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Things Discussed in Episode:
- Explainer: Omicron 'stealth' COVID variant BA.2 now dominant globally
- This key indicator may determine how bad a BA.2 wave could be in the US
- A4A Urges White House to Lift Predeparture Testing Requirements, Mask Mandate
- America Is About to Test How Long ‘Normal’ Can Hold
- What Happened to Hong Kong?
- New PCR test can identify all SARS-CoV-2 variants in a positive patient sample
- America Is Zooming Through the Pandemic Panic-Neglect Cycle
- The surprising link between Covid-19 deaths and ... internet access
- A New Strategy for Staying One Step Ahead of the Virus
- Hope is not optimism
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 vendetta podcast.
We equip you to live the mostreal life possible in the face
of these crises.
My name is Matt Barker and I'mjoined with my one good friend,
Dr.
Steven Kissler, Napa dealer, theHarvard school of public health.
How are you on this incrediblyspring month?
Stephen Kissler (00:15):
Ish.
It's spring down.
It's a spring month.
Yeah, it is spring it's.
I mean, it's actually sort oflike raining really hard last
couple of days here in Boston,which, which is spring time
here.
So yeah, it's finally gettingwarmer and Boy man.
It's it?
It is a, it always feels like amiraculous thing when you emerge
out of the Boston winter.
Cause it was just so cold and solong and so dark.
So yeah, everybody's feeling it.
(00:36):
That's good.
Matt Boettger (00:36):
Yeah.
I cannot imagine I'm so used toColorado three days of, of in a
year.
And those two days, I'm likereally angry and life and I, and
then I feel bad cause most ofthe other world has many more
times.
So, I'm sorry for those who wereprobably expecting a podcast
episode on Monday, a good newsfor me is I got a job another
(00:58):
job.
So I've been doing other randomstuff, got a full-time gig
started on Monday.
So the first few days were kindof crazy.
So, this kind of, this might bean ever evolving, changing,
shifting release.
And I know I haven't even toldSteven yet, but I'll be gone for
over a month.
And so we'll throw that out away from Colorado.
So there might be some timeswhere we might not have an
(01:19):
episode right on time, but we'restill gonna strive hard to be as
regular as humanly possible andregular, I mean that on episode
wise, not like biologically orlike regular, always squarely.
I'm always striving for that at44.
So, I don't know whether Ishould cut that out and I'll
find that out.
I'll, I'll determine that lateron.
(01:40):
But before we get going theregular good stuff.
If you can leave us a review, welove it.
Haven't had one in a few weeks.
Just get inspired by thoselittle drops of notes.
You can do that on applepodcasts.
There's other platforms.
You can do that as well.
We'd love that.
Give us a rating.
Also patrion.com/pandemicpodcast.
As little as$5 a month can helpus keep this going or just a
(02:00):
one-time.
PayPal Venmo all in the shownotes.
Okay.
So it has been a little over twoweeks, Steven.
I feel like there's a decentamount to cover, which is always
interesting.
So I keep thinking that at somepoint in time, we're going to
just sit here and stare at eachother for 45 minutes and then
close up shop and they can hearus breathing.
At the still there's still stuffto talk about.
(02:22):
But the first thing I want tocheck in with you is just
dealing with the, the variantthere's BA too.
I just read an article thismorning about this I guess a BA
three, that's kind of sittingaround, not doing much, but who
knows, but you want to give us astatus of where we're at with B2
because we've heard of Europehaving increasing cases.
There's been a lot of newsarticles about expecting a surge
(02:43):
here.
We've definitely seen an uptick,but nothing dramatic.
Is it Is it more than that?
What should we be expecting thissummer?
Felicity?
Stephen Kissler (02:53):
Yeah.
So, it's, we're sort of in thisspot where it's really hard to
tell for a lot of the pandemic,we have trailed Europe in our
case counts, you know, it's,it's pretty much like when, when
Europe goes up, then we go uppretty consistently about a
month or so later.
You know, why, why that is.
Sure, but it's, it seems to havebeen a relatively consistent
(03:13):
pattern.
And so, and actually, to a largeextent that that is what we're
seeing now, we're starting tosee an uptick in cases in some
parts of the country.
I know here in the Northeast,we've just surpassed the point
where BA two is making up morethan half of the COVID cases
that are being sequenced.
So it's now a majority of what'scirculating here.
And as Europe is to the U Softentimes the coasts of the U S
(03:36):
are to the rest of the country.
And so since we're starting tosee that rise in the proportion
of BA two cases here, I thinkthat we can probably expect that
to happen across much of therest of the country.
But the big question is like,you know, how, how big and how
long will.
B I am not yet convinced thatit's going to be a major feature
of our spring time COVIDexperience here in the U S and
(03:59):
that's to a large extent,because we've had BA to
circulating in the U S for quitesome time.
We've had introductions of BA tohere all the way back since
December.
And so I think that if we'regoing to do something really.
Huge and sharp and sudden itprobably would have done so
already.
Now that's not to say that we'renot going to see a rise in cases
(04:19):
because there, there may be somestrange interactions with
previous immunity and waningimmunity.
And, you know, the fact that ourbehaviors are changing quite a
bit.
Mass mandates are sort oflifting just about everywhere
and You know, every, Icertainly, my behavior has
changed over the last month ortwo.
I've been seeing people more,I've been out and about more.
And and so all of that is goingto contribute to so I think the
(04:41):
most important thing is to tonote that, you know, BA two is
probably more infectious, moretransmissible than the original
Omicron variant, but it's thedifference between BA one and is
nowhere near the differencebetween.
And be a one.
So we're going to start CBA tostart to take over.
But I think that a lot of thesurge that we're seeing is
actually probably behaviorlydriven.
And and, and I think we're goingto be helped by the fact that
(05:05):
this is happening as we're goinginto the spring, as it's easier
to move some of theseinteractions outdoors.
And and so hopefully that'llhelp prevent this from turning
into a major surge.
And it'll just be sort of one ofthose blips that we're, we're
probably going to be dealingwith for a very, very long.
Matt Boettger (05:19):
Yeah, I can imagine.
And yeah, you can already hit italready, but it seems like this
is not necessarily just a BA toreality when it comes to this
uptick in the U S you mentionedthe idea of our behaviors are
changing.
We're going to get into the nextpart of our little discussion
about policies, guidelines andthe CDC.
And is that a good move of theCDC?
Is it, you know, the governmentfunding is starting to go away.
(05:41):
So there's a lot of things thatare kind of coming in the
pipeline that are going tochange this summer dramatically.
Hitting one more part of thiskind of uptick in the us.
I've read an article.
This is great.
Or whatever.
Once in a while I hit an articleand like, oh, that's Steven,
he's actually in there becausethere was a scene where you
quote, you, you were quotedtalking about one of the, kind
of the metrics is looking at the65 and older group I've seen,
(06:05):
what's going to happen.
Can you talk more about that aswe begin to venture forward and
kind of see how do we plan forany future surges cases?
What do we, what things we needto be looking for and
monitoring.
And this other article I talkedabout, which is deeply related,
I think it was by the Atlanticabout this increased desire to
look at another metric, which iskind of the immunity
(06:27):
surveillance.
And so clearly we can watch the65 and older group as they enter
into the hospital.
But I feel like that's kind of alittle bit late.
Are there other things thatwe're doing preparing to help be
a little more preventative tosee?
Okay.
When should we be.
The different measures went to,we encourage the 64.
And all the group to take thesecond booster and that becomes
(06:48):
available those kinds of things.
Stephen Kissler (06:50):
Yeah.
Yeah.
So, you know, with, with the,with the thoughts about the
immunity in the 65 and older agegroup, it's really basically.
A couple of things, you know,first back in, gosh, I don't
even remember what year it isanymore.
It was when when vaccines weresort of first coming online.
So I guess it was like end of20, beginning of 2021.
(07:10):
There was a lot of asking about,you know, who how should we
prioritize vaccine doses andshould we prioritize it to
interrupt, to transmit?
Which would suggest vaccinatingyoung adults.
We should, we should, weprioritize it to reduce severity
of disease primarily, whichwould, which would prioritize
vaccinating the elderly and andsort of prioritizing vaccination
by age group that with each, youknow, as, as you get older, the
(07:30):
more important it is that youget vaccinated.
And based off of the modelingand the information that we had
about the severity of COVID.
By age, it really seemed that itwas by far, in a way, the best
strategy to vaccinate the oldestpeople first.
And that's really been Kind ofsupported by some well, and I
think we'll probably talk aboutthis in a little while too, but
the experience in Hong Kong soone of the really big issues
(07:51):
that seems to be in play in HongKong is that they were able to
keep cases low for a very longtime.
But there's been a lot ofvaccine hesitancy amongst the
older age groups, and that hasled to a really big surge in
hospitalizations and deaths inHong Kong that really hasn't
been.
Seen in other countries like NewZealand, for example, where
there's higher vaccine uptakeamongst the older age groups.
(08:13):
But have had a similarexperience with COVID previously
where it was kept suppressed avery low levels.
So both the modeling and thereal-world experience suggest
that the more immunity you havein the oldest age groups the
better you're going to fair as asociety overall.
I think that it's, you know,this is another one of those
examples where it's reallydifficult to reason.
(08:33):
When we're thinking aboutexponential relationships
instead of linear relationships.
So when I'm talking about therisk of hospitalization and
death increasing with age, Idon't mean that it's still
linear increase where it's likewith each year, your risk goes
up by a fixed amount.
It's really pretty muchexponential, right?
So like, as, as you get olderthe, the risk just increased.
(08:54):
So much that if you compare therisk of hospitalization and
death for somebody who's overthe age of 80, for example
that's, you know, it the risk ofsomebody who's much younger,
really, really pales incomparison.
And so, so that's really why youknow, getting back to this quote
in this article why I reallythink that one of the most
important indicators for howcommunities are going to fare as
(09:17):
we move forward is vaccinate.
And immunity rates in the oldestmembers of our population.
And I do want to say that thisalso extends to other groups who
are vulnerable.
You know, it's not just theelderly who are vulnerable to
severe outcomes.
In many ways that's sort of thelargest and easiest group to
identify with a single category.
(09:37):
But we can ask ourselves, youknow, what is it that makes
people who are elderly morevulnerable to severe disease
from COVID.
So part of it is the immuneresponse that as you get older,
your immune system just doesn'tget fired up as easily.
And so, so of course, that alsothen extends to people who are
immunocompromised.
It extends to people withco-morbidities that either
prevent them from mounting agood immune response, or that
(09:57):
make them more likely to havesevere COVID outcomes.
Because again, as you're elderlyyou tend to have more
cardiovascular conditions.
You tend to have.
The rates of obesity increasethe rates of diabetes increase.
So all of those thingsindependently also affect your
risk of severe disease fromCOVID-19.
So we really want to make sureimmunity is high in those
populations as well.
But again, if, if, if you had tosort of say, you know, if I had
(10:19):
to, you know, if I had 10seconds to tell you what my
strategy would be for gettingcommunities through this, I
would have to, I would have tostick with that oldest age
groups because that's that'ssort of does the best job of
sort of encapsulating all ofthat together.
Yeah.
So that's, that's a, long-windedanswer to the first part of your
question.
I know you had another one aboutimmune correlates too, but let
me know if you want to dive offon another tangent.
Matt Boettger (10:41):
That's great.
I think let's go into thatbecause I think just
understanding, cause you, youyou're setting the stage for
this then how do we begin toprep or monitor in.
Have immunity surveillance asbeing a key criteria for us to
be ahead of the curve a littlebit in a different perspective
of monitoring.
When these people, I can kind ofsee how you might be able to do
(11:01):
this on a macro level we werekind of already doing this,
like, oh, it looks like immunityresponse decreases around six or
seven months, but maybe evengetting into a particular
response as part of your, in mymind, like part of your, your
physical and your physical baby,there's something down the road
that encompasses.
Where are you at on particularantibodies for veterans?
(11:23):
Diseases.
Stephen Kissler (11:23):
Right.
Totally.
Yeah.
You know, and so yeah, a couple,a couple of thoughts on that.
I think you're, you'reabsolutely right.
That really what we're talkingabout here is amount of
immunity.
And ideally what we would beable to measure is a person's
antibodies or other immuneresponses to a given pathogen
with.
It correlates with vaccinationand previous infection, but, but
(11:46):
it's not perfect.
It's a pretty noisy correlation.
Right.
What we've seen from studieswhere people have been looking
at antibodies in the blood isthat people really do have a
very wide range of responses tothe vaccine and a previous
infection.
And while it's very much truethat on average, your protection
increases with increasingexposures there are some people
who just really repeatedly, justdon't know how to very good
response at all.
(12:07):
And and so it'd be really worthunderstanding.
And who those people are andwhat we can do.
Again, like I said, you know,for, for some individuals who
already know that they have somekind of immune compromised
condition, that makes sense.
They have reason to suspect thatthey might be one of these
people who don't respond well,but for some other people, it
might be random.
Or, you know, th there may besome underlying condition that
(12:27):
they're not aware of.
And, and that leads to this hugeamount of variation between
people.
So I do think, you know, we'renot yet at the point where we
can.
Do a serology for COVID-19 onsort of a widespread population
basis.
And then say like, you know,like your immune response,
hasn't been very good.
You would really benefit fromanother dose of the vaccine or
you might want to take theselist of precautions, but that
(12:51):
realistically I think that thatmay be.
A direction that we're headingit with immunity to both
COVID-19 and other infectiousdiseases.
There are certain infections forwhich we already do this for
people who are working inhealthcare, for example.
So for, I think it's hepatitisB.
If you're going to be working ina hospital frequently, you have
to basically get an antibodytiter.
(13:13):
You, you do a circle.
And most of us are vaccinatedfor Hep B, but if you if, if
your titer isn't up to snuff,you get a booster before you go
into the hospital.
And so there's, there's alreadya sort of a paradigm for this.
But it's pretty reserved.
Really only the groups who needit most.
And but my hope is that as wemove forward forward, we'll both
(13:33):
see the value in this kind oftesting.
And also the cost of doing thesekinds of tests will go down as
the interest and investment inthem goes back.
And so hopefully that'll meanthat it's no longer just
reserved to the people who areworking in hospitals, who
admittedly are the ones whoreally.
You know, th they're the oneswho need to be getting this sort
of test right now.
But it would be wonderful tostart to see that become more
(13:55):
widely available for COVID-19for other infectious diseases,
because it really is that that'sreally what we're trying to
measure here is, is how, howimmune you are and not
necessarily how many doses of avaccine that you've gotten.
Yep.
Great.
Matt Boettger (14:07):
And do you expect then this for like the second
booster dose or the fourth?
If you're taking Pfizer as beinglike.
A common thing that's gonna bein this fall.
Like, are we, you know, we werekind of didn't know w initially
thinking that, oh, maybe likethat initial booster is going to
take us far, like maybe a yearor two, three years down the
road.
I don't know where we're at forresearch with how long it seems
(14:27):
like even the booster, somearticles say maybe six months,
again, it might start to wane alittle bit, given the prevalence
of homo Cron and this kind ofstuff.
Are you going to, do you seethat this fourth dose being
pretty much a.
Not required, but are highlyrecommended things for 65 and
older come this fall, or evensooner.
Stephen Kissler (14:46):
Yeah.
You know, I to be honest, Ihaven't really reviewed the data
very closely on the fourth doseyou know, additional booster
kind of Another dose in theseries.
I know that it has been, I thinkit already has been approved and
even recommended for people over50 by the FDA and CDC.
And, but I, I really kind ofwould love to dig into the data
a little bit more because as faras I can tell, it does seem like
(15:09):
the booster has provided asubstantial and more durable
response than the initial seriesdid.
And I think there's still somequestions as to how durable that
responses and also what there isto gain by getting a fourth
dose.
Absolutely.
I think that, like, if you getanother dose of the vaccine,
it's going to rev up your immunesystem again, and that's
probably a good thing, you know,it will, it will give you more
(15:30):
protection.
But there are also all of thesedifferent layers of protection
that we need to bear in mind.
It does seem like the boostergoes a very long way and does a
very durable, consistent job ofprotecting people from
hospitalization and death.
I imagined that a fourth dosewill probably go even further
and help prevent people fromgetting symptoms in the first
place, which is great.
And, but it's, it's not clear.
Yeah.
(15:50):
How much added benefit therewill be in a severe disease
camp.
And part of it is just because Idon't know that we've collected
the data.
And even if we have, Iadmittedly have not been able to
dig into it much yet.
So, but that's definitely, youknow, that's, that's been a big
topic over the last couple ofweeks, so it's something I'm
going to be looking at soon.
So hopefully we, hopefully we'llbe able to dig into that a
little bit more in in the nearfuture.
Matt Boettger (16:10):
Great.
Great.
Well, let's get an, youmentioned the CDC.
Let's talk about that now,because now we're seeing, you
know, all the guidelines of theCDC.
We talked about this just overtwo weeks ago and how some of
the goods.
So the pros and the cons of thechanging towel now with the new
guidelines, what was consideredhigh risk for a particular state
is now low risk and there'sdifferent criteria.
(16:32):
And now on top of that, we, thislayer of funding being removed.
So I just want to get your, yourinsights of where you, where you
think, where are you thinkingabout the direction of the lack
of funding?
It seems like in my mind, I th Ijust kinda thought things were
like, they're gearing up.
We're establishing kind of a newmaintenance routine of how to
deal with infectious disease.
And once this funding goes away,it can go in like autopilot and
(16:54):
keep going.
But it sounds like.
Drop, maybe like things thatwere installed are helpful.
We're going to no longer havefunding and they're going to be
removed.
And where do you see all thisgoing?
What would you buy?
The biggest thing.
But I don't see clearly, as Iread these articles about
complaining about the fundingbeing dropped, but I don't see
too often, these benchmarks oflike, well, we didn't read, we
(17:16):
didn't reach this benchmarks.
We need X amount of more months.
It's just more like, we need thefunding.
And for me it's like, oh, thatcould go on forever.
And we can't do that forever.
But do you see like a benchmarkthat we haven't quite got to,
that you would say, oh, weshould keep this funding.
Or where do you see yourself inthe midst of all?
Stephen Kissler (17:34):
Yeah.
You know, it's, it's hard.
And this gets into thecomplexities of, of national
budgets, which I have zeroexperience.
Because you're right.
It's like, you know, absolutely.
I think we need to bemaintaining a consistent and
responsive approach.
To managing COVID-19 cases inthe us.
(17:54):
But it, it is one of manypriorities as, as a country.
And and so it's, it's like hardto know how to, how to weigh
those things together.
So of course I think that youknow, dropping funding
altogether from COVID-19response would be a huge
mistake.
I don't think that's reallywhat's being proposed.
The, what I would really hope tosee as we move forward is, you
know what I, it does seem to melike we're, we're beginning to
(18:17):
move out of a phase and I thinkthis is this is.
You know, an accurate reading onthe part of sort of the general
political mill, you you know, ththat we're, we're moving out of
this crisis phase of thepandemic and, and moving into a
management phase.
And some of that has to do withepidemiological factors.
You know, we've been through amajor wave of cases that
(18:38):
actually didn't translate tohospitalizations and deaths at
quite the same rate as it hadbeen before.
So that's a good move.
In cases are relatively lowright now.
We're going into spring andsummer when historically cases
have been, you know, nationallysort of more manageable.
So if there were ever a time tosort of regroup and evaluate
where we want to go forward withthis, you know, this, this is
it.
And so I think that, you know,what it really makes sense to do
(18:59):
is to maintain funding in theareas that will allow us to
respond quickly and efficientlyto new searches.
So it's still possible that anew variant can emerge at any
time and we'll have to deal withit in short order.
Right.
And so I want to make sure thatwe, you know, we have the
resources to do that.
And so it remains true that likehaving a Yeah, a stockpile of
vaccines makes sense.
(19:20):
And that's partly informed bythe fact that you know, two
doses of an MRN, a didn't helpall that much against McCrone,
but three very much did.
It could be that in the future,variant three may not help as
much, but for well I don't knowfor sure, but, but it makes
sense to have some amount onhand to vaccinate, especially
the vulnerable very quicklymakes sense to have tests
available.
(19:41):
Maintaining investment in rapidtests and making sure that
they're available and that youdon't have to like go searching
through 20 different CVS as tofind one like we have in the
past.
Like that, that makes sense.
And those things don't reallyexpire very quickly.
So I think making sure that wehave a good stockpile of those
make sense pharmacy.
Again, like those things, we canreally stockpile and make sure
that we have on hand.
(20:01):
And so my sense is that as longas we have enough of those
things available to deal with animpending surge in short order,
then it's okay to sort of backoff of some of the other funding
for maintenance.
And, and I will say that, youknow, there are other areas
where the government and the CDChave been investing in sort of a
longer-term approach towardsmanaging infectious diseases,
including like funding this newcenter for outbreak analytics.
(20:22):
That's going to be doing a lotof modeling, a lot of
surveillance.
Both for COVID-19 and for otherinfectious disease threats.
So my hope is that some of thatfunding that is being taken away
from COVID specific efforts willalso be transitioned to, into
sort of thinking about, okay,what's next.
And and I think that's probablythe best thing that we can do at
this point.
Matt Boettger (20:39):
I like that.
Yeah.
Moving things from like an acuteallocation for acute crisis to
more of a long-term maintenanceof, of systems to put in place
to, to govern and, and growthis.
Okay.
The one other thing on this, onthis kind of area is my friends.
This article, they from airlinesAmerica for airlines kind of
provoking the airline.
To reconsider relinquishingmasks and particularly the
(21:02):
testing, you know, before youcome back home and showing like
the economic downtown people,not wanting to go and travel
overseas because they're afraidof getting stuck.
And there, you know, this art,this letter kind of provided the
scientific evidence.
This is really isn't necessary.
I don't know if you wanted toweigh in on that.
If you could likeepidemiologically, is there any.
Support the can for continuedmass in the airport at this
(21:26):
point in time and like testingand, you know, do you have any
opinion on where this stands forwhen it comes to airlines when
their next, their next move forthe summer?
Stephen Kissler (21:36):
Yeah.
I think that with with thetesting issue, it's, it's tricky
because, you know, like yousaid, it's It does, you know,
you're, there, there is thisconcern of being stuck
somewhere.
And that, I mean, Yeah.
It's like, I don't know, is thatbetter than flying with COVID-19
then going to the airport likethat?
Maybe so, you know, so I'm, I'm,I'm hesitant to say that like,
(21:59):
yeah, we should just sort ofdrop the testing requirement.
But, but I do recognize, youknow, that maybe the added
benefit of tests.
When people are getting on anairplane is not that great when
we're not actually testinganywhere else.
Most, most of the spread that'shappening right now is not
coming from travelers, you know,coming from other places.
I think that testing makes a lotof sense in the context of a new
variant when we're trying tosort of slow the spread of
(22:21):
something like Omicron and eh,their, their testing makes an
awful lot of sense.
Now it's kinda hard to say it'skind of everywhere.
And so it's like, you know,spreading it through an era,
like you're just as likely toget it anywhere else as you are
in an airport or on the airplanewhen it comes to masks.
I think that I like.
(22:42):
Honestly, I don't plan to ditchmy mask in airports anytime
soon.
There were times way before thepandemic that I kind of felt
like I should be wearing a maskanyway, but I felt a little
weird about it, you know?
And that's, I don't think themasks are keeping anyone from
traveling.
I could be wrong, but I, youknow, like that's and there, you
know, it also, the other thingis that the masks are probably
most important while you're inthe airport.
(23:02):
I had this funny.
The last time I was travelingwhere you know, there's somebody
who is like wearing an N 95around their neck and, you know,
while they were waiting in lineto get on the airplane.
And then as soon as they got onthe airplane, they like put on
the mask and it's like, youknow, in many ways that's kind
of the opposite of what youwanna do.
Cause it's in the airport whereyou're not going to have as good
ventilation.
And you're mixing with a ton ofdifferent people.
Once you're on the airplane,like you're probably sharing air
(23:24):
with maybe the people right nextto you.
But otherwise, like those thingshave HEPA filters and like a
huge number of air transitions.
Such.
So it's like actually the riskof spread on an airplane is not
huge.
And so, so I could see anargument for saying, like, be
masked to airports, but then youcan like be less stringent about
them on the airplane.
I think that would also reallyhelp.
(23:45):
I know that a lot of poor flightattendants have had a lot of
issues with compliance withmasks on planes.
Right.
And there's been a lot of, sortof like.
Argumentation and even violence.
And so like, if it helps withthat then great.
You know, if we can say like,you know what masks are optional
when you're actually on theairplane and if that makes
flight attendants jobs easierthan absolutely.
I can get behind that because Iactually am not convinced that
(24:07):
masks.
Do a huge amount of help whenyou're actually on the airplane,
but in the airport.
Definitely.
So those, those are sort of someof the things that I'm thinking
about as I'm thinking aboutchanging policies with, with,
with travel.
Matt Boettger (24:18):
Great.
Well, the distinction, so let'sget into quickly to Hong Kong
because it's, you know, totalchange shift of what's been
happening there.
We just love to get yourinsights of like, what happened,
you know, and this is anonpolitical statement,
honestly, but I'm like, I feltlike when I was reading some of
these articles, some of theaftermath of what's happened,
Hong Kong felt like.
Nick and mini America, many ofus like the lack of trust and a
(24:41):
vaccine hesitancy, all thesekind of similar, similar
overtures that we have here aswell.
But clearly just being riddledwith hospitalizations, just
wanted to get your reflectionson what's going on there.
And w w what happened thatcreated to create that
situation?
Stephen Kissler (24:56):
Yeah.
Yeah.
So Hong Kong is a reallyinteresting sort of case in you
know, thinking about themanagement of COVID-19 getting
into for any listeners whohaven't, haven't had a chance to
look at, you know, the, the datayou know, hospitals like cases
and deaths in Hong Kong lately.
It's pretty remarkable.
I've, I've got it pulled upright now next to me.
And you can just type intoGoogle, Hong Kong COVID cases.
(25:17):
And it's like flatline.
Like all the way up until a fewmonths ago.
Like nothing.
And then there's this huge surgeand that's, you know, driven by
the Macron variant.
And so, you know, one of theother things I want to pull up
here is so looking also at.
For example, COVID 19 cases inNew Zealand.
So in many ways prior to theOmicron surge New Zealand and
(25:41):
Hong Kong had actually prettysimilar experiences with the
virus in the sense that theywere able to get it out early
and keep it out for essentiallythe duration of the pandemic up
until this point.
And then lately they've beenrelaxing, travel restrain.
And so that's, you know,inevitably COVID has been able
to spread.
But one of the big issues inHong Kong seems to be the fact
that again, the older age groupsthere's been a lot more vaccine
hesitancy amongst those groups.
(26:02):
There's been lower vaccinationrates amongst those groups than
there have been, for example, inNew Zealand where despite a
pretty big surgeon cases, thenumber of deaths has remained
pretty low.
Really an order of magnitudelower than what we've seen in
Hong Kong.
And and so I really think itcomes down to that in, in very
large part.
And I think, you know, w what alot of this speaks to is that
(26:22):
these issues of vaccinehesitancy of trust in the
medical establishment of reallyjust evaluating personal risk
and thinking about vaccinationas such like these are not.
American issues.
These are not necessarily like,American and European issues.
You know, they, these are, theseare really human issues and they
look, they look different indifferent places for sure.
(26:43):
But but we we have some reallysort of.
Deep questions to resolve here.
And and so I think that, youknow, the, probably the, you
know, the, the short explanationof this is really just like
differences in which age groupshave been most highly
vaccinated.
But that really points towards amuch bigger issue of like, what
is it about vaccination thatmakes some people more likely to
accept it on others less?
(27:04):
And yeah, just like what.
What can we do about lack oftrust in the medical
establishment?
What can we do aboutmisinformation?
What can we do about you know,there are many people who have
very good reasons to not getvaccinated, but then like, what
do we do to make sure that wehear and honor those, those
reasons as well?
You know, and I think I thinkthose are, those are questions
(27:27):
that we don't really have goodanswers to.
And unfortunately in Hong Kong,we're seeing that you know, the
lower rates of vaccination seemto have.
Had a heavy toll.
And I think that just points toall the more than needs to to
answer these questions, all themonitored.
Matt Boettger (27:39):
That's great.
And I think also part of that,I'm not, I'm not too familiar
with all the Hong Kong stuff,but they rolled out a vaccine
really early and they chose notto go with the Pfizer one and
some other one.
And I don't share that.
I don't even know if anybodyknows the data on that
particular vaccine.
So you have a vaccine hesitancyon top of the vaccine that was
rolled out early and I'm notentirely sure how good it is,
(28:00):
right against Macron.
Whereas Pfizer in modern arejust pretty, pretty good,
especially with the booster.
So a lot of different threadscoming together to form.
A pretty big mess in Hong Kongright now.
Yep.
So next we talk.
One thing I wanted to mentionjust briefly you mentioned this
early on, maybe like a month ortwo ago, who, who says most
likely scenario shows, covets,Verity deal decrease over time,
(28:21):
which is just another layer ofright.
As we begin to unfoldrestrictions and do more things.
It's like, this is another kindof.
Prosthetic voice, whether it'sright or not, we don't know.
Right.
It's most like it could bedifferent, but again, another
reason to, or incentive todecrease the measures by which
we funding those kinds of thingswhere Alex metrics, because we
(28:42):
were.
And to be better down the road,even though it's not necessarily
true.
Stephen Kissler (28:47):
Right.
And I think an important pointwith that is that it's not
necessarily the inherentseverity of COVID that's going
to decrease over time.
I think that that's, that'sanother element of this story in
Hong Kong too, is that therewas, there's been a lot of, sort
of, you know, claims that oh,Macron is just like a wimpier
version of COVID-19.
But actually it's a, it's aTestament to our immune systems.
And I think what we're seeing inHong Kong is that Omicron is, is
(29:08):
every bit as severe.
Maybe not as Delta, butcertainly as the pre Delta
variants of COVID-19 But in muchof the rest of the world, we've
got a lot more immunity built upeither through vaccination or
through multiple rounds ofprevious infection.
And, and that's, that's thestory there.
It's, it's not, it's notnecessarily that SARS, cov two
is evolving to become.
The severe, it could, I'm notsaying that that's out of the
(29:30):
picture, but that doesn't seemto be what's happened so far.
I think what's behind thestatement is that the critical
piece of this and, and the wayin which severity decreases is
by increasing immunity.
And I think that's usefulbecause that that points to.
Ways that we can respond to it.
You know, one, we can just sortof sit and wait and wait for the
virus to get wimpier, but Idon't think that's realistic
because immunity is actuallysomething that we can be
proactive about.
(29:50):
We can think about vaccinationand we can think about ways of
getting boosted.
We can think about, you know,making sure that the people who
are immunocompromised areprotected and all the ways that
they need to be protected and.
How do we decrease coveredseverity over time?
That was
Matt Boettger (30:01):
great.
Thanks for that nuance.
That's really that's great.
So now when it comes todetecting COVID, I just want to
drop this as well.
A new PCR tests can identify allSARS, cov, two variants, any
positive patient sample.
This seems pretty cool.
Even going down like even colorcoding, you know, w whether it's
an OMA, Cron Delta, you know, soI'm not sure it'll get to the
point where, like, I get my.
(30:22):
Let's say you you're positiveand you got Delta or, you know,
you got an Omicron.
I'm not sure I'll get that, butwhat ramifications this have for
surveillance, if this becomes acommonplace, a common way by
which we do.
Stephen Kissler (30:35):
Yeah.
Yeah.
So, you know, this is, this isgreat.
I'm going to, I'm going to geekout a little bit if that's all
right.
If you'll indulge me for a fewmoments.
Right.
So, do you know how, like in acomputer colors are stored like
the little data structures?
Usually it's just like a stringof numbers.
They're like numbers andsymbols.
So, there are a lot of differentways to do it, but one of the
most common ways is a hex code.
So they're basically.
Six digits that encapsulate acolor.
(30:57):
And with that, you canencapsulate a ton of different
colors.
Another way of doing it is by aslightly longer string, that's
just binary.
So ones and zeros that basicallygive you, you know, different
shades and hues and things.
And the longer the string themore, you know, the more binary
digits that you have, the moreprecisely you're able to
articulate specifically whatcolor you're talking about.
(31:18):
And so essentially what they'retalking about with PCR detection
of new variants is exactly thesame principle, but on a
molecular scale.
So essentially what PCR is ableto do.
Is to give you a yes, no answer.
If a specific short geneticsequence is present in a sample
that you're trying to test.
So with existing PCR tests it'sactually not just testing a
single genetic sequence for SARScov two.
(31:40):
It's actually three differentsequences that are present on
different parts of the virus.
And they're in for SARS cov two,since it's an RNA virus, there's
testing for sequences of RNA.
So basically just little stringsof RNA letters and seeing,
seeing if they're present in anasal.
And one of the reasons thatpreviously we've been able to
distinguish between for example,alpha and Delta or Delta and
(32:02):
Omicron is because with each ofthose transitions, one of those
three sequences that we'retesting for is mutated in the
virus.
And so it drops out.
And so now you sort of have thisbinary string where.
A Delta infection probablyrepresents a 1, 1, 1 in each of
those different things.
It's a success like each ofthose targets has been
(32:22):
identified, whereas an alpha oran Omicron infection would be
like a 0 1, 1 because one ofthem drops out the S gene target
drops out.
Whereas the the other twotargets remain.
Well, there's no reason why wejust have to test her two or
three different parts of thevirus we can test for 10 or 15.
Or we could think more aboutwhich three we want to use in a
(32:43):
PCR to, to test the virus.
And so essentially what you cando is you can identify.
Parts of the virus that differbetween variants and you can use
those as your tags.
And so by doing that if it, youknow, if one set of those tags
amplify in one sample, you cansay, well, this was probably be
a one.
And then if a different set youcan say, well, that's BA two,
(33:04):
because you happen to include inyour tags.
A little bit of the sequencethat distinguishes BA one from
BA two.
So to do this, you really haveto have a good sense of what the
variants are, what theirsequence.
Yeah.
That's, you know, and weactually do have a pretty good
sense of that.
But once you do that, then youcan actually make these, what we
call like multiplex PCR tests,where you're testing sort of
multiple parts of the viralgenome.
(33:24):
And you're testing the piecesthat give you the most amount of
information about which variantit is.
And then you sort of read outthis binary code and based on
what that code is, you can get.
The certainty about what variantit actually is that a person is
infected with in the same amountof time that it takes to run a
regular PCR, because that's,that's really just what we're
doing already.
So that's the idea behind this.
It's pretty cool because itwould allow us to do much better
surveillance of what iscirculating, where and the
(33:46):
relative prevalence of differentstrains in a given population
without actually having tosequence everything.
You can just rely on the PCRtests.
So this will allow you to detectnew.
It's necessarily, unless youstart to see some really strange
Binary sequences that don'tmatch anything that you've seen
before.
And then you'll have to do thesequencing to figure out what's
going on, but this can go a longway towards helping us figure
(34:07):
out.
What's actually one of thethings that we already know of
what's what's circulating in apopulation at a given time.
Matt Boettger (34:13):
That's great.
I'm guessing this is probably ahuge, because I know, I know we
used to say that UK led genomicresearch and that's a separate
industry, so to speak.
And now if you can build intothe PCR, which has already
mainstream that's.
Almost like exponentially growour capacity to do surveillance
in the U S and I feel like, Iguess if it, if it's
comprehensive enough, like yousaid that then new variants that
(34:35):
come up, hopefully we'll see it.
Anomic, that's weird.
And then that weird allows us tolike start exploring earlier
than, than maybe, you know, sothat's, I'm not sure when I'm
guessing, is this somethingthat's gonna be down the road
mainstream that it's gonna takesome, a lot of some checks and
balances before we're going touse this as a replacement, or
can this be a quick turnaround,like, oh, let's start using
these.
Stephen Kissler (34:56):
Yeah.
You know, we in theory, we couldstart using these next week.
You know, it, it would take awhile to sort of like, you know,
distribute to them, make all thereagents and figure all of that
out for sure.
But but changing the set oftargets that you're testing for
is a pretty routine thing to dowith PCR tests.
So if you have access to.
You could do this tomorrow.
And if you know how to do PCR, Idon't have no idea how to run a
PCR, but but, but, but peopledo, you know.
(35:18):
But, but I think that that is tosay that it's it, the, the, the
technical challenge is minimal.
It's just a matter of deciding,you know, if this is something
of public value to do.
And if so, finding the resourcesto sort of update the
infrastructure that we alreadyhave and update it to this new
sort of version of PCR.
Matt Boettger (35:36):
Great.
Fabulous.
Okay.
So next part here, we're gettingclose to the end.
Another interesting article Iread, and I know this was
interesting to you cause you,you read this as well.
So the surprising link betweenCOVID 19 and deaths is internet
access.
Now this, these, this thing,when I read it got me excited,
but it also made me a littleweird.
Like I'm like, okay, can thisreally be true?
(35:58):
The internet access and they,you know, they can get some so,
and I'm glad I brought it to youbecause you say this is a great,
maybe a great segue of helpingto understand the audience or
get people up to speed of how tobe able to look at this data and
see the nuances behind, youknow, what's real, what's not,
what's complicated, what needsto be considered in light of
this.
So I want you to take it away.
And what were your firstimpressions when you read this
(36:20):
article and and the nuancesbehind.
Yeah,
Stephen Kissler (36:24):
right.
So, I think, you know, when youhear a headline like this, the
first thing that shouldimmediately spring to your mind
is correlation is not causation,right?
Like that's like, you know, ifthat, and I hope that at this
point in the pandemic that isjust drilled into everyone's
heads.
And anytime you hear a causalclaim immediately those alarm
bells should come up and youshould ask, like, is this a
relationship or is this a causallink between two different
(36:46):
things?
That said, you know, digginginto this article they really
did go to great lengths to tryto what we call in statistics to
control for different variablesthat could be other explanations
for.
Difference in COVID-19 rates forpeople who haven't have internet
versus who don't like theobvious ones being like
(37:07):
socioeconomic status or urbanand rural location.
There are a lot of differentthings that you could say like,
oh, well this is just a proxyfor this other thing.
And that's, what's actuallydriving the difference.
Well, there are ways that youcan at least sort of nominally.
Adjust for these differentfactors to sort of include them
in the analysis and say like,no, even when we've adjusted for
all of these different things,there still seems to be this
(37:28):
difference associated withinternet access.
Now that still doesn't go so faras say, The cause there, you
know, the other thing is thatthere could still be some
underlying factors that are notyet perfectly accounted for by
the other variables that you putinto your analysis, but it does
make that link a little bitstronger, you know, where it's
like, well, we can't justtotally discount this difference
(37:50):
in COVID cases, by individualswho have, or don't have internet
access at home.
And and so, and so it, it begsfor a further look.
So, so the first thing, youknow, I think you know, we can
first play with the idea thatmaybe there, maybe there isn't a
difference.
Maybe, maybe there is a causallink and we can start to ask
ourselves, you know, why, whymight that be the case?
And you can imagine all sorts ofthings from like access to
information.
(38:10):
And I think that's really themain one is like ability to
access and to find informationabout COVID-19 in relatively
short order.
But then, you know, what are,what are some other confounders
that might be available?
So you can think, okay, if youcontrol for someone who has the
same socioeconomic status livingin the same neighborhood same
demographic characteristics, butone has internet.
And one doesn't.
(38:31):
You might imagine that the onewho has internet is already a
little bit more plugged intosocial services that has helped
them get that internet than theperson who isn't.
And so maybe those socialservices are actually the things
that are helping them reducetheir rates of COVID 19 and not
the internet itself.
And that wasn't really able tobe low.
Rigorously in this statisticalcontrol design.
So there could very much beother what we call confounders
(38:51):
that are behind this, eventhough they tried to control for
as much as they could.
So the way that I read a study,like this is sort of as this
like, point of interest, youknow, I read a study like this
and I go like, huh.
You know, like, that's, that'sbasically as much as it, you
know, as, as it's able to do.
And so it's not that I.
That I now believe that givingeveryone internet is now going
(39:14):
to reduce their chances ofgetting COVID-19 or future
infectious diseases.
It could, and there are a ton ofother really good reasons to
make internet much more widelyavailable.
Right.
So, so sure I can get behindthat.
And maybe this is one morereason that, you know, one more
thing that could tip the balancein favor of giving people
internet, but really, you know,scientifically what this is.
You know, begins a narrative inmy mind where now, anytime I
(39:35):
come across another study thatsays internet and infectious
disease, I'm going to be like,oh, I can put this in the
context of this other thing thatI've read.
And over time, hopefully we canbuild sort of a scientific
consensus where we're looking atthis question and a lot of
different populations and from alot of different angles and
maybe even some experiments aredone.
Give people, internet.
And then you see if that changestheir experience with infectious
(39:57):
diseases over time.
So it's more of a controlledexperiments as opposed to you
know, just an observationalstudy and then maybe we can
build up an evidence base aboutthis.
So the most important thing isthat one study never really
gives scientific proof.
It's sort of a consensus betweenan entire set of studies.
Really that's that's thecurrency by which science
(40:17):
operates.
And so what this does is it saysit sort of raises an interesting
question and does a pretty solidinitial attempt to give evidence
for, and against the reason whyinternet access may or may not
affect a person's experiencewith COVID-19.
And so really for me, what thisdoes, is it sort of earmarks
this, this sort of thread ofthought and I'll sort of carry
it with me as I go forward in myresearch.
(40:38):
That's
great.
Matt Boettger (40:38):
Awesome.
I love that.
One of the things I wanted toend on is this whole long COVID
thing.
This is always it's funnybecause I've read a number of
articles and I just kind of beenstacking them in a little area
for us to talk about.
And then we ended up not talkingabout.
And, and, and, and, and becauseI think you brought it up before
(40:59):
we got on the air.
So this is where I'm going to,I'm going to bring it back to
the surface because I read thesethings like memory and
concentration problems affects70% of long COVID patients
living with, with COVID longcoveted becoming a pediatric
public health crisis.
So these things keeppercolating.
Right.
And I, and I want to talk aboutit, cause I know we have
listeners who have actuallyemailed us saying they suffer
from Lancome.
It's just not, I don't have acare about it.
(41:21):
I'm not trying to be empathetic,but I've always struggled with.
Into the discussion because Idon't even know where to go with
it.
And I think you helped to like,pin this of like why this is
such a complicated reality.
So I wanted to bring it rightback into this discussion as we
end this episode of.
Yeah.
A, have you heard anything aboutlong COVID Dennis have a B I
(41:41):
think more importantly is why isthis such a complicated topic to
topic to talk about when we'retalking even about COVID and
it's long COVID like, it justseems like an anomaly, even
though it's not, I'm notwrestling with a psychological,
how do I fit this in and, and,and, and, and, you know, and
address it to something that wecan actually give valuable
information to people who are.
Stephen Kissler (42:01):
Yeah.
Yeah.
So yeah, there's, there's somuch complexity here.
And you know, I, I also have anumber of friends who are still
suffering from long COVIDeffects.
And so it's like, you know,it's, it, it's very real.
And and I, I you know, I've,I've been sort of.
But personally aware of a lot ofthe frustration of the people
(42:22):
who are suffering from it andthe sense of like, you know,
why, why don't we have moreinformation, more answers?
Why do I feel like not evenbeing heard?
And so I think that, you know,there are so many different
aspects to this issue and youknow, and, and partly, you know,
behind the reason why it's beendifficult for us to even sort of
like talk about on the podcast,because it is such a.
(42:44):
Complex issue.
So I think there are a couple ofthings in place, so, you know,
one of them and one that I thinkthat I've been trying to follow
is is the sense of first beliefin a person's reporting of their
own illness and symptoms.
You know, one of the, there,there are very well-documented
studies that that depending onyour Socioeconomic racial and
(43:06):
ethnic gender status.
You're more or less likely to bebelieved by a physician of, you
know, and and so if, you know, aperson of one set of
characteristics comes in andcomplains of, you know, brain
fog and headaches one might bebelieved and one might not be,
and that's, you know, not acrossthe board, but it's, you know,
it's, it's a fairlywell-documented trend.
(43:27):
And and so, and so that's partof what may be in play and that
like, that at baseline sort ofthis constellation of symptoms
You know, there, there areprobably a lot more people
suffering from it than arenecessarily picked up by the
healthcare system than arenecessarily sort of, seen and
trusted by the healthcaresystem.
And, and so there, there aredefinitely these issues with
sort of the healthcare response,but I don't think that's
(43:47):
everything either.
So another aspect of it is thesort of scientific structure of
our medical.
System and it's, I think eventhat phrase is important here,
where it is fundamentallyscientific and science is based
off of things that you canobserve and measure.
And when it comes to disease, wehave things that are signs and
(44:08):
we have things that are symptomsand signs are sort of
objectively measurable things.
Like I had a fever of 103degrees Fahrenheit.
Whereas a symptom is somethinglike I don't know, I'm feeling
like a little woozy and lungCOVID It does have signs, but it
is principally made up of bysymptoms.
And one of the things that a lotof researchers are trying to do
is to find signs of co of longCOVID of, you know, things that
(44:30):
you can objectively image ormeasure that indicate, you know,
this is long COVID or this is aperson who might be suffering
from long COVID.
And the difficulty betweenhaving a really science-based
medical system is that we oftentend to, and this is true of
science overall, is that we tendto think that things that we
can't measure.
Don't exist.
And you know, that reallydoesn't do us a very good
service either, because clearlythere are lots of things we
(44:51):
can't measure that do very muchexist.
But but I think that's one ofthe barriers here too, is that
we don't really have goodmeasurements for what
constitutes lung COVID adding ontop of all of this is that lung
COVID, the more we dig into it,it doesn't seem like it's a
single.
You know, syndrome, but actuallysort of a collection of things
that can manifest in long-termchronic effects from COVID-19.
(45:15):
And we have a lot of otherdiseases for which this is the
case.
You know, I think aboutdiabetes, which, you know, we
already know that there's typeone and type two diabetes, which
manifest differently have verydifferent causes, have very
different.
Treatments that you need.
And even within those, there aremultiple types of type one and
type two diabetes that also comefrom different places and need
different sorts of treatments.
This is true of cancer as well.
(45:36):
You know, we have cancer thatdescribes this overarching you
know, set of illnesses, but youknow, different cancers.
Utterly different from oneanother and again, come from
different places and requiredifferent sorts of treatment.
And I think that may well betrue of long COVID here too.
That it's actually probably anentire constellation of
conditions.
And it helps to talk about as asingle thing, because it sort of
(45:56):
raises the awareness of thisconstellation of symptoms and
signs and effects from COVID-19.
There's also this difficulty,which is that when we're
studying long COVID, we'reactually probably not studying
one thing.
We're studying a hundreddifferent things and it can be
really difficult to sort of findthe common threads through that
constellation of causes andeffects and figure out what it
(46:18):
is that we can then do about it.
So all of these things arereally conspiring to make it
really difficult, to talk aboutlung COVID and.
Scientific way and leads to alot of the really well justified
frustration on the people whoare suffering from it, because
it is a complex problem and it'sone that I think deserves much
more attention, even more thanit's getting.
But even inherently it's, it'ssuch a complex problem and it
(46:40):
plays on a lot of the weaknessesthat are already inherent in our
medical system.
And so because of all of thesethings, it is, it is just a
complex deal.
Yeah.
Matt Boettger (46:48):
That's well said.
Thanks, Steven, putting that inperspective.
And I know we'll definitely tryto keep our pulse on it at all
times.
So if we want to pro you know,we want to provide value to this
and we know some people havesuffered from it.
And whenever things surface, wewant to make sure that people
are aware of the resourcesavailable.
And what's, what's been theleading research on it.
But it is a complex reality, youknow, we're gonna end on one
last thing and we have to gohave meeting here in a little
(47:08):
bit and we've got to get goingand we'll see you in a couple of
weeks, but this one article.
Steven, I haven't talked aboutit.
I gave it to him to read but Iwant you, our listeners to read
it is called true hope.
Takes a hard look at reality,then makes a plan.
I sent this to mark.
For those of you have listenedfor a long time.
He was part of our, our podcast.
Stephen's brother.
He loved it.
He's a doctor.
This really put a lot of thingsin perspective of dealing with a
(47:30):
juxtaposition between optimum.
And genuine hope.
And the reason why I plant thisseed is because even as a little
bit late to the game cause we'rekind of all wrapping this up,
going to endemic mode.
And I don't think we're seeingthe crisis as much as we did
even six months ago when we hadthat peak.
But nonetheless, I think it'sstill relevant of dealing,
especially when you reflect backon early in 2020, when things
(47:50):
have.
About, you know, first this ideaof optimism, you know, two week
shutdown, this is going to beover with, and you know,
everything's going to flatline.
We'll be okay.
And then realizing thiscontinues to just surface its
ugly head and continue andcontinue and continue.
So optimism turns into despair,right?
It's not going to end.
And now this is going to lastforever.
Right?
So then there's these emotionsthat evoke with this word
(48:11):
forever.
And this article did a great jobof showing how optimism isn't
necessarily the thing we want tocultivate.
We want to cultivate hope andI'll leave you with.
This line that the author puthere, and then I hope you can go
into the show notes and read ityourself, said, namely, he
realized that hopeful peopleshared three things in common
goals, pathways and agency,although Snyder called these the
(48:33):
three components of hope.
It may be more useful to thinkof them as the three conditions
for hope to thrive.
And so if you're, if you're.
Peaks your interest.
It's a little bit longer read,maybe 15, 20 minutes.
It'll get perspective of how tolive in the context of hope and
not optimism as we move forward.
It really encouraged me and Ihope it encourages you as well.
That lands are playing for thisepisode.
(48:55):
Thank you for hanging in there.
Thank you for listening.
If you want to.
Patrion.com/pandemic podcasts aslittle as$5 or one time gift
PayPal, then all in the shownotes and as well, please give
us a review.
You can do that apple podcast.
If you want to get ahold ofSteven S T E P H E N K S S L E R
on Twitter, or just email me, Iwill forward it along to Steven
andmark@mattatlivingthereal.com.
(49:17):
Okay guys, and gals have awonderful week.
We'll see you.
I'm sure.
In two weeks ish and one way oranother.
Okay.
See you soon.
Bye-bye.
You're listening to the vendetta podcast.
We equip you to live the mostreal life possible in the face
of these crises.
My name is Matt Barker and I'mjoined with my one good friend,
Dr.
Steven Kissler, Napa dealer, theHarvard school of public health.
How are you on this incrediblyspring month?
Stephen Kissler (00:15):
Ish.
It's spring down.
It's a spring month.
Yeah, it is spring it's.
I mean, it's actually sort oflike raining really hard last
couple of days here in Boston,which, which is spring time
here.
So yeah, it's finally gettingwarmer and Boy man.
It's it?
It is a, it always feels like amiraculous thing when you emerge
out of the Boston winter.
Cause it was just so cold and solong and so dark.
So yeah, everybody's feeling it.
(00:36):
That's good.
Matt Boettger (00:36):
Yeah.
I cannot imagine I'm so used toColorado three days of, of in a
year.
And those two days, I'm likereally angry and life and I, and
then I feel bad cause most ofthe other world has many more
times.
So, I'm sorry for those who wereprobably expecting a podcast
episode on Monday, a good newsfor me is I got a job another
(00:58):
job.
So I've been doing other randomstuff, got a full-time gig
started on Monday.
So the first few days were kindof crazy.
So, this kind of, this might bean ever evolving, changing,
shifting release.
And I know I haven't even toldSteven yet, but I'll be gone for
over a month.
And so we'll throw that out away from Colorado.
So there might be some timeswhere we might not have an
(01:19):
episode right on time, but we'restill gonna strive hard to be as
regular as humanly possible andregular, I mean that on episode
wise, not like biologically orlike regular, always squarely.
I'm always striving for that at44.
So, I don't know whether Ishould cut that out and I'll
find that out.
I'll, I'll determine that lateron.
(01:40):
But before we get going theregular good stuff.
If you can leave us a review, welove it.
Haven't had one in a few weeks.
Just get inspired by thoselittle drops of notes.
You can do that on applepodcasts.
There's other platforms.
You can do that as well.
We'd love that.
Give us a rating.
Also patrion.com/pandemicpodcast.
As little as$5 a month can helpus keep this going or just a
(02:00):
one-time.
PayPal Venmo all in the shownotes.
Okay.
So it has been a little over twoweeks, Steven.
I feel like there's a decentamount to cover, which is always
interesting.
So I keep thinking that at somepoint in time, we're going to
just sit here and stare at eachother for 45 minutes and then
close up shop and they can hearus breathing.
At the still there's still stuffto talk about.
(02:22):
But the first thing I want tocheck in with you is just
dealing with the, the variantthere's BA too.
I just read an article thismorning about this I guess a BA
three, that's kind of sittingaround, not doing much, but who
knows, but you want to give us astatus of where we're at with B2
because we've heard of Europehaving increasing cases.
There's been a lot of newsarticles about expecting a surge
(02:43):
here.
We've definitely seen an uptick,but nothing dramatic.
Is it Is it more than that?
What should we be expecting thissummer?
Felicity?
Stephen Kissler (02:53):
Yeah.
So, it's, we're sort of in thisspot where it's really hard to
tell for a lot of the pandemic,we have trailed Europe in our
case counts, you know, it's,it's pretty much like when, when
Europe goes up, then we go uppretty consistently about a
month or so later.
You know, why, why that is.
Sure, but it's, it seems to havebeen a relatively consistent
(03:13):
pattern.
And so, and actually, to a largeextent that that is what we're
seeing now, we're starting tosee an uptick in cases in some
parts of the country.
I know here in the Northeast,we've just surpassed the point
where BA two is making up morethan half of the COVID cases
that are being sequenced.
So it's now a majority of what'scirculating here.
And as Europe is to the U Softentimes the coasts of the U S
(03:36):
are to the rest of the country.
And so since we're starting tosee that rise in the proportion
of BA two cases here, I thinkthat we can probably expect that
to happen across much of therest of the country.
But the big question is like,you know, how, how big and how
long will.
B I am not yet convinced thatit's going to be a major feature
of our spring time COVIDexperience here in the U S and
(03:59):
that's to a large extent,because we've had BA to
circulating in the U S for quitesome time.
We've had introductions of BA tohere all the way back since
December.
And so I think that if we'regoing to do something really.
Huge and sharp and sudden itprobably would have done so
already.
Now that's not to say that we'renot going to see a rise in cases
(04:19):
because there, there may be somestrange interactions with
previous immunity and waningimmunity.
And, you know, the fact that ourbehaviors are changing quite a
bit.
Mass mandates are sort oflifting just about everywhere
and You know, every, Icertainly, my behavior has
changed over the last month ortwo.
I've been seeing people more,I've been out and about more.
And and so all of that is goingto contribute to so I think the
(04:41):
most important thing is to tonote that, you know, BA two is
probably more infectious, moretransmissible than the original
Omicron variant, but it's thedifference between BA one and is
nowhere near the differencebetween.
And be a one.
So we're going to start CBA tostart to take over.
But I think that a lot of thesurge that we're seeing is
actually probably behaviorlydriven.
And and, and I think we're goingto be helped by the fact that
(05:05):
this is happening as we're goinginto the spring, as it's easier
to move some of theseinteractions outdoors.
And and so hopefully that'llhelp prevent this from turning
into a major surge.
And it'll just be sort of one ofthose blips that we're, we're
probably going to be dealingwith for a very, very long.
Matt Boettger (05:19):
Yeah, I can imagine.
And yeah, you can already hit italready, but it seems like this
is not necessarily just a BA toreality when it comes to this
uptick in the U S you mentionedthe idea of our behaviors are
changing.
We're going to get into the nextpart of our little discussion
about policies, guidelines andthe CDC.
And is that a good move of theCDC?
Is it, you know, the governmentfunding is starting to go away.
(05:41):
So there's a lot of things thatare kind of coming in the
pipeline that are going tochange this summer dramatically.
Hitting one more part of thiskind of uptick in the us.
I've read an article.
This is great.
Or whatever.
Once in a while I hit an articleand like, oh, that's Steven,
he's actually in there becausethere was a scene where you
quote, you, you were quotedtalking about one of the, kind
of the metrics is looking at the65 and older group I've seen,
(06:05):
what's going to happen.
Can you talk more about that aswe begin to venture forward and
kind of see how do we plan forany future surges cases?
What do we, what things we needto be looking for and
monitoring.
And this other article I talkedabout, which is deeply related,
I think it was by the Atlanticabout this increased desire to
look at another metric, which iskind of the immunity
(06:27):
surveillance.
And so clearly we can watch the65 and older group as they enter
into the hospital.
But I feel like that's kind of alittle bit late.
Are there other things thatwe're doing preparing to help be
a little more preventative tosee?
Okay.
When should we be.
The different measures went to,we encourage the 64.
And all the group to take thesecond booster and that becomes
(06:48):
available those kinds of things.
Stephen Kissler (06:50):
Yeah.
Yeah.
So, you know, with, with the,with the thoughts about the
immunity in the 65 and older agegroup, it's really basically.
A couple of things, you know,first back in, gosh, I don't
even remember what year it isanymore.
It was when when vaccines weresort of first coming online.
So I guess it was like end of20, beginning of 2021.
(07:10):
There was a lot of asking about,you know, who how should we
prioritize vaccine doses andshould we prioritize it to
interrupt, to transmit?
Which would suggest vaccinatingyoung adults.
We should, we should, weprioritize it to reduce severity
of disease primarily, whichwould, which would prioritize
vaccinating the elderly and andsort of prioritizing vaccination
by age group that with each, youknow, as, as you get older, the
(07:30):
more important it is that youget vaccinated.
And based off of the modelingand the information that we had
about the severity of COVID.
By age, it really seemed that itwas by far, in a way, the best
strategy to vaccinate the oldestpeople first.
And that's really been Kind ofsupported by some well, and I
think we'll probably talk aboutthis in a little while too, but
the experience in Hong Kong soone of the really big issues
(07:51):
that seems to be in play in HongKong is that they were able to
keep cases low for a very longtime.
But there's been a lot ofvaccine hesitancy amongst the
older age groups, and that hasled to a really big surge in
hospitalizations and deaths inHong Kong that really hasn't
been.
Seen in other countries like NewZealand, for example, where
there's higher vaccine uptakeamongst the older age groups.
(08:13):
But have had a similarexperience with COVID previously
where it was kept suppressed avery low levels.
So both the modeling and thereal-world experience suggest
that the more immunity you havein the oldest age groups the
better you're going to fair as asociety overall.
I think that it's, you know,this is another one of those
examples where it's reallydifficult to reason.
(08:33):
When we're thinking aboutexponential relationships
instead of linear relationships.
So when I'm talking about therisk of hospitalization and
death increasing with age, Idon't mean that it's still
linear increase where it's likewith each year, your risk goes
up by a fixed amount.
It's really pretty muchexponential, right?
So like, as, as you get olderthe, the risk just increased.
(08:54):
So much that if you compare therisk of hospitalization and
death for somebody who's overthe age of 80, for example
that's, you know, it the risk ofsomebody who's much younger,
really, really pales incomparison.
And so, so that's really why youknow, getting back to this quote
in this article why I reallythink that one of the most
important indicators for howcommunities are going to fare as
(09:17):
we move forward is vaccinate.
And immunity rates in the oldestmembers of our population.
And I do want to say that thisalso extends to other groups who
are vulnerable.
You know, it's not just theelderly who are vulnerable to
severe outcomes.
In many ways that's sort of thelargest and easiest group to
identify with a single category.
(09:37):
But we can ask ourselves, youknow, what is it that makes
people who are elderly morevulnerable to severe disease
from COVID.
So part of it is the immuneresponse that as you get older,
your immune system just doesn'tget fired up as easily.
And so, so of course, that alsothen extends to people who are
immunocompromised.
It extends to people withco-morbidities that either
prevent them from mounting agood immune response, or that
(09:57):
make them more likely to havesevere COVID outcomes.
Because again, as you're elderlyyou tend to have more
cardiovascular conditions.
You tend to have.
The rates of obesity increasethe rates of diabetes increase.
So all of those thingsindependently also affect your
risk of severe disease fromCOVID-19.
So we really want to make sureimmunity is high in those
populations as well.
But again, if, if, if you had tosort of say, you know, if I had
(10:19):
to, you know, if I had 10seconds to tell you what my
strategy would be for gettingcommunities through this, I
would have to, I would have tostick with that oldest age
groups because that's that'ssort of does the best job of
sort of encapsulating all ofthat together.
Yeah.
So that's, that's a, long-windedanswer to the first part of your
question.
I know you had another one aboutimmune correlates too, but let
me know if you want to dive offon another tangent.
Matt Boettger (10:41):
That's great.
I think let's go into thatbecause I think just
understanding, cause you, youyou're setting the stage for
this then how do we begin toprep or monitor in.
Have immunity surveillance asbeing a key criteria for us to
be ahead of the curve a littlebit in a different perspective
of monitoring.
When these people, I can kind ofsee how you might be able to do
(11:01):
this on a macro level we werekind of already doing this,
like, oh, it looks like immunityresponse decreases around six or
seven months, but maybe evengetting into a particular
response as part of your, in mymind, like part of your, your
physical and your physical baby,there's something down the road
that encompasses.
Where are you at on particularantibodies for veterans?
(11:23):
Diseases.
Stephen Kissler (11:23):
Right.
Totally.
Yeah.
You know, and so yeah, a couple,a couple of thoughts on that.
I think you're, you'reabsolutely right.
That really what we're talkingabout here is amount of
immunity.
And ideally what we would beable to measure is a person's
antibodies or other immuneresponses to a given pathogen
with.
It correlates with vaccinationand previous infection, but, but
(11:46):
it's not perfect.
It's a pretty noisy correlation.
Right.
What we've seen from studieswhere people have been looking
at antibodies in the blood isthat people really do have a
very wide range of responses tothe vaccine and a previous
infection.
And while it's very much truethat on average, your protection
increases with increasingexposures there are some people
who just really repeatedly, justdon't know how to very good
response at all.
(12:07):
And and so it'd be really worthunderstanding.
And who those people are andwhat we can do.
Again, like I said, you know,for, for some individuals who
already know that they have somekind of immune compromised
condition, that makes sense.
They have reason to suspect thatthey might be one of these
people who don't respond well,but for some other people, it
might be random.
Or, you know, th there may besome underlying condition that
(12:27):
they're not aware of.
And, and that leads to this hugeamount of variation between
people.
So I do think, you know, we'renot yet at the point where we
can.
Do a serology for COVID-19 onsort of a widespread population
basis.
And then say like, you know,like your immune response,
hasn't been very good.
You would really benefit fromanother dose of the vaccine or
you might want to take theselist of precautions, but that
(12:51):
realistically I think that thatmay be.
A direction that we're headingit with immunity to both
COVID-19 and other infectiousdiseases.
There are certain infections forwhich we already do this for
people who are working inhealthcare, for example.
So for, I think it's hepatitisB.
If you're going to be working ina hospital frequently, you have
to basically get an antibodytiter.
(13:13):
You, you do a circle.
And most of us are vaccinatedfor Hep B, but if you if, if
your titer isn't up to snuff,you get a booster before you go
into the hospital.
And so there's, there's alreadya sort of a paradigm for this.
But it's pretty reserved.
Really only the groups who needit most.
And but my hope is that as wemove forward forward, we'll both
(13:33):
see the value in this kind oftesting.
And also the cost of doing thesekinds of tests will go down as
the interest and investment inthem goes back.
And so hopefully that'll meanthat it's no longer just
reserved to the people who areworking in hospitals, who
admittedly are the ones whoreally.
You know, th they're the oneswho need to be getting this sort
of test right now.
But it would be wonderful tostart to see that become more
(13:55):
widely available for COVID-19for other infectious diseases,
because it really is that that'sreally what we're trying to
measure here is, is how, howimmune you are and not
necessarily how many doses of avaccine that you've gotten.
Yep.
Great.
Matt Boettger (14:07):
And do you expect then this for like the second
booster dose or the fourth?
If you're taking Pfizer as beinglike.
A common thing that's gonna bein this fall.
Like, are we, you know, we werekind of didn't know w initially
thinking that, oh, maybe likethat initial booster is going to
take us far, like maybe a yearor two, three years down the
road.
I don't know where we're at forresearch with how long it seems
(14:27):
like even the booster, somearticles say maybe six months,
again, it might start to wane alittle bit, given the prevalence
of homo Cron and this kind ofstuff.
Are you going to, do you seethat this fourth dose being
pretty much a.
Not required, but are highlyrecommended things for 65 and
older come this fall, or evensooner.
Stephen Kissler (14:46):
Yeah.
You know, I to be honest, Ihaven't really reviewed the data
very closely on the fourth doseyou know, additional booster
kind of Another dose in theseries.
I know that it has been, I thinkit already has been approved and
even recommended for people over50 by the FDA and CDC.
And, but I, I really kind ofwould love to dig into the data
a little bit more because as faras I can tell, it does seem like
(15:09):
the booster has provided asubstantial and more durable
response than the initial seriesdid.
And I think there's still somequestions as to how durable that
responses and also what there isto gain by getting a fourth
dose.
Absolutely.
I think that, like, if you getanother dose of the vaccine,
it's going to rev up your immunesystem again, and that's
probably a good thing, you know,it will, it will give you more
(15:30):
protection.
But there are also all of thesedifferent layers of protection
that we need to bear in mind.
It does seem like the boostergoes a very long way and does a
very durable, consistent job ofprotecting people from
hospitalization and death.
I imagined that a fourth dosewill probably go even further
and help prevent people fromgetting symptoms in the first
place, which is great.
And, but it's, it's not clear.
Yeah.
(15:50):
How much added benefit therewill be in a severe disease
camp.
And part of it is just because Idon't know that we've collected
the data.
And even if we have, Iadmittedly have not been able to
dig into it much yet.
So, but that's definitely, youknow, that's, that's been a big
topic over the last couple ofweeks, so it's something I'm
going to be looking at soon.
So hopefully we, hopefully we'llbe able to dig into that a
little bit more in in the nearfuture.
Matt Boettger (16:10):
Great.
Great.
Well, let's get an, youmentioned the CDC.
Let's talk about that now,because now we're seeing, you
know, all the guidelines of theCDC.
We talked about this just overtwo weeks ago and how some of
the goods.
So the pros and the cons of thechanging towel now with the new
guidelines, what was consideredhigh risk for a particular state
is now low risk and there'sdifferent criteria.
(16:32):
And now on top of that, we, thislayer of funding being removed.
So I just want to get your, yourinsights of where you, where you
think, where are you thinkingabout the direction of the lack
of funding?
It seems like in my mind, I th Ijust kinda thought things were
like, they're gearing up.
We're establishing kind of a newmaintenance routine of how to
deal with infectious disease.
And once this funding goes away,it can go in like autopilot and
(16:54):
keep going.
But it sounds like.
Drop, maybe like things thatwere installed are helpful.
We're going to no longer havefunding and they're going to be
removed.
And where do you see all thisgoing?
What would you buy?
The biggest thing.
But I don't see clearly, as Iread these articles about
complaining about the fundingbeing dropped, but I don't see
too often, these benchmarks oflike, well, we didn't read, we
(17:16):
didn't reach this benchmarks.
We need X amount of more months.
It's just more like, we need thefunding.
And for me it's like, oh, thatcould go on forever.
And we can't do that forever.
But do you see like a benchmarkthat we haven't quite got to,
that you would say, oh, weshould keep this funding.
Or where do you see yourself inthe midst of all?
Stephen Kissler (17:34):
Yeah.
You know, it's, it's hard.
And this gets into thecomplexities of, of national
budgets, which I have zeroexperience.
Because you're right.
It's like, you know, absolutely.
I think we need to bemaintaining a consistent and
responsive approach.
To managing COVID-19 cases inthe us.
(17:54):
But it, it is one of manypriorities as, as a country.
And and so it's, it's like hardto know how to, how to weigh
those things together.
So of course I think that youknow, dropping funding
altogether from COVID-19response would be a huge
mistake.
I don't think that's reallywhat's being proposed.
The, what I would really hope tosee as we move forward is, you
know what I, it does seem to melike we're, we're beginning to
(18:17):
move out of a phase and I thinkthis is this is.
You know, an accurate reading onthe part of sort of the general
political mill, you you know, ththat we're, we're moving out of
this crisis phase of thepandemic and, and moving into a
management phase.
And some of that has to do withepidemiological factors.
You know, we've been through amajor wave of cases that
(18:38):
actually didn't translate tohospitalizations and deaths at
quite the same rate as it hadbeen before.
So that's a good move.
In cases are relatively lowright now.
We're going into spring andsummer when historically cases
have been, you know, nationallysort of more manageable.
So if there were ever a time tosort of regroup and evaluate
where we want to go forward withthis, you know, this, this is
it.
And so I think that, you know,what it really makes sense to do
(18:59):
is to maintain funding in theareas that will allow us to
respond quickly and efficientlyto new searches.
So it's still possible that anew variant can emerge at any
time and we'll have to deal withit in short order.
Right.
And so I want to make sure thatwe, you know, we have the
resources to do that.
And so it remains true that likehaving a Yeah, a stockpile of
vaccines makes sense.
(19:20):
And that's partly informed bythe fact that you know, two
doses of an MRN, a didn't helpall that much against McCrone,
but three very much did.
It could be that in the future,variant three may not help as
much, but for well I don't knowfor sure, but, but it makes
sense to have some amount onhand to vaccinate, especially
the vulnerable very quicklymakes sense to have tests
available.
(19:41):
Maintaining investment in rapidtests and making sure that
they're available and that youdon't have to like go searching
through 20 different CVS as tofind one like we have in the
past.
Like that, that makes sense.
And those things don't reallyexpire very quickly.
So I think making sure that wehave a good stockpile of those
make sense pharmacy.
Again, like those things, we canreally stockpile and make sure
that we have on hand.
(20:01):
And so my sense is that as longas we have enough of those
things available to deal with animpending surge in short order,
then it's okay to sort of backoff of some of the other funding
for maintenance.
And, and I will say that, youknow, there are other areas
where the government and the CDChave been investing in sort of a
longer-term approach towardsmanaging infectious diseases,
including like funding this newcenter for outbreak analytics.
(20:22):
That's going to be doing a lotof modeling, a lot of
surveillance.
Both for COVID-19 and for otherinfectious disease threats.
So my hope is that some of thatfunding that is being taken away
from COVID specific efforts willalso be transitioned to, into
sort of thinking about, okay,what's next.
And and I think that's probablythe best thing that we can do at
this point.
Matt Boettger (20:39):
I like that.
Yeah.
Moving things from like an acuteallocation for acute crisis to
more of a long-term maintenanceof, of systems to put in place
to, to govern and, and growthis.
Okay.
The one other thing on this, onthis kind of area is my friends.
This article, they from airlinesAmerica for airlines kind of
provoking the airline.
To reconsider relinquishingmasks and particularly the
(21:02):
testing, you know, before youcome back home and showing like
the economic downtown people,not wanting to go and travel
overseas because they're afraidof getting stuck.
And there, you know, this art,this letter kind of provided the
scientific evidence.
This is really isn't necessary.
I don't know if you wanted toweigh in on that.
If you could likeepidemiologically, is there any.
Support the can for continuedmass in the airport at this
(21:26):
point in time and like testingand, you know, do you have any
opinion on where this stands forwhen it comes to airlines when
their next, their next move forthe summer?
Stephen Kissler (21:36):
Yeah.
I think that with with thetesting issue, it's, it's tricky
because, you know, like yousaid, it's It does, you know,
you're, there, there is thisconcern of being stuck
somewhere.
And that, I mean, Yeah.
It's like, I don't know, is thatbetter than flying with COVID-19
then going to the airport likethat?
Maybe so, you know, so I'm, I'm,I'm hesitant to say that like,
(21:59):
yeah, we should just sort ofdrop the testing requirement.
But, but I do recognize, youknow, that maybe the added
benefit of tests.
When people are getting on anairplane is not that great when
we're not actually testinganywhere else.
Most, most of the spread that'shappening right now is not
coming from travelers, you know,coming from other places.
I think that testing makes a lotof sense in the context of a new
variant when we're trying tosort of slow the spread of
(22:21):
something like Omicron and eh,their, their testing makes an
awful lot of sense.
Now it's kinda hard to say it'skind of everywhere.
And so it's like, you know,spreading it through an era,
like you're just as likely toget it anywhere else as you are
in an airport or on the airplanewhen it comes to masks.
I think that I like.
(22:42):
Honestly, I don't plan to ditchmy mask in airports anytime
soon.
There were times way before thepandemic that I kind of felt
like I should be wearing a maskanyway, but I felt a little
weird about it, you know?
And that's, I don't think themasks are keeping anyone from
traveling.
I could be wrong, but I, youknow, like that's and there, you
know, it also, the other thingis that the masks are probably
most important while you're inthe airport.
(23:02):
I had this funny.
The last time I was travelingwhere you know, there's somebody
who is like wearing an N 95around their neck and, you know,
while they were waiting in lineto get on the airplane.
And then as soon as they got onthe airplane, they like put on
the mask and it's like, youknow, in many ways that's kind
of the opposite of what youwanna do.
Cause it's in the airport whereyou're not going to have as good
ventilation.
And you're mixing with a ton ofdifferent people.
Once you're on the airplane,like you're probably sharing air
(23:24):
with maybe the people right nextto you.
But otherwise, like those thingshave HEPA filters and like a
huge number of air transitions.
Such.
So it's like actually the riskof spread on an airplane is not
huge.
And so, so I could see anargument for saying, like, be
masked to airports, but then youcan like be less stringent about
them on the airplane.
I think that would also reallyhelp.
(23:45):
I know that a lot of poor flightattendants have had a lot of
issues with compliance withmasks on planes.
Right.
And there's been a lot of, sortof like.
Argumentation and even violence.
And so like, if it helps withthat then great.
You know, if we can say like,you know what masks are optional
when you're actually on theairplane and if that makes
flight attendants jobs easierthan absolutely.
I can get behind that because Iactually am not convinced that
(24:07):
masks.
Do a huge amount of help whenyou're actually on the airplane,
but in the airport.
Definitely.
So those, those are sort of someof the things that I'm thinking
about as I'm thinking aboutchanging policies with, with,
with travel.
Matt Boettger (24:18):
Great.
Well, the distinction, so let'sget into quickly to Hong Kong
because it's, you know, totalchange shift of what's been
happening there.
We just love to get yourinsights of like, what happened,
you know, and this is anonpolitical statement,
honestly, but I'm like, I feltlike when I was reading some of
these articles, some of theaftermath of what's happened,
Hong Kong felt like.
Nick and mini America, many ofus like the lack of trust and a
(24:41):
vaccine hesitancy, all thesekind of similar, similar
overtures that we have here aswell.
But clearly just being riddledwith hospitalizations, just
wanted to get your reflectionson what's going on there.
And w w what happened thatcreated to create that
situation?
Stephen Kissler (24:56):
Yeah.
Yeah.
So Hong Kong is a reallyinteresting sort of case in you
know, thinking about themanagement of COVID-19 getting
into for any listeners whohaven't, haven't had a chance to
look at, you know, the, the datayou know, hospitals like cases
and deaths in Hong Kong lately.
It's pretty remarkable.
I've, I've got it pulled upright now next to me.
And you can just type intoGoogle, Hong Kong COVID cases.
(25:17):
And it's like flatline.
Like all the way up until a fewmonths ago.
Like nothing.
And then there's this huge surgeand that's, you know, driven by
the Macron variant.
And so, you know, one of theother things I want to pull up
here is so looking also at.
For example, COVID 19 cases inNew Zealand.
So in many ways prior to theOmicron surge New Zealand and
(25:41):
Hong Kong had actually prettysimilar experiences with the
virus in the sense that theywere able to get it out early
and keep it out for essentiallythe duration of the pandemic up
until this point.
And then lately they've beenrelaxing, travel restrain.
And so that's, you know,inevitably COVID has been able
to spread.
But one of the big issues inHong Kong seems to be the fact
that again, the older age groupsthere's been a lot more vaccine
hesitancy amongst those groups.
(26:02):
There's been lower vaccinationrates amongst those groups than
there have been, for example, inNew Zealand where despite a
pretty big surgeon cases, thenumber of deaths has remained
pretty low.
Really an order of magnitudelower than what we've seen in
Hong Kong.
And and so I really think itcomes down to that in, in very
large part.
And I think, you know, w what alot of this speaks to is that
(26:22):
these issues of vaccinehesitancy of trust in the
medical establishment of reallyjust evaluating personal risk
and thinking about vaccinationas such like these are not.
American issues.
These are not necessarily like,American and European issues.
You know, they, these are, theseare really human issues and they
look, they look different indifferent places for sure.
(26:43):
But but we we have some reallysort of.
Deep questions to resolve here.
And and so I think that, youknow, the, probably the, you
know, the, the short explanationof this is really just like
differences in which age groupshave been most highly
vaccinated.
But that really points towards amuch bigger issue of like, what
is it about vaccination thatmakes some people more likely to
accept it on others less?
(27:04):
And yeah, just like what.
What can we do about lack oftrust in the medical
establishment?
What can we do aboutmisinformation?
What can we do about you know,there are many people who have
very good reasons to not getvaccinated, but then like, what
do we do to make sure that wehear and honor those, those
reasons as well?
You know, and I think I thinkthose are, those are questions
(27:27):
that we don't really have goodanswers to.
And unfortunately in Hong Kong,we're seeing that you know, the
lower rates of vaccination seemto have.
Had a heavy toll.
And I think that just points toall the more than needs to to
answer these questions, all themonitored.
Matt Boettger (27:39):
That's great.
And I think also part of that,I'm not, I'm not too familiar
with all the Hong Kong stuff,but they rolled out a vaccine
really early and they chose notto go with the Pfizer one and
some other one.
And I don't share that.
I don't even know if anybodyknows the data on that
particular vaccine.
So you have a vaccine hesitancyon top of the vaccine that was
rolled out early and I'm notentirely sure how good it is,
(28:00):
right against Macron.
Whereas Pfizer in modern arejust pretty, pretty good,
especially with the booster.
So a lot of different threadscoming together to form.
A pretty big mess in Hong Kongright now.
Yep.
So next we talk.
One thing I wanted to mentionjust briefly you mentioned this
early on, maybe like a month ortwo ago, who, who says most
likely scenario shows, covets,Verity deal decrease over time,
(28:21):
which is just another layer ofright.
As we begin to unfoldrestrictions and do more things.
It's like, this is another kindof.
Prosthetic voice, whether it'sright or not, we don't know.
Right.
It's most like it could bedifferent, but again, another
reason to, or incentive todecrease the measures by which
we funding those kinds of thingswhere Alex metrics, because we
(28:42):
were.
And to be better down the road,even though it's not necessarily
true.
Stephen Kissler (28:47):
Right.
And I think an important pointwith that is that it's not
necessarily the inherentseverity of COVID that's going
to decrease over time.
I think that that's, that'sanother element of this story in
Hong Kong too, is that therewas, there's been a lot of, sort
of, you know, claims that oh,Macron is just like a wimpier
version of COVID-19.
But actually it's a, it's aTestament to our immune systems.
And I think what we're seeing inHong Kong is that Omicron is, is
(29:08):
every bit as severe.
Maybe not as Delta, butcertainly as the pre Delta
variants of COVID-19 But in muchof the rest of the world, we've
got a lot more immunity built upeither through vaccination or
through multiple rounds ofprevious infection.
And, and that's, that's thestory there.
It's, it's not, it's notnecessarily that SARS, cov two
is evolving to become.
The severe, it could, I'm notsaying that that's out of the
(29:30):
picture, but that doesn't seemto be what's happened so far.
I think what's behind thestatement is that the critical
piece of this and, and the wayin which severity decreases is
by increasing immunity.
And I think that's usefulbecause that that points to.
Ways that we can respond to it.
You know, one, we can just sortof sit and wait and wait for the
virus to get wimpier, but Idon't think that's realistic
because immunity is actuallysomething that we can be
proactive about.
(29:50):
We can think about vaccinationand we can think about ways of
getting boosted.
We can think about, you know,making sure that the people who
are immunocompromised areprotected and all the ways that
they need to be protected and.
How do we decrease coveredseverity over time?
That was
Matt Boettger (30:01):
great.
Thanks for that nuance.
That's really that's great.
So now when it comes todetecting COVID, I just want to
drop this as well.
A new PCR tests can identify allSARS, cov, two variants, any
positive patient sample.
This seems pretty cool.
Even going down like even colorcoding, you know, w whether it's
an OMA, Cron Delta, you know, soI'm not sure it'll get to the
point where, like, I get my.
(30:22):
Let's say you you're positiveand you got Delta or, you know,
you got an Omicron.
I'm not sure I'll get that, butwhat ramifications this have for
surveillance, if this becomes acommonplace, a common way by
which we do.
Stephen Kissler (30:35):
Yeah.
Yeah.
So, you know, this is, this isgreat.
I'm going to, I'm going to geekout a little bit if that's all
right.
If you'll indulge me for a fewmoments.
Right.
So, do you know how, like in acomputer colors are stored like
the little data structures?
Usually it's just like a stringof numbers.
They're like numbers andsymbols.
So, there are a lot of differentways to do it, but one of the
most common ways is a hex code.
So they're basically.
Six digits that encapsulate acolor.
(30:57):
And with that, you canencapsulate a ton of different
colors.
Another way of doing it is by aslightly longer string, that's
just binary.
So ones and zeros that basicallygive you, you know, different
shades and hues and things.
And the longer the string themore, you know, the more binary
digits that you have, the moreprecisely you're able to
articulate specifically whatcolor you're talking about.
(31:18):
And so essentially what they'retalking about with PCR detection
of new variants is exactly thesame principle, but on a
molecular scale.
So essentially what PCR is ableto do.
Is to give you a yes, no answer.
If a specific short geneticsequence is present in a sample
that you're trying to test.
So with existing PCR tests it'sactually not just testing a
single genetic sequence for SARScov two.
(31:40):
It's actually three differentsequences that are present on
different parts of the virus.
And they're in for SARS cov two,since it's an RNA virus, there's
testing for sequences of RNA.
So basically just little stringsof RNA letters and seeing,
seeing if they're present in anasal.
And one of the reasons thatpreviously we've been able to
distinguish between for example,alpha and Delta or Delta and
(32:02):
Omicron is because with each ofthose transitions, one of those
three sequences that we'retesting for is mutated in the
virus.
And so it drops out.
And so now you sort of have thisbinary string where.
A Delta infection probablyrepresents a 1, 1, 1 in each of
those different things.
It's a success like each ofthose targets has been
(32:22):
identified, whereas an alpha oran Omicron infection would be
like a 0 1, 1 because one ofthem drops out the S gene target
drops out.
Whereas the the other twotargets remain.
Well, there's no reason why wejust have to test her two or
three different parts of thevirus we can test for 10 or 15.
Or we could think more aboutwhich three we want to use in a
(32:43):
PCR to, to test the virus.
And so essentially what you cando is you can identify.
Parts of the virus that differbetween variants and you can use
those as your tags.
And so by doing that if it, youknow, if one set of those tags
amplify in one sample, you cansay, well, this was probably be
a one.
And then if a different set youcan say, well, that's BA two,
(33:04):
because you happen to include inyour tags.
A little bit of the sequencethat distinguishes BA one from
BA two.
So to do this, you really haveto have a good sense of what the
variants are, what theirsequence.
Yeah.
That's, you know, and weactually do have a pretty good
sense of that.
But once you do that, then youcan actually make these, what we
call like multiplex PCR tests,where you're testing sort of
multiple parts of the viralgenome.
(33:24):
And you're testing the piecesthat give you the most amount of
information about which variantit is.
And then you sort of read outthis binary code and based on
what that code is, you can get.
The certainty about what variantit actually is that a person is
infected with in the same amountof time that it takes to run a
regular PCR, because that's,that's really just what we're
doing already.
So that's the idea behind this.
It's pretty cool because itwould allow us to do much better
surveillance of what iscirculating, where and the
(33:46):
relative prevalence of differentstrains in a given population
without actually having tosequence everything.
You can just rely on the PCRtests.
So this will allow you to detectnew.
It's necessarily, unless youstart to see some really strange
Binary sequences that don'tmatch anything that you've seen
before.
And then you'll have to do thesequencing to figure out what's
going on, but this can go a longway towards helping us figure
(34:07):
out.
What's actually one of thethings that we already know of
what's what's circulating in apopulation at a given time.
Matt Boettger (34:13):
That's great.
I'm guessing this is probably ahuge, because I know, I know we
used to say that UK led genomicresearch and that's a separate
industry, so to speak.
And now if you can build intothe PCR, which has already
mainstream that's.
Almost like exponentially growour capacity to do surveillance
in the U S and I feel like, Iguess if it, if it's
comprehensive enough, like yousaid that then new variants that
(34:35):
come up, hopefully we'll see it.
Anomic, that's weird.
And then that weird allows us tolike start exploring earlier
than, than maybe, you know, sothat's, I'm not sure when I'm
guessing, is this somethingthat's gonna be down the road
mainstream that it's gonna takesome, a lot of some checks and
balances before we're going touse this as a replacement, or
can this be a quick turnaround,like, oh, let's start using
these.
Stephen Kissler (34:56):
Yeah.
You know, we in theory, we couldstart using these next week.
You know, it, it would take awhile to sort of like, you know,
distribute to them, make all thereagents and figure all of that
out for sure.
But but changing the set oftargets that you're testing for
is a pretty routine thing to dowith PCR tests.
So if you have access to.
You could do this tomorrow.
And if you know how to do PCR, Idon't have no idea how to run a
PCR, but but, but, but peopledo, you know.
(35:18):
But, but I think that that is tosay that it's it, the, the, the
technical challenge is minimal.
It's just a matter of deciding,you know, if this is something
of public value to do.
And if so, finding the resourcesto sort of update the
infrastructure that we alreadyhave and update it to this new
sort of version of PCR.
Matt Boettger (35:36):
Great.
Fabulous.
Okay.
So next part here, we're gettingclose to the end.
Another interesting article Iread, and I know this was
interesting to you cause you,you read this as well.
So the surprising link betweenCOVID 19 and deaths is internet
access.
Now this, these, this thing,when I read it got me excited,
but it also made me a littleweird.
Like I'm like, okay, can thisreally be true?
(35:58):
The internet access and they,you know, they can get some so,
and I'm glad I brought it to youbecause you say this is a great,
maybe a great segue of helpingto understand the audience or
get people up to speed of how tobe able to look at this data and
see the nuances behind, youknow, what's real, what's not,
what's complicated, what needsto be considered in light of
this.
So I want you to take it away.
And what were your firstimpressions when you read this
(36:20):
article and and the nuancesbehind.
Yeah,
Stephen Kissler (36:24):
right.
So, I think, you know, when youhear a headline like this, the
first thing that shouldimmediately spring to your mind
is correlation is not causation,right?
Like that's like, you know, ifthat, and I hope that at this
point in the pandemic that isjust drilled into everyone's
heads.
And anytime you hear a causalclaim immediately those alarm
bells should come up and youshould ask, like, is this a
relationship or is this a causallink between two different
(36:46):
things?
That said, you know, digginginto this article they really
did go to great lengths to tryto what we call in statistics to
control for different variablesthat could be other explanations
for.
Difference in COVID-19 rates forpeople who haven't have internet
versus who don't like theobvious ones being like
(37:07):
socioeconomic status or urbanand rural location.
There are a lot of differentthings that you could say like,
oh, well this is just a proxyfor this other thing.
And that's, what's actuallydriving the difference.
Well, there are ways that youcan at least sort of nominally.
Adjust for these differentfactors to sort of include them
in the analysis and say like,no, even when we've adjusted for
all of these different things,there still seems to be this
(37:28):
difference associated withinternet access.
Now that still doesn't go so faras say, The cause there, you
know, the other thing is thatthere could still be some
underlying factors that are notyet perfectly accounted for by
the other variables that you putinto your analysis, but it does
make that link a little bitstronger, you know, where it's
like, well, we can't justtotally discount this difference
(37:50):
in COVID cases, by individualswho have, or don't have internet
access at home.
And and so, and so it, it begsfor a further look.
So, so the first thing, youknow, I think you know, we can
first play with the idea thatmaybe there, maybe there isn't a
difference.
Maybe, maybe there is a causallink and we can start to ask
ourselves, you know, why, whymight that be the case?
And you can imagine all sorts ofthings from like access to
information.
(38:10):
And I think that's really themain one is like ability to
access and to find informationabout COVID-19 in relatively
short order.
But then, you know, what are,what are some other confounders
that might be available?
So you can think, okay, if youcontrol for someone who has the
same socioeconomic status livingin the same neighborhood same
demographic characteristics, butone has internet.
And one doesn't.
(38:31):
You might imagine that the onewho has internet is already a
little bit more plugged intosocial services that has helped
them get that internet than theperson who isn't.
And so maybe those socialservices are actually the things
that are helping them reducetheir rates of COVID 19 and not
the internet itself.
And that wasn't really able tobe low.
Rigorously in this statisticalcontrol design.
So there could very much beother what we call confounders
(38:51):
that are behind this, eventhough they tried to control for
as much as they could.
So the way that I read a study,like this is sort of as this
like, point of interest, youknow, I read a study like this
and I go like, huh.
You know, like, that's, that'sbasically as much as it, you
know, as, as it's able to do.
And so it's not that I.
That I now believe that givingeveryone internet is now going
(39:14):
to reduce their chances ofgetting COVID-19 or future
infectious diseases.
It could, and there are a ton ofother really good reasons to
make internet much more widelyavailable.
Right.
So, so sure I can get behindthat.
And maybe this is one morereason that, you know, one more
thing that could tip the balancein favor of giving people
internet, but really, you know,scientifically what this is.
You know, begins a narrative inmy mind where now, anytime I
(39:35):
come across another study thatsays internet and infectious
disease, I'm going to be like,oh, I can put this in the
context of this other thing thatI've read.
And over time, hopefully we canbuild sort of a scientific
consensus where we're looking atthis question and a lot of
different populations and from alot of different angles and
maybe even some experiments aredone.
Give people, internet.
And then you see if that changestheir experience with infectious
(39:57):
diseases over time.
So it's more of a controlledexperiments as opposed to you
know, just an observationalstudy and then maybe we can
build up an evidence base aboutthis.
So the most important thing isthat one study never really
gives scientific proof.
It's sort of a consensus betweenan entire set of studies.
Really that's that's thecurrency by which science
(40:17):
operates.
And so what this does is it saysit sort of raises an interesting
question and does a pretty solidinitial attempt to give evidence
for, and against the reason whyinternet access may or may not
affect a person's experiencewith COVID-19.
And so really for me, what thisdoes, is it sort of earmarks
this, this sort of thread ofthought and I'll sort of carry
it with me as I go forward in myresearch.
(40:38):
That's
great.
Matt Boettger (40:38):
Awesome.
I love that.
One of the things I wanted toend on is this whole long COVID
thing.
This is always it's funnybecause I've read a number of
articles and I just kind of beenstacking them in a little area
for us to talk about.
And then we ended up not talkingabout.
And, and, and, and, and becauseI think you brought it up before
(40:59):
we got on the air.
So this is where I'm going to,I'm going to bring it back to
the surface because I read thesethings like memory and
concentration problems affects70% of long COVID patients
living with, with COVID longcoveted becoming a pediatric
public health crisis.
So these things keeppercolating.
Right.
And I, and I want to talk aboutit, cause I know we have
listeners who have actuallyemailed us saying they suffer
from Lancome.
It's just not, I don't have acare about it.
(41:21):
I'm not trying to be empathetic,but I've always struggled with.
Into the discussion because Idon't even know where to go with
it.
And I think you helped to like,pin this of like why this is
such a complicated reality.
So I wanted to bring it rightback into this discussion as we
end this episode of.
Yeah.
A, have you heard anything aboutlong COVID Dennis have a B I
(41:41):
think more importantly is why isthis such a complicated topic to
topic to talk about when we'retalking even about COVID and
it's long COVID like, it justseems like an anomaly, even
though it's not, I'm notwrestling with a psychological,
how do I fit this in and, and,and, and, and, you know, and
address it to something that wecan actually give valuable
information to people who are.
Stephen Kissler (42:01):
Yeah.
Yeah.
So yeah, there's, there's somuch complexity here.
And you know, I, I also have anumber of friends who are still
suffering from long COVIDeffects.
And so it's like, you know,it's, it, it's very real.
And and I, I you know, I've,I've been sort of.
But personally aware of a lot ofthe frustration of the people
(42:22):
who are suffering from it andthe sense of like, you know,
why, why don't we have moreinformation, more answers?
Why do I feel like not evenbeing heard?
And so I think that, you know,there are so many different
aspects to this issue and youknow, and, and partly, you know,
behind the reason why it's beendifficult for us to even sort of
like talk about on the podcast,because it is such a.
(42:44):
Complex issue.
So I think there are a couple ofthings in place, so, you know,
one of them and one that I thinkthat I've been trying to follow
is is the sense of first beliefin a person's reporting of their
own illness and symptoms.
You know, one of the, there,there are very well-documented
studies that that depending onyour Socioeconomic racial and
(43:06):
ethnic gender status.
You're more or less likely to bebelieved by a physician of, you
know, and and so if, you know, aperson of one set of
characteristics comes in andcomplains of, you know, brain
fog and headaches one might bebelieved and one might not be,
and that's, you know, not acrossthe board, but it's, you know,
it's, it's a fairlywell-documented trend.
(43:27):
And and so, and so that's partof what may be in play and that
like, that at baseline sort ofthis constellation of symptoms
You know, there, there areprobably a lot more people
suffering from it than arenecessarily picked up by the
healthcare system than arenecessarily sort of, seen and
trusted by the healthcaresystem.
And, and so there, there aredefinitely these issues with
sort of the healthcare response,but I don't think that's
(43:47):
everything either.
So another aspect of it is thesort of scientific structure of
our medical.
System and it's, I think eventhat phrase is important here,
where it is fundamentallyscientific and science is based
off of things that you canobserve and measure.
And when it comes to disease, wehave things that are signs and
(44:08):
we have things that are symptomsand signs are sort of
objectively measurable things.
Like I had a fever of 103degrees Fahrenheit.
Whereas a symptom is somethinglike I don't know, I'm feeling
like a little woozy and lungCOVID It does have signs, but it
is principally made up of bysymptoms.
And one of the things that a lotof researchers are trying to do
is to find signs of co of longCOVID of, you know, things that
(44:30):
you can objectively image ormeasure that indicate, you know,
this is long COVID or this is aperson who might be suffering
from long COVID.
And the difficulty betweenhaving a really science-based
medical system is that we oftentend to, and this is true of
science overall, is that we tendto think that things that we
can't measure.
Don't exist.
And you know, that reallydoesn't do us a very good
service either, because clearlythere are lots of things we
(44:51):
can't measure that do very muchexist.
But but I think that's one ofthe barriers here too, is that
we don't really have goodmeasurements for what
constitutes lung COVID adding ontop of all of this is that lung
COVID, the more we dig into it,it doesn't seem like it's a
single.
You know, syndrome, but actuallysort of a collection of things
that can manifest in long-termchronic effects from COVID-19.
(45:15):
And we have a lot of otherdiseases for which this is the
case.
You know, I think aboutdiabetes, which, you know, we
already know that there's typeone and type two diabetes, which
manifest differently have verydifferent causes, have very
different.
Treatments that you need.
And even within those, there aremultiple types of type one and
type two diabetes that also comefrom different places and need
different sorts of treatments.
This is true of cancer as well.
(45:36):
You know, we have cancer thatdescribes this overarching you
know, set of illnesses, but youknow, different cancers.
Utterly different from oneanother and again, come from
different places and requiredifferent sorts of treatment.
And I think that may well betrue of long COVID here too.
That it's actually probably anentire constellation of
conditions.
And it helps to talk about as asingle thing, because it sort of
(45:56):
raises the awareness of thisconstellation of symptoms and
signs and effects from COVID-19.
There's also this difficulty,which is that when we're
studying long COVID, we'reactually probably not studying
one thing.
We're studying a hundreddifferent things and it can be
really difficult to sort of findthe common threads through that
constellation of causes andeffects and figure out what it
(46:18):
is that we can then do about it.
So all of these things arereally conspiring to make it
really difficult, to talk aboutlung COVID and.
Scientific way and leads to alot of the really well justified
frustration on the people whoare suffering from it, because
it is a complex problem and it'sone that I think deserves much
more attention, even more thanit's getting.
But even inherently it's, it'ssuch a complex problem and it
(46:40):
plays on a lot of the weaknessesthat are already inherent in our
medical system.
And so because of all of thesethings, it is, it is just a
complex deal.
Yeah.
Matt Boettger (46:48):
That's well said.
Thanks, Steven, putting that inperspective.
And I know we'll definitely tryto keep our pulse on it at all
times.
So if we want to pro you know,we want to provide value to this
and we know some people havesuffered from it.
And whenever things surface, wewant to make sure that people
are aware of the resourcesavailable.
And what's, what's been theleading research on it.
But it is a complex reality, youknow, we're gonna end on one
last thing and we have to gohave meeting here in a little
(47:08):
bit and we've got to get goingand we'll see you in a couple of
weeks, but this one article.
Steven, I haven't talked aboutit.
I gave it to him to read but Iwant you, our listeners to read
it is called true hope.
Takes a hard look at reality,then makes a plan.
I sent this to mark.
For those of you have listenedfor a long time.
He was part of our, our podcast.
Stephen's brother.
He loved it.
He's a doctor.
This really put a lot of thingsin perspective of dealing with a
(47:30):
juxtaposition between optimum.
And genuine hope.
And the reason why I plant thisseed is because even as a little
bit late to the game cause we'rekind of all wrapping this up,
going to endemic mode.
And I don't think we're seeingthe crisis as much as we did
even six months ago when we hadthat peak.
But nonetheless, I think it'sstill relevant of dealing,
especially when you reflect backon early in 2020, when things
(47:50):
have.
About, you know, first this ideaof optimism, you know, two week
shutdown, this is going to beover with, and you know,
everything's going to flatline.
We'll be okay.
And then realizing thiscontinues to just surface its
ugly head and continue andcontinue and continue.
So optimism turns into despair,right?
It's not going to end.
And now this is going to lastforever.
Right?
So then there's these emotionsthat evoke with this word
(48:11):
forever.
And this article did a great jobof showing how optimism isn't
necessarily the thing we want tocultivate.
We want to cultivate hope andI'll leave you with.
This line that the author puthere, and then I hope you can go
into the show notes and read ityourself, said, namely, he
realized that hopeful peopleshared three things in common
goals, pathways and agency,although Snyder called these the
(48:33):
three components of hope.
It may be more useful to thinkof them as the three conditions
for hope to thrive.
And so if you're, if you're.
Peaks your interest.
It's a little bit longer read,maybe 15, 20 minutes.
It'll get perspective of how tolive in the context of hope and
not optimism as we move forward.
It really encouraged me and Ihope it encourages you as well.
That lands are playing for thisepisode.
(48:55):
Thank you for hanging in there.
Thank you for listening.
If you want to.
Patrion.com/pandemic podcasts aslittle as$5 or one time gift
PayPal, then all in the shownotes and as well, please give
us a review.
You can do that apple podcast.
If you want to get ahold ofSteven S T E P H E N K S S L E R
on Twitter, or just email me, Iwill forward it along to Steven
andmark@mattatlivingthereal.com.
(49:17):
Okay guys, and gals have awonderful week.
We'll see you.
I'm sure.
In two weeks ish and one way oranother.
Okay.
See you soon.
Bye-bye.
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