,
use the same kind of paradigmaround decision for vaccinating,
my kids as I did, with myselfand as I recommend with my
patients, which is, we're gonnalook at the evidence which.
(12:39):
So far to date has not shown atremendous downside to vaccine.
And in younger people, therehave been, there have been a lot
of reports and a lot of certainmedia coverage of like a
myocarditis or vaccine relatedmy carditis and younger people
in particular.
And I think that's probably dueto the robust immune response
that young people have.
And anytime we see things likethat, we always always have to.
(13:04):
Hold that up against, what's therisk with infection, natural
infection too, and there's,there can be I think a false
sense where, oh, it's better toget, like, if you're going to
get myocarditus, it's better toget it from the natural
infection.
Cause it's not.
Yeah, sure.
And then like this artificialvaccine or whatever, and a lot
of suspicion around that.
I, I'm more of a mind of let'sjust look at overall what's our
(13:26):
relative risk relative risk ofserious complications and
morbidity, and also bearing inmind that there's still this
component.
With COVID of asymptomaticspread and presymptomatic
spread, which has always beenone of the distinguishing
factors and made this kind of atougher thing to get
epidemiologic hold on.
And so there's this benefit tohaving more people vaccinated
(13:47):
because of that that component,that that's going to continue to
help to protect our communities.
It's a long winded way ofsaying, I think I, I don't.
Severe, significant reservationsabout getting my kids
vaccinated.
And I think globally, as westart to think about, is this a
good thing?
Epidemiologically.
It's probably a good thing forthe vaccine age to March down a
(14:07):
little bit.
And again, I think we just haveto be really conscious of our
messaging around that.
And the way that we talk aboutit, both in our families and
communities, and thenprofessionally, because this is
just such a highly charged issueand it has been for years and
it's just going to continue todo.
Yeah.
Super, super supercharged goingforward.
Matt Boettger (14:24):
Yeah.
No.
Great.
Thanks mark.
Yeah, let's get into this alittle bit about the variants,
because I think this is on a lotof people's minds.
We see, we saw, we're seeing alittle bit of resurgence of the
spread in the U S Dow.
Particularly like you just said,mark and unvaccinated areas is
where we see the highest, whichkind of goes back to this idea
of like really trying to.
Do our best to talk about itwith our friends and our family
(14:46):
who aren't vaccinated to helpencourage them to be able to get
facts.
And if they're not vaccinealready, because yeah.
It prevents yourself, but alsothe community at large to have a
resurgence and those kinds ofthings.
Steve, I want to go back to youand just looking at the Delta
variant, where we've seen itright now in light of its it's
spread it's a couple of thingsthat come to mind when I saw
(15:07):
here with the Delta.
There were some questions aboutparents and unvaccinated kid at
the Delta variant.
If there's anything that we knowabout, if there's any difference
when it comes to kiddos.
And the biggest thing I sawhere, we talked about this off
the before we started recordingis an interesting, Israel had a
resurgence and and so there wasthis one study, small study.
Presuming that maybe Pfizer orthe, the, the vaccine doesn't
(15:29):
work as well against the Deltavariant.
So like only like a 64%protection against infection.
That's different though, ofcourse, against
hospitalizations, still on theupper nineties, those kinds of
things, the dangerous parts of,of COVID that kind of stuff.
Also Fowchee re said that, that.
That's really true.
So in light of what you'reseeing, where are we seeing with
a Delta variant right now?
(15:49):
And it's spread in the us and inanything that's looks more
dangerous for us whatsoever.
Stephen Kissler (15:55):
Yeah.
So the, the Delta variant inmany ways is kind of changed the
game.
Not, It's not, we're stilldealing with COVID, it's still
the same virus that we'redealing with, but it, it really
has affected how we're going tolive with it in, in the next
months, two years.
And so, The Delta variant rightnow makes up the majority of
(16:15):
cases in the United States.
I think it's now over 80% of allnew cases are associated with
the Delta variant.
And so it swept the the viralpopulation pretty quickly.
And we saw this with the alphavariant to the The one was
originally detected in the UK.
That also happened where it veryquickly made up the majority of.
(16:36):
New COVID cases.
And as soon as it started to dothat, then we started to see
cases rise again.
And that was because it was moreinfectious.
And so the things that we weredoing that were able to suppress
the previous variants of thevirus were no longer effective
and know no longer as effective.
And so the alpha variant startedto rise and now the Delta
variant has replaced that one.
And so we're starting to seecases of that go up again, too.
(16:56):
So there's, there's a lot ofdifferent things going on here.
So first.
So we have the Delta variant,which is more infectious that
starting to cause rises incases, especially in communities
where vaccination rates are low,but it's also spreading in
locations where vaccinationrates are high.
Why?
Okay.
So, we ask ourselves, we got, wegot the vaccine to prevent
(17:18):
clinical illness for sure, butalso to prevent the spread of
disease.
And there are some places thatare verging on the, the
thresholds that we were talkingabout for her to immunity.
Why are we.
See the spread of Delta, even inplaces that should ostensibly
have gotten some degree of herdimmunity and that that can be
largely traced back to the factthat the Delta is so much more
infectious.
Right?
When we were talking about SARScov two originally back in
(17:41):
beginning of 2020, we weretalking about reproduction
numbers on the order of threewhereabouts, one infected person
would infect three others, allth all of the things being
equal.
By the time it jumps to thealpha and the Delta variant, the
Delta variant now has a closerto a reproduction number of
around six.
Right.
And that's a huge, hugedifference.
It's like twice as infectious aswhat we'd been dealing with
before.
And some simple calculationssuggest that with It's that
(18:04):
infectious you need about 85% ofpeople protected from infection
to get herd immunity.
Now, the, the vaccines areprobably only on the order of 70
to 80% optimistically effectiveagainst infection.
So even if you have the entirepopulation back, You would still
be able to see the spread of theDelta Varian.
So that's one big reason, thisthere's been a lot of suggestion
(18:26):
that like, well, why are wegetting vaccinated in the first
place?
They clearly don't work becausethe Delta variant is spreading
in highly vaccinatedpopulations.
And to some extent, that's true,but that's just because this
virus is such a formidable foein terms of its
transmissibility.
The good thing about thevaccines is they are preventing
people from getting symptomaticillness that preventing people
from going to the hospital andpreventing people from dying.
(18:46):
And that's true for the Deltavariant as well.
Even if the Delta variant isactually more severe as well,
which it seems to be thevaccines still do a very good
job of preventing against thesymptomatic illness and the
onward, hospitalization anddeath.
So that's all good news.
But again, it's not, as we'vebeen saying.
For a very long time to thesevaccines are not the magic
bullet that we hope for them tobe always, they're not a hundred
(19:08):
percent effective.
They don't protect everyone.
And even vaccinated peoplesometimes do get hospitalized
and some of them die too.
And we, we don't want that.
We don't want that.
But that's happening in, in muchsmaller numbers amongst the
vaccinated population.
It's really complex.
Right.
And and it's difficult and thevoltage Delta variant will
continue to spread.
And so, and so that's kind ofthe situation that we're in
(19:28):
right now where it's spreading,it's spreading mostly and
unvaccinated populations are lowvaccination populations, but
it's continuing to in highlyvaccinated populations too.
And so that's where we're at.
Matt Boettger (19:39):
Okay.
Kind of reminds me of like,Groundhog's day for us.
Like it's like kind of dealingwith the same questions in the
same concerns, over differentcycles of different variants.
Kind of like when the verybeginning, when we were doing
unlocked down and we were doingsocial distancing and there was
accusations, see, it's notworking, it's not working.
It's not working.
They're still infected stillgrowing because it's, it's, it's
so hard when you don't haveanything to compare it to.
(20:00):
Right.
You can't compare the same thingto the same stand in the same
way, because you're actuallydealing with that variable.
And it wasn't until, for us, atleast for me, maybe not for
everybody, but it wasn't untilwe saw, oh my gosh, flu cases
are non-existent this year.
That comparison help me realize,oh, could you, so if that
affected the flu thatdramatically, could you imagine
if we wouldn't have done what wedid?
(20:21):
What if COVID would have donethe same thing now?
It's like, oh, vaccines, aren'tworking.
Lord help us if we didn't have avaccine right now and what it
might look like, and like on ageographical scale with a Delta
variant going crazy, right.
That it's so effective.
And the fact that we're stillseeing a rise in cases, we
should just be counting ourlittle blessings that we have
it, that it could be so muchworse, right.
(20:41):
So much worse.
So, no, thanks for thatcomparison.
There really appreciate that.
That helps make sensitive,these, these articles that I
read that it's kind of hard,cause I'm not.
This niche, this area ofexpertise.
So when they start with titles,like called a top health expert,
and like, I have no idea whetherthere's actually really is a top
health expert, that's the title.
So that's the magistarium,that's the must be the truth.
Right?
(21:02):
So top health expert saysvaccinated, people are spreading
Delta variant, and that helpsnow you put everything into
restaurant.
Of course, it's going to at somelevel, because of the extremity
of, of the spread.
Of the virus.
Mark, do you wanna add anythingto this conversation?
Stephen Kissler (21:21):
W I love that.
I just think not to put too fineof a point on it.
I think you guys said itexactly, but that's the sense of
anytime we resort then to,jumping to this conclusion, Oh,
the vaccines don't work or thisabsolutism around that.
Especially when, with, whenthat's kind of retreating into a
sense of kind of fatalism about,it's like, well, nothing that we
do matters.
Yeah.
(21:41):
Let's just go back to doingwhatever we feel like, I think
there's a, there's just thisreal draw sometimes to say, I
just want my intuitions to bevalidated and I'm going to kind
of follow the evidence until thepoint in which my intuitions are
validated.
And then I'm going to stop.
And that's just it's so hard andI feel like that's, those are
some of the conversations, thatwe ha have been having and are
(22:02):
having continually about some ofthese things, because we've got
to push through to that level alittle higher resolution and
it's helpful.
I find that just really helpfulto situate what is really going
on with vaccines, Delta spread,and then, and then that makes a
material difference in what Ifeel comfortable doing.
With me and my family, so Iappreciate it.
Great to kind of, oh yeah, no, Iwas just one of the things that
(22:24):
I've been thinking about linkingall of these things together.
I really appreciate that, thatpoint, mark.
And is that like, like how, howI feel myself tempted towards a
sort of fatalism in the otherdirection that like, we're never
going to be able to understand.
To, to, to accept the sort ofbehavioral changes, the sorts of
acknowledgement of thecomplexity of the world that
(22:45):
will allow us to engage with theworld in the way that it exists,
as opposed to the way that wewish it would be.
But then again, I think thatthere's when, when I'm tempted
towards those moments of sort offatalism on, on the other side
of the spectrum I think it'slike, it's always helpful for me
to remember that.
Then times when actually ourcollective behavior has changed
profoundly in response todifferent risks or different
(23:08):
threats that we've faced on apopulation scale.
For example, putting on aseatbelt when I go into a car,
right?
Like I, I never drive without myseatbelt on.
And when seatbelts were firstintroduced, there was a lot of
rules.
Against them.
People actually thought theywould be harmful.
And it took a long time to youknow, for, for that to integrate
now, it's, it's second nature.
I don't even think about it whenI get into a car.
More to the point of infectiousdisease, as we think about
(23:30):
navigating this transition Ithink a lot about the experience
we had an actually especiallythe gay community had with HIV
in the 1980s, going into thenineties and two thousands,
right?
Like HIV is still spreading.
Right.
And it's still a threat to Twopeople and it's it causes
disease.
And there had to be some vest,behavioral changes different
(23:52):
ways that people thought aboutthe risks of certain activities,
different ways about the risk ofinteracting with other people.
And yeah.
A lot had to change.
And in many ways, a lot haschanged and that's been
integrated into culture.
It's been integrated into theways that people lead their
lives.
And so I think in some ways,what COVID is forcing us to do
is to do those same sorts ofthings on a more mainstream,
broad scale population level.
(24:13):
But there are things that we, orat least different parts of.
Society have done before.
And so I do think that there ishope and there's actually even
like roadmaps that others havegone through previously that we
can look to and draw forinspiration for very clear
practical guidance on how to dothis.
And I think that that'ssomething we're going to have to
really, we rely on in the comingmonths and years to.
(24:35):
Navigate this, this ongoing sortof simmering crisis.
Yeah, I think and just, maybe itwas kind of my, my last
contribution to this particularpoint to bring it back to our
conversation at the beginningof, what do we do now and how.
Think about recalibrating ourrisk.
It feels to me that one of thebig conversations that's going
on amongst different differentpeople in different communities
(24:58):
is the sense of, to what degreedo we value safety in
relationship to other goods.
To what degree do we value ourprotection against infectious
disease in relationship to otherthings that are also important.
And good.
And I think there's, there is away there's of course there's,
absolutisms on every side, andthere is potentially a way to
(25:21):
prevent, a huge amount ofinfectious disease by never,
ever seeing anybody again.
And, by doing all these thingsthat are otherwise damaging.
To, to other human goods.
And so I think there's, wedon't, I don't know if we always
have that conversation on thatlevel about like, okay, what are
the, what are the underlyingthings that I'm wanting?
That I'm shooting forward for myself and my community.
And how do we talk about the,just real granular details about
(25:45):
how, how the, our numberaffects?
Yeah.
My sense of, whatever, communalintegration and, and, social
justice or whatever, likethat's, that's a complicated
calculus, but there is a sense,I think that we're transitioning
into a period where making thatconversation a little bit more
explicit, could be useful.
And and I think could alsobridge a little bit of these
(26:05):
different communities where thathave reacted to COVID.
Different ways, if that makessense that there's the, I think
that lots and lots of thesedifferent reactions have been
deeply motivated by somedifferent underlying assumptions
about what is important and whatis worth protecting.
And And I think if we can startto think about that a little bit
(26:28):
and and recognize that we're ina different phase right now, in
which some of those otherconcerns may be rising a little
bit on the priority list, how dowe then react?
You know our conversation sothat we're not quite so siloed
and just continue to be siloedand moving in the opposite
directions from here on out.
Matt Boettger (26:46):
Yeah.
I don't want to make this soundlike exaggeration, but you know,
up until this point, I feltlike, fundamentally we were.
Rational animals.
I think we're kind offundamentally irrational animals
and like, everyone, like, Ithink, I think we, because I
think there is stuff beyondrationality that we consider as
part of our importance and thatkind of stuff.
And it's it's, and I've learnedthis the hard way of like, I
(27:07):
have things in my own life thatI put prioritize.
I prioritize in my life.
That anybody on the outsidelook, that's fundamentally
irrational.
It doesn't make any sense whyyou'd prioritize that over this
statistically, that kind ofstuff.
But helping people guidance intonormalcy through statistics,
I've learned that does notreally work that well.
Like, just constantly hammeringthe idea that, oh, now the
summer it's June, it's July,it's going to be August and
(27:28):
statistically, you have 103chance, one a hundred, three
chance to get in a car accidentand have some failures and
versus one in a million chancetoo, die of COVID and you're
like solved.
It didn't really solve anyproblems.
Statistic doesn't really matterright now because I feel scared
and it's a bit of a big hardyear and there's been a lot of
things that's happened and theyhave a narrative and I've got to
find my way and my way totransition into it.
(27:49):
So combining rationality andirrationally as a hard quest to
move forward in normalcy.
But my biggest, my biggest PSA.
Now is the time to do thattransition because it's a time,
at least in the U S where it'sone of the safest times to be
able to, Hey, and if you're in,yeah, you can be outside, you
(28:09):
can go to the pool, you can doall those kinds of things begin
to, to reintegrate those thingsthat you value that you've
sacrificed for over a year now.
But you know, in relationship toother things like, so now
there's other variants there'sLambda there's Absalon as well,
any contributions to that,Stephen on this stuff.
Besides.
Alphabet I know Landa looks likethat's hitting south America
(28:30):
pretty intensely.
And it seems to be prettyaggressive, I guess Peru was hit
and they have one of thebiggest, mortality rates per
capita.
So I'm not sure what Lambda isin relationship to Delta.
We have Epsilon, which I guessis a California variant.
Right.
And so I have a couple ofquestions.
So just these two ones.
So if you can maybe get us up tospeed on these two, where, where
(28:50):
they were in a relationship.
And then my other question, justto throw out you and your you're
at Harvard, you can hold theseintention.
Right?
So, in that is the other one ishow has variants in general
changed over the course ofvaccines?
So, before the vaccine, this wasspreading all over.
Is there a, has there been likea change of rate in it that's
been noticeable in the amount ofvariance because of vaccinated
(29:14):
people?
Is it, is, has that changed orare we seeing them still come on
the scene roughly at the samerate as before the backseat?
Stephen Kissler (29:23):
Yeah.
So, first the overview of thevariants that we have so far,
right?
They, we do have a number ofdifferent variants and it's been
interesting as time has gone on,they've shifted between their
different classifications of howconcerning they are, how
interesting they are, or, howsuddenly they are, right.
The classification.
And so, So it's hard to keeptrack of.
Even, even as an epidemiologist,who's looking at these things
(29:44):
all the time, but I think theupshot of all of this is that
there are multiple variantsspreading.
In addition to the Delta, thereare others.
And even within those, there aredifferent, different subjects.
Sub lineages within thosevariants that have different
attributes.
And so, but really the broadpicture is that, the key three
things that we're interested inwhen we're looking at the
variance is theirtransmissibility.
(30:06):
So their ability to spread theirability to evade our immunity
and their severity.
And those are the three axesthat the virus.
Moving around the evolutionaryspace and and trying to figure
it out now, now the only onethat the, that it's really being
well.
So, so the virus will naturally.
(30:27):
Evolve to be both be moretransmissible.
And when it's spreading incommunities where immunity is
high, if a variant emergencethat is able to get around that
immunity, it will naturallyspread more easily too.
And so we'll start to see moreof that variant as well.
It doesn't necessarily try tobecome more severe.
In fact, sometimes it tries tobecome less severe.
It just depends on sort of theseother axes and how they're all
linked together.
(30:48):
So each of these variants thatyou just listed off kind of
differ in how far along they areon each of these axes.
The big concern with the Deltais just how much more
transmissible it is.
And that's usually the realconcern, because if you're more
transmissible, you can justinfect way, way, way more, many
more people.
And so you get sort of the, theeffect becomes much larger.
So that's the issue there, butyeah.
(31:08):
The variants of different, someof them are able to get around
to some amount of naturalimmunity as well.
And so they make both immunityfrom previous infection and
immunity from vaccination alittle bit less strong when,
when faced with that variant.
So there's the question of, howdoes vaccination play into all
of this?
Well, it's pretty wellestablished now that on average,
the immunity that you get fromvaccination is stronger than the
(31:31):
immunity that you get fromnatural infant.
And so, it seems to last longer,it seems to be more durable.
It seems to be, more effectiveon a, on a challenge by
challenge basis when you'reexposed to the virus.
As far as we can tell there's ofcourse, we have a lot of
vaccines too, so it depends onwhich vaccine we're talking
about here March.
That seems to be the case.
So that's all good.
And so there's, there's been alot of speculation, like.
(31:54):
So we, we now have vaccines andnow we're hearing a lot about
these variants.
It's very easy to say.
Okay, well, let's draw a causallink between the two vaccines,
therefore variants vaccines, ormaybe the reason why we're
seeing more and more variants.
I'm not going to be able tosatisfyingly say that.
Absolutely.
No, that's not the case, but Idon't think that it's nearly
that simple.
And I think that we would becontinuing to see new variants
(32:14):
emerging regardless of whetheror not the vaccines were there.
And in fact, I think that thevaccines are probably helping to
suppress the development andspread of variants rather than
to encourage them.
Why is that?
When we're thinking about theevolution of a virus the the,
the, the sweet spot for evolvingsomething that is a worst
(32:34):
variant in terms of eithergetting around immunity or being
able to spread more easily isthese intermediate levels that
we can get into.
So I'm thinking about likeintermediate immunity where
either, yeah.
Only small fractions of thepopulation are protected, or the
people who are protected areonly protected at a middling
level.
So one of the good things aboutvaccinating with a very good
vaccine and vaccinating veryhard really getting the vaccine
(32:57):
distributed to many people isthat it moves you from that
middle area where protection ison the on the middle scale to
very high levels of protection,where many people are highly
protected.
And what that does is that thatdrives cases down.
It prevents the amount of itkeeps the amount of virus that's
spreading in the population low.
And that just gives usstatistically fewer chances to
(33:17):
develop new variants in thefirst.
So really the worst scenariothat we can be in is when we
have half of people beingnaturally infected with this
infection that sort of gives youa middle level of immunity.
And that really allows the virusto to explore the space of
possibilities and be.
It's come up against people whoare partially protected, but not
fully protected.
(33:37):
And so it can get around theseevolutionary barriers a little
bit more easily.
So of course, in places thathave a very good vaccine, that
sort of middling vaccination.
That can contribute to someamount of the evolution of
variants, but that's not to say,that the vaccines are causing
the evolution of the variants.
This, this is the virus doingwhat viruses do, and all viruses
(33:59):
do this to some degree.
All biological organisms do thisto some degree they're following
the same rules and the samepatterns.
And so we would be seeing.
Whether or not the vaccines arehere and I'm, and based off of
all the evidence that I see, Ithink the vaccines have actually
probably helped us keep somevariants from spreading that
would have spread otherwise.
That's my rough take on, on, on,on the interplay between all of
(34:20):
these different complex
Matt Boettger (34:21):
factors.
So you were talking about howthere is speculation that
somehow vaccines could actuallybring about more variants in
what situation could have, coulda vaccine actually bring about
more variants?
Is it that somehow people arecarrying it?
There's the assumption thatpeople are carrying it.
It's stain in the body.
And then, and then, or thevaccine itself is making it,
(34:42):
what's the name?
Contributes to that theory.
Stephen Kissler (34:44):
So it would be really it's.
If the vaccine provides, maybeonly partial protection, like
very low degrees of protection,basically the more the vaccine
resembles natural infection, themore likely it is for it to to
contribute to the development ofvariants, basically.
And so, So, yeah, roughlyspeaking, that, that seems to be
the case.
Yeah.
(35:04):
We were predicting, predictingevolution is as just an
incredibly difficult thing.
And it's something that we'restill scientifically very in the
early stages of doing so.
So that's why I'm hedging somuch about these things.
But you know, it really, really,it is that like, If you one sort
of general rule in the evolutionof anything, but especially, do
variants of a virus and theevolution of resistance or the
(35:25):
evolution of greatertransmissibility is that if you
give the virus sort of a lowhurdle to clear, if, if you give
it many low hurdles to clear,it's able to evolve new variants
more easily than if you give ita very high wall.
And so the vaccines are our highwall and natural infection these
low hurdles in, in some sense,roughly speaking.
(35:46):
And so that's why that's myintuition behind why the
vaccines helping prevent thesevariants from spreading.
We want, we want to present itwith high walls as frequently as
we can because the low hurdlesare what allows it to
incrementally change.
And then eventually, we, we getsomething that's really new and
is able to spread through thepopulation.
Matt Boettger (36:02):
Great.
Awesome.
One of the things hitting thevaccine Pfizer, we've been
hearing about booster shotscoming up like boosters or B.
I think Pfizer has got onecoming up and it's been
available.
And I don't know if he has noinformation about this.
To what extent are we going toneed a booster?
I saw an article here, a veryexciting study indicates MRN
vaccines could provide here as aprotection.
(36:22):
Against COVID-19 they'll haveany clue where this is true, but
is there at this point in time,is there any indicator by which
we might need a booster in ayear or so?
Or is this looking like theevidence is showing that, Hey,
we could be rocking it for like2, 3, 4, 5 years with the, with,
with, with, with one goodvaccine.
Stephen Kissler (36:41):
Yeah.
We have no idea.
As far as I should.
Check that off.
Yeah.
I mean, it's one of those thingswhere right where you, you only
know, well, how long immunitylasts by following people until
the immunity fails.
Yeah.
That's the only way to know forsure.
The immune system is so complexthat we won't know for certain,
until we start seeing people whogot vaccinated early on and
(37:02):
start to get reinfected.
And hopefully that doesn'thappen for a very long time.
And, and that's something we'reabsolutely watching closely, but
it's unfortunately, one of the.
You can't really know untiluntil after you would want to
have known it until after, afteryou're able to really do
something about it.
That's not entirely true,they're working on boosters so
that if, and when it becomesclear that boosters are needed,
we can just deploy themimmediately.
(37:22):
And, and that's a very goodthing, but there's been a lot of
speculation of how long immunitylasts and if we're going to need
booster shots, and frankly,there's just.
Not only does the evidence notexist, but it couldn't exist at
this point to know thatquestion.
The answer to that question, forsure.
Matt Boettger (37:37):
Yeah.
Yep.
Okay, great.
I saw a couple of things here.
I'm trying to look it up here.
CDC warns COVID 19 vaccines maynot protect people who are
immune compromised there.
So there's been a little bit ofa guidance on that quick
question though.
What does it mean to be immunecompromised?
Because I get the.
And there's no.
And I'll get to like, well,maybe I'm immune compromised who
knows maybe have it, like, I'mguessing this is like, I'm gonna
(37:58):
throw this to you, mark.
I'm guessing this has like areal.
Definition.
It's not like, oh, I haveallergies.
And so I might be immunecompromised.
Stephen Kissler (38:06):
Yeah.
I think that's that's exactlyit, that I would not worry about
somebody with seasonal allergiesor general kind of general
medical conditions as being inthat category.
That means a very specific setof things.
And it's true.
We have seen.
Where I've cared for patients,or I know people who have really
good example of this is maybesomebody has rheumatoid
arthritis and is on animmunosuppressive medication,
(38:29):
which part of the role of thatmedication is to tamp down the
immune system.
So you're not creating theseauto Antabuse.
To make your arthritis worse.
Well that also works with thesame processes that your immune
system needs to do to respond toa vaccine.
And so, there have even been,folks who've been fully
vaccinated and then checked afew months later to see if the
antibody response and it's beenthere.
(38:50):
Largely as a result becausetheir therapeutic is working as
it should.
And so then there's a few,they're typically more rare
conditions when there's, isn'tmedication-related it's more
rare for someone to have animmune deficiency to the degree,
to which they're not going torespond to the vaccine, but that
also happens.
And we do see folks like that inthe hospital as well.
We have some differentconsiderations.
(39:11):
In terms of our therapeuticapproach to those patients.
And so things that we might doto help support them in the case
of an infection.
And I think that typicallythat's more often than not,
that's going to be somethingthat you know about.
It's not going to be somethingthat you just discover as a
result of getting COVID afterthe vaccine.
(39:32):
So it's definitely not somethingI would incur, encourage people
to really worry about if it'snot something you already know.
I do think if you are, what, onone of these, these
immunosuppressive medicationsare not necessarily rare.
There's some of the conditionsthat they treat or have a
reasonable prevalence in thecommunity.
And so I think if that's thecase for you, then having some
(39:52):
conversations with your doctoror being really thoughtful about
what additional.
Risk reduction, methods.
Should I take in the, and sodoes that mean that I'm one of
the people who, even though I'mvaccinated, I'm still wearing a
mask in public or, beingthoughtful about the time when I
go to the store or things likethat, just knowing that my own
personal risk is still a littlebit elevated compared to other
(40:14):
vaccinated folks.
Yeah.
Matt Boettger (40:16):
Okay.
T and a to advance a cause forpeople getting vaccinated to
help those people who can'tquite get the full benefits of
vaccination as well we'll landon this.
I read this article.
There's a lot more stuff.
A lot of talk about this ourfirst and back in weeks, we'll
catch up over the coming weeks.
Hopefully we'll have mark back alittle more often.
I saw this a guideline kind of,it kind of surprised me, mark.
I don't know if you've read orsaw this America American
(40:38):
academy of pediatrics recommendsmasks in schools, even for
vaccinated going further thanthe CDC.
Any, any reason for that?
Or is this just over caution or.
Did you have you
Stephen Kissler (40:50):
any, I haven't, I'll have to read it, then see
what their what the evidencebase is that they're using for
that?
I don't know, Stephen, if that'ssomething you're familiar with,
I actually just, there's been aconversation at my kids' school
about mask or no mask in thefall.
And they've gone actually backand forth.
On this.
And so it's going to beinteresting to see where this
lands.
I suspect personally that a lotof it's going to have to do with
(41:11):
where we're at on that saw toothcurve of up and down infection.
And and again, kind of treatingthis in a more chronic season.
And almost, the metaphor thatStephen used, it's like the
weather report, there's like aweather report and then there's
kind of a COVID infectivityreport.
And we may have to ma minorlyalter our behaviors as a result
of where we're at on that curve.
(41:31):
And then we can relax them intimes when that's less less of
an issue I'm interested to see.
I'll have to, I don't want tocome in yet, but I'll have to
take a look and see what theAmerican academy of pediatrics
is drawing that recommendation.
I think it's interesting.
I think it's interesting too.
Cause it just highlights yetagain, this complex interaction
between based statistics, expertopinion and our social response
(41:55):
to expert opinion, each of whichhas a lot wiggle room.
So somebody interesting to seebut I'll take a look.
Good.
Matt Boettger (42:02):
My last thought here, before we go on, as I keep
going back to what you said, thevery beginning mark, about how
am I, right?
You said you guys were thinkingas a hospital, but how to
thinking about how taking theCOVID war to the patients and
basically integrating them intothe whole normal respiratory
illness, basically wing or area.
So think of it, not as siloedreality, but it's just.
(42:24):
One piece of a bigger puzzle ofrespiratory viruses.
So that's part of theconversation right now.
Mark.
I want
Stephen Kissler (42:30):
to make it clear.
That's not I'm not involvedright now in any of the
operations conversations aroundthat.
So it's not as if we're havingat least that I'm privy to.
Conversations about physicallymoving patients or
re-integrating on the teams,different hospitals manage this
in different ways.
So far, we have siloed our COVIDpatients on a particular one,
too many COVID teams over thecourse of the pandemic,
(42:54):
depending on how many folks wehave at at the time.
But what I do know what more I'msaying.
From a conversation standpoint,as we're thinking about it, just
as physicians caring for thesepatients.
I do think there's a sense thatat a certain point, there, there
may be, there's just maybe atipping point at which that
makes a lot of sense.
And so we have had some of thoseinformal conversations, but
(43:15):
nothing that I know of in termsof like formal operational
changes, Sure.
Matt Boettger (43:20):
Well, I'm just thinking of landing the plane
with this kind of metaphor ofjust seeing that, how our lives
are, trying to work that, thatstring of COVID and refabricate
it into our life versus seeingit as a siloed reality.
And to seeing that hospital'slike as a metaphor of like,
we're all working with takingthis siloed reality for a good
point.
And how do we.
The string and now fabricate it.
(43:41):
So now, instead of looking atseparately, it's part of the
life that we live with.
Right.
And that is the hard, but Ijust, that imagery that you said
early on, just maybe like thatstruck me.
Yeah,
Stephen Kissler (43:51):
absolutely.
I think re-integration orintegrating any illness
experience into the story thatproceeded it and follows it is a
major part of how humans copewith disease.
And so I think that asabsolutely we're at this funny,
we've talked about some of the,the narrative structure of life
and disease over the course ofthis pandemic and talking a lot
about illnesses is aninterruption illnesses causing
(44:13):
chaos or an UN UN narrator.
Sort of state, and that at acertain point, there's an
opportunity, I think.
And of course we don't want toforce this and we don't want to
be too prescriptive about it,but there's a certain point at
which a type of integrationbecomes appropriate or possible.
And I think we're starting tomaybe turn the corner into that
(44:34):
phase with COVID.
Matt Boettger (44:35):
Yep.
Yeah, I agree.
Well, this is great.
Great to end on that thought.
And I just hope that we all cantry to begin to kind of take
that metaphor and how we beginto make those steps of
refabricating that, that bigpart of a siloed life into the
normal part of our life which isfor the overall wellbeing of all
of us.
Well, thanks so much guys forcoming back.
It's great to have both of youSteve and mark on it.
(44:57):
Good to see your faces.
Can we see in person we'll bedone.
Regularly as best as we canweekly bi-weekly, we're striving
for weekly until we feel like wemight provide more value
bi-weekly so, we're here.
I got a couple of emails, like,did you guys leave?
Do you guys drop off?
Please come back, but we're thatwas just a little break.
We'll be back for theforeseeable future.
Thanks so much for Katina.
(45:17):
Listen to us and subscribe tous.
You can always do that to giveus a rating.
Give us a review, keeps usinspired.
Keeps us going.
Do you want to support us?
patrion.com/bending podcast.
One time a gift of Venmo peopleall in the show notes.
Thank you again.
Have a wonderful week.
We'll see you guys all nextMonday.
Take care and bye-bye.
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