All about the efficacy, safety, and asymptomatic transmission of the vaccines

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Things Discussed on Episode:

• Hospitals at breaking point as Brazil hits new COVID death record
• The Pandemic’s Dr. Doom Bets It All
• What’s the Best Covid Vaccine? Why It’s Not So Simple
• People Are Keeping Their Vaccines Secret
• The Pfizer, Moderna, and Johnson & Johnson Vaccines, Compared - The Atlantic
• Eli Lilly's combo therapy for COVID-19 cuts serious illness and death in large study
• New coronavirus drug said to be 80x more potent than the antibody drug Trump was given
• Scientists Respond to CDC COVID Vaccine Guidelines: 'Asking for Trouble'

Transcript

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Matt Boettger 0:00

You're listening to the pandemic podcast. We equip you to live the most real life possible in the face of these crises. My name is Matt Boettger and I'm joined with my two great friends. And there's something with you, Stephen, by the way, you just look really good today. And after you put on like a, I don't know if you put out like a button-down shirt, you normally don't or what? Something's dead.

Mark Kissler 0:18

It's the lighting, the light ext. Yeah, he's got a. It's got a little bit of a

Matt Boettger 0:24

clue. He's got a, he's got a youth filter on and he looks great. So that's Dr. Stephen Kissler. It looks like he does not much has changed. And he is an epidemiologist at Harvard School of Public Health. And we've got Dr. Mark Kissler for the third week in a row. So this literally is. The biggest miracle. That's a record. This is a record. This is phenomenal. So Dr. Mark is in the house. He's with us, a doctor at the University of Colorado Hospital, and we're here to talk all things. COVID. So let's get going before we do that. Just a couple of things. We love reviews. We haven't had one like a wordy one since like February 16th. So we'd love wordy one. So if you want to go out there and go 41, that'd be great. But give the star that's worthy that you think it's worth. We love that stuff. You wanna support us. We'd greatly appreciate that. patreon.com/pandemicpodcast. As little as $5 a month goes a long way and a one-time guests pay PayPal, Venmo all in the show notes. I think that's all the big ticket items. Oh, totally random. Mark Stephen, getting ready to drop an episode and live in the real. I think we should do this for the pandemic. I've been reflecting on the six or seven things I've learned from the pandemic. Just as bigger than the pandemic and just reflecting on how it's changing my life and how it's still, it still hasn't quite landed. So if you guys are interested in going live in the real.com, you can sign up to join a subscribe to my podcast, but we'll be releasing soon, but it didn't, it was a really been fun reflection going deep and seeing some things. Most of it is still unraveling if you could probably imagine, but I think we need to add that to our episode in the future as well. Okay. So let's get going. First of all, there's big news. I can barely get out of my house guys. So

Mark Kissler 2:03

I know that snow is incredible. I don't know, Stephen. We got Oh, probably two feet at my house. Well,

Matt Boettger 2:11

you beat us. That's crazy, Mark. I'm guessing we got 16 or 18 inches. Yeah, we

Mark Kissler 2:15

have drifts. Yeah. We easily have drifts that are bigger than my children in the back.

Matt Boettger 2:20

And have you done the child count lately?

Mark Kissler 2:24

Yeah, exactly. Actually

Matt Boettger 2:26

that drift is not a natural drift, but it's awesome. Yeah, no, it's big. Yeah. So we had a lot of snow and I was so excited that like a month ago on Facebook and Facebook is literally the magisterium of reality. It's all truth. And I saw that spring is supposed to come early in Colorado and I was. So excited March was a month and now we're slammed with this. So I don't think, I mean, this

Stephen Kissler 2:52

is Colorado spring. That's

Matt Boettger 2:53

yes, that's true. That's true. So I lost all trust in Facebook now as if I didn't.

Mark Kissler 3:00

Good. Good. I'm glad that's. Let's drive the program.

Matt Boettger 3:05

You Oh, man. Okay. To chat about. Cause we mentioned, I think last week we were going to focus on the vaccine. Ethical. I have a few questions that are a little random here and we're going to start those in a second, but just want to frame this for everybody that we really want to frame this as being vaccine day talking about it because I'm getting a lot of questions more and more and more because of course, as the phases roll out. People are available. It's one thing to be like it's a healthcare system. It's going to be a long while, but now it's starting to really expedite. And so now the question is, do I get it? Do I not get it? Do I wait? And so there's just a lot of pressure and other questions coming my way. So this is about trying to help you guys who are listening to get some good well-balanced perspective of whether you should take it, how safe it is, all those kinds of things. But before we get into let's talk about a few questions. Oh, Mark. Do you have something?

Mark Kissler 3:49

Yeah. I just wanted to reflect on that. I've been getting a lot of questions too recently about the vaccine. And I think there's this funny way that it sort of concentrates a lot of our, a lot of the feelings that we've had around the whole pandemic in this moment of decision. And so all of a sudden now, like the pandemic has been something that's happened to us for a year. And this in certain ways is this weird way that we're acting into that now and making a choice. And then if. Funny ways of kind of a lot of the intensity of our feelings, about. The whole pandemic had been concentrated on this moment, getting the vaccine, whether they're, people are elated and just like super, super excited to get it or more hesitant or they want to get it. But there's just like complexity around that. Which is super understandable because there's just been so much I think, going on, so I think it's interesting. The way that the vaccine is bringing out some aspects of sort of our whole coping process, the maybe have been a little bit more subterranean up until now. But I've definitely seen that in, just in like my own self and in interactions with folks as they're making this decision about

Matt Boettger 4:52

whether or not to get it. Yep, absolutely. And then that's just the first layer, right? And the second layer is what I've seen in the Atlantic is that once you get it, there's a whole other set of realities of people are being secret about it and not sharing it because of tons of reasons. Number one, it's like a Scarlet letter, right? Because it's one thing, it may convey a pre some kind of condition that you have. You don't want people to know. And that's what made you slated for the tier. You don't feel to know that or. Maybe you just don't want to go to work. And so you don't want people to know you gotta get the vaccine or maybe you don't want to be shamed because you might look like a perfectly healthy person in their twenties or thirties, and then yours can be ridiculed. So before, after in the middle, this is

Mark Kissler 5:36

not ending. Yup. Yeah. It's kind of a fun thing. So yeah, so we should get into it. I think there's lots to talk. Okay.

Matt Boettger 5:42

Let's handle a few questions, I think are pretty fun and by fun, I mean, I think I have questions behind these questions which are exciting. The first one, we have two questions, Carla. She says, first one random. This is, she has a friend who was, I mean, this is kind of nuanced question, right? So she has a friend who got a vaccine, number one, and then she got pregnant. And now the question is, does she get vaccine number two? I mean, this is I'm. This is talk about a niche market right now. We're talking about that

Mark Kissler 6:11

subset of the population. So first off, congratulations to your friend. I think, So the, one of the difficult things about COVID vaccine and pregnancies, we don't have a lot of data, right? We haven't done a lot of there are studies that are underway, making sure they, all the animal studies didn't show any issues in pregnancy. All of our, regulatory bodies don't have pregnancy as a country indication to getting the vaccine. And from a physiologic standpoint, there's not. Really a strong argument that, so for instance, the MRN vaccines, don't, intercalate into our genome and change our genes. And so there's not really a sense that there's a reason why a pregnant person shouldn't get the vaccine. That's couched in understanding that sure. We don't have long-term data about this. We don't have, large study randomized controlled trials. But yeah, there's not, it hasn't been any real compelling, anecdotal evidence, in the first wave of folks who got the vaccine some of which were also pregnant, healthcare workers and things like that, who got it. And so we haven't been seeing anything. But it is sort of a matter of personal discernment, I think, and decision. One thing that I do know is that pregnancy does put you at risk for more morbidity with a COVID infection. And so I think that as this decision is being made, one of the things is getting COVID also could cause problems blood clots, Other, just, respiratory issues, things like that in pregnancy. And I've definitely seen some pretty ill pregnant women in the hospital, at various points during the pandemic. And so I think that's really, the calculus is getting the sense of getting COVID while you're pregnant. It's also probably not a good thing. And that has some potential, an untoward effects on w th. The mother and child. And so I think it's a very personal decision. Different people are gonna have different thresholds around that. The fact that already you've had the first vaccine, is kind of an interesting. Ray throws a wrench into it because you have some immunity, from that first dose. And so do you decide that's enough and, go with it? I think it's a very, very personal decision, but I don't see anything any compelling evidence that there's a red flag or that one should not do that. I don't see any evidence to that

Matt Boettger 8:17

effect, Stephen, anything to add to that?

Stephen Kissler 8:19

Exactly. That I think that, that's, we're just trying to weigh sort of the. Like Mark said the risks of each and, hopefully we'll have less of a risk from COVID going forward, but nevertheless, it's, there've been a lot of pregnant people who have gotten the vaccine so far. I mean, it's pretty mind boggling. How many vaccines have already been given. And again, we still lacking that longterm data, but it's like we've gathered a lot of information. And so, and like Mark said, we haven't seen any any unusual adverse effects, so, good. So yeah.

Matt Boettger 8:46

Great. Great. My only tin information for this, cause I'm not qualified to this question. I can only because of my own personal experience of having going through a pregnancy, not myself, but my wife is that if you are prone to morning sickness, And you're in the middle of morning sickness and you get the second one that has more symptoms. He may have 24 hours of feeling a little extra icky. So, Hey that's my only thing I can think of right now. That's my, that might be a real even I want to take that day off from from work. So that's my counsel. That's my, my, my professional council. There's another followup question here from Carla, which is, I think fascinating because even thinking about this is why I love our listeners. They have really cool questions that are insightful again. This is about. Okay, so Stephen, Mark, we are making available vaccines by May 1st to every adult in the U S so potentially in theory, every adult could be vaccinated, which leaves nor was a population of children left. So Carla, his question is, Hey, what happens then? We're not going to see children getting vaccinated until late, probably in the winter. I mean, we'll start with high schoolers, maybe in the fall. But the little kiddos, my kiddos four or five, six, maybe not until winter. What's the possibility that like COVID because it's constant trying to mutate and can't find any host it's trying to find the place to populate that it begins to mutate in such a way to start infecting or affecting children, way more than it previous did. I mean, that could be a huge fear for so many moms. What's the likelihood of this. And I mean, Mark, do you want to start new you? I, we talked about this question a little bit off the air and you had some insight before we handed the Stephen.

Mark Kissler 10:19

Yeah, what I love. So I was going to talk a little bit about the question and then I'll let Stephen actually answer the question. Because I think that the question itself embedded in the question is an interesting idea, right? And and the word you use is is COVID going to try to mutate XYZ. And I think that it's very easy as we start to think about the sort of this evolutionary. Pressures that are exerted on a virus or something like that to falsely attribute like an intentionality to a virus. Right. And it seems silly when you call it out. But I think it's implicitly the way that we think a lot of how these processes work, that it's like the virus is trying to get a host. And so it's engineering towards something that's going to make it more infected for disclaimer,

Matt Boettger 10:59

I'll just say real quickly. These are moms who have kids, which means all of their little COVID viruses on paper have smiley faces. And eyes, right? So you can kind of see where this is going. I mean, my, my look coronaviruses have all happy faces, so just give a little bit of extra more credit, right? So a

Mark Kissler 11:19

little, a little personification, right? And so I think it's helpful as we start, as we answer those questions to have this sense of okay. There's there are different pressures, that are being exerted population Tully on a virus that are going to influence the strains that persist and the strains, the die out. And so I do think there, so the question itself is, is a really perceptive when in a valid one is, as it loses hosts within the adult population. Does that mean that strains or, subtypes that preferentially infect children are going to have that pressure, competitive pressure removed and take a little bit more percentage of the T of the the population. So I think that's That, that's a super interesting question. And just wanting to like to lead us towards, like, how do we start to think about that? I can a couple of things, number one, I think one of the scenarios that a lot of people have talked about including Stephen's group has been that as SARS, cov two, gets through the entire population that, much of the time in the future, people are going to be exposed to this as children first. And that even perhaps that's the way that all of the Corona viruses that we interact with happened, that they started as a similar pandemic situation. Now they caused the common cold, but in part that's, because we've been exposed to them as children before with mild illness. And so I think there's a. There's a reasonable, reasonably plausible thing where yes, actually, kids are going to keep getting COVID and be exposed to this particular to SARS cov two, maybe somewhat preferentially higher rate, but also just because kids get a bunch of irises. Yeah. But then I think the question of does that cause severe disease or does that start to cause severe disease in children is sort of a separate question. And in, in one of the things that could potentially happen is it actually continues to just cause mild disease in children. And then that exerts sort of a protective effect on our global population. Over the next

Matt Boettger 13:15

generation. Okay. And to frame this a little more for Stephen, because I think when I read this, it kind of provoked, Oh yeah. This is a real question. I think the reason why it provokes such a big Oh, I think this is real is because going back to when you said, Oh my gosh, how did this mutate to begin with? COVID normally doesn't mutate this quickly. It's much more slowly. And now we're seeing these kinds of more gradual mutations. And one of the suggestions was, in my mind, he humans. Trying to get a grasp on COVID and getting treatments, which was delaying their healing, which gave them more time for them to replicate. So I'm thinking, Oh, we caused it. Right. So then I have that kind of potentially right. And so now I'm like, okay, could that happen again? Because we're causing it again because we're only selecting a population to vaccinate. So that's my, that's where I got my bells went off. And Stephen, you want to speak into that?

Stephen Kissler 14:04

Yeah. So it's there's so much good stuff here. This is like one of the areas that I really enjoy thinking about a lot is like the intersection between like population dynamics of infectious disease and then how they actually evolve because that's, that's the golden ticket right there. As we learn more about that, that's how we figured out really how to. Help public health in terms of infectious disease. So it's a lot of, one of the things Is that so I do have a lot of sympathy for the way of speaking. What about evolution in sort of personified terms? I mean, we, as scientists often do that too, despite the fact that we like there's this recognition that that it's not actually. True, but it can be a helpful metaphor in the way that, our vocabulary is so, structured around telling narratives and telling narratives around actors, doing things that it's kind of difficult to communicate. And you can almost sort of, Subvert the thing that you're trying to communicate by trying to be too precise about it sometimes. And so, but that of course gets you into difficulties where there are these gaps where the metaphor only goes so far and then it stops. And so that's where there's sort of this like underlying intuition where I know that what I'm speaking about is like I'm assigning the virus, this activity that it doesn't actually have, and I'm using it to communicate that. And we do that amongst ourselves, even as a community, but then there's sort of this understanding that like, we always have to keep checking ourselves and making sure that we don't get. Too caught up in that narrative, because again, like Mark said, it's it only goes so far. So right. So the. Taking the first sort of question about SARS Coby to potentially mutating and that changing the way that it interacts with kids. I think there are two levels to work on this. And the first is that again, speaking in terms of the personified virus viruses. Wants to transmit. They don't necessarily want to kill or cause severe illness. The way that evolution works is that the thing that replicates more gets the advantage. It replicates more and that's just why you see it more because it replicates faster. It replicates. And oftentimes actually replication and disease are at odds from one another. If you kill your host too quickly, then yeah, you can't spread. And in many cases and so. That's not a guarantee that viruses will always evolve to be less severe. There are reasons why they can actually evolve to be more severe as well. But generally speaking, those two processes don't necessarily have to be coupled at all. So, so I think that's one thing is that even if it were to evolve, to be more infectious in children, that doesn't necessarily that it will evolve to be more severe in children. And in fact, the opposite could happen. Both could happen at the same time where it becomes more infectious, but actually less severe. I think that's something that could very easily happen as well. Now with the asymmetry sort of having different populations, vaccinated at different rates. Really interesting thing. So. Where my mind usually goes is, so what we're doing right now is we have some population of adults who are vaccinated and some who are not. And in fact the selection pressure that we're applying, the thing, basically the filter that we're applying against the viruses transmission is actually happening in adults. So the first thing that I expect to happen and something that we've actually been seeing is that the virus will actually evolve to escape. Immunity unity and adults because we have a whole diversity of viruses that are circulating and competing right now. And some of them just happen to have mutations that would make it easier for them to get around the vaccine. Now, prior to the vaccine, that didn't matter because nobody was vaccinated. And so they were equally good at spreading, but now those viruses that happen to have those lucky mutations will be able to get around that immunity. And they'll tend to spread a little bit more quickly. And that's what we're starting to see what some of the variants, for example, that like the P one variant, for example, seems to be able to get around both natural immunity and to some extent vaccine induced immunity, although it still seems like previous infection probably provides some level of protection against severe disease and illness, which is all good news. It's possible that having kids be unvaccinated and adults be vaccinated I can think of a scenario in which so, so the way that I would think about this is that, again, maybe again, there's this whole diversity of viruses circulating and some of them happen to be more infectious in kids and those ones maybe spread more easily among kids, but less easily among adults. And since they're just more adults than kids, then those things sort of got out competed. And now as we're vaccinating, we might see those ones that are more infectious and kids sort of rise and be a little bit more common, but I. It's harder for me to rationalize that. It's usually I don't think of Viruses as sort of having attributes that make them more infectious in a certain age group, per se. It all just has to do with our underlying levels of immunity to a large part now disease severity. Absolutely. And yeah, but a lot of these other things I think have to do with just pre-exposure to the virus. So all of that is to say that I think it's. It's unlikely that vaccinating adults will lead to either a more transmissible or a more severe variant in kids. It could randomly arise, but I think that those selection pressures that we're putting on are not necessarily pushing the virus in that direction. And Mark said I agree with that. I think that. Probably what we're looking towards is a world in which everyone is exposed to SARS cov too many times. By the time they turn 10, 12, in which case they're probably hardly going to notice infection. And by that time, then that will hopefully build up enough underlying immunity. That it'll be much like the other coronaviruses that we already know about. Not for sure, but I think that's, if I had to put my stake in the ground, that's where I'd put it.

Matt Boettger 19:22

Okay. Great. Is it fair then to say that you said like it could happen randomly, which means if that was the case it would happen randomly with, with either with vaccinating adults or without vaccines. They're like, it's not like thinking intentively well, that all populations been vaccinated. So we're going to randomly go over here. It just means. That's just the neutral Plainfield.

Stephen Kissler 19:43

Yeah. And we've seen that before. I mean, early in the pandemic, there was there was a mutation that occurred and we had some speculation about this back in the spring, where there is a mutation where is it more infectious? It seems like this mutation is taking off. And after seeing it happen, in the calculations that we've been able to run in hindsight is that, yeah. I mean, even though. Basically everybody was susceptible. We weren't doing anything to mess around with the virus as ability to spread it. Still had this random mutation that made it more infectious and allowed it to spread more easily. And that, that can just happen. That's again, just sort of how viruses behave and if they find a strategy that allows them to spread more quickly and to more people than that is just going to naturally sort of rise. So yeah, so I think that there are things that we can, that we do that affect how the virus. Evolves. But a lot of it also has to do with just if it gets that lucky mutation. So, yeah.

Matt Boettger 20:35

Okay, great. Okay. Last question. This one is from Mali one of our longtime listeners, and I know Mark, you set the state, you kinda mentioned this before. We're talking about getting vaccines and I think you didn't say it as like absolutely for sure. True. But there were suggestions that may be that if you get vaccinated to maybe don't take Tylenol or, before. It's one thing. Once you get the symptoms and once you get a fever, yeah, go ahead. But like before you get a vaccine to help the vaccine have a stronger hold, maybe just don't take that before preparing for it. So Molly has a question that she's not slated for a vaccine yet. It's not even up for, but just thinking if she were to be up for it. She just got on some kind of a, it looks like Bactrim for sinus infection and I don't know what that is or what it is for and just, she didn't know. And something like a case like this, would it be ideal to wait until the 14 days is over? It doesn't even matter. What would be your stance on this kind of area of what you're taking before you get the vaccine?

Mark Kissler 21:32

Yeah. So to just go to your previous point first just to reiterate, there is some evidence, both in animal models and I believe in the pediatric literature, and there's a lot of physiologic plausibility to the sense that when you get a vaccine, you need your immune system to respond to that vaccine. And there are certain, especially the INSEAD class of drugs, so ibuprofen and those sorts of related drugs that don't include Tylenol can actually. Decrease some of that initial immune response. And so, there is some recommendation, even Dr. Fowchee has said this and the CDC that don't pretreat and don't, especially with ibuprofen or in a related drugs. Yeah. After you get the vaccine, if you're having symptoms it's generally thought of, okay, and I would recommend using a SITA manifest at that point. And if, if you need, if you're having fevers, rigors, things like that just for symptom control and in some ways that makes sense. Just physiologically thinking your immune system has already responded because that's why you feel terrible. And so then it's okay to start to tamp that down a little bit. And now the second phase where you're getting the, the antigen presented to your memory cells and things like that as is already underway. And so, so that's still, that's still holds not recommended to pre-treat if you're having symptoms afterwards considered Tylenol or acetaminophen The other question, again, I wouldn't, I don't want give any specific medical advice at all. And so I think the, the boiler plate answer is make sure you chat with your physician, and have an understanding of kind of what's going on in general, the drug drug interactions for things like our routine antibiotics. Like the, the the one that you mentioned. Is not thought to change the efficacy of the vaccine. And so as long as from a global health perspective you're doing okay. I wouldn't. Worry too much about that. But I would also, of course, talk to your local doc and make sure that there's no other contraindications to getting the second dose of the vaccine. Right. Thanks

Matt Boettger 23:31

so much. Yeah. I just saw him here. We got, we had somebody to say to leave a review. Don't know who it is, but whoever you are, thanks so much when an anonymous person just says, I'll leave review. I realize I really must have come off really desperate. Thank you to whoever you are. I really appreciate it. Those who are watching live,

Mark Kissler 23:49

they didn't say it would be a positive review. That's true. Yeah, it is

Matt Boettger 23:53

pretty true. We follow the live in the real.com and please present a draft of your review first. I really appreciate you. I will edit it and send it back. Okay. So let's get into some of this stuff. Stephen, I want to throw this back to you just again, because Brazil is getting hit pretty intensely and hospitals are just getting to the breaking point. And again, I want to put all this into one question. So you have, you have Brazil kind of at a breaking point. You have now this information coming out, that Europe flatlined. Right. Kind of plateaued out, not flat line, but plateaued out before they started having a surge. Right. We've been hearing from Dr. Fowchee that we are plateauing. We have a tendency to follow Brazil, and then you have AK would I just now learn as Dr. Doom, Dr. Auster home, which I that's, I guess a nickname for him. So Dr. Doom. Right. He he's, he's really pushing on this with a lot of gas and he's even saying quote, like he's willing to risk his entire career on this, that if he's wrong, he realizes that he could be a washed up epidemiologist. I doubt that's going to be the case, but that'd be a bit, but he's really, he's willing to really put a lot of effort. So coming back to you, Stephen here's Brazil. We're seeing a plateau. We've got Dr. Doom coming out saying this is really serious. And we're just now having all these States relinquish all of these protections. This is becoming the perfect storm. Hey, it's spring break. By the way, FYI, I want to give kudos university of Colorado Boulder, because I didn't have the foresight to realize, I don't know why they did this, but. Back in the fall, they, they completely removed spring break. There's no spring break. They have to health days, mental health days. And that's it right. Sprinkled in way different months. So you can't like, and I kept thinking, why on earth would you do that? It makes no sense. I thought maybe just cause the shorten and I'm like, Oh, you are smart. Cause, you don't want them going places to the beach in Florida and like brilliant. But other universities haven't followed suit right. There is spring break and a lot of places, Stephen, going back to where, where are we at right now with Dr. Ostrow home and these kinds of

Stephen Kissler 25:55

cases. Oh boy. Yeah. So, wonder if people have to think about me as Dr. Duma? No, but I think I need it. Like I said, There are, I think we need to be watching what's happening in other countries really closely. Because as we've seen, way back in the beginning, we had the example of Italy, for example. And the big question at the time was like, will we become like Italy and I mean, the answer was yes in spades and then some and in different ways. And so, So I think that there are lessons that other countries can provide that I think we really need to pay close attention to meanwhile, paying close attention to the distinctions as well. So, Similarities. We have a lot of variants circulating here in the United States. In some States, the variant, which is the UK variant has surpassed half of all cases that are being tested that are being sequenced which is a very high proportion. And as soon as B one, one seven tipped past that threshold in many places in Europe, that's where they really started to see surges and infection. Brazil, they have Different sort of combinations of variants circulating there. There but nevertheless there seems to be a surge that's being partially driven by variants, partially driven by opening up their, their climate is very different than ours as well. And so they've just sort of seen a different set of dynamics. They've No, they also, currently the the, the national administration is again, really downplaying the severity of COVID, which makes it really difficult to present a unified front. It's been, very, many yeah, people have been really ridiculed for getting the vaccine by by very high ranking members of the government. And so, there's, there's a lot of sort of confusion there as well. That is sort of feeding the fire so to speak now. So again, here, here we are in the United States where we have, we're seeing surges in Europe. Now we're a little bit further along in the year. We're a little bit closer to summer, which is helpful. We've had frankly quite a bit more spread in many places. So levels of natural immunity in some communities are very high. Certainly not all. Rates of vaccination are pretty high. Now, now that the, our vaccination rates have been really steadily increasing We're among the more vaccinated to countries in the world, even though we still have a very long way to go. And so all of this is sort of, Fighting together. And so, so what we've seen epidemiologically is that we saw this really sharp decline in cases across the United States. And then it just sort of like, there's this like remarkable, just sort of, like it stops and it it sort of plateaus and it's still going down, but It's almost I heard another epidemiologic ologist, describe this as sort of like, it was like this receding tide. And then all of a sudden you're seeing the rocks at the bottom where it's like these persistent communities, clusters of transmission that are still going in a, in a really hard to get control of because they're moving and there's variants in these kinds of things. So I I expect there to be more spread. I mean, I think that there's going to be a, a long time. Yeah. Live infection. We might well see a surge. I think that again, it's going to look very different from place to place as, as this has already. So I think that some States and some communities will almost definitely see a surge from the variants, but some won't and we'll get to the summer in cases, we'll probably start to go down. We just don't know where those are going to be yet. And so I think that my, my outlook is probably a little bit more hopeful than Dr. Foster homes. And and again, I think that that has to do with the fact that, some of the things that are working in the favor of spread in the United States. But but I'm prepared to be surprised.

Matt Boettger 29:15

Okay. I'm feeling the same way. I'm hoping, I mean, again, I'm not qualified, but I know just like everything, my body and I feel like this is. This is not going to be like, whatever it is. It's not going to be like it was in December or January that, I mean, gosh, we just saw like Friday, wasn't it like 3.5 million doses were given out in one day. I mean, we're just, this is, this is phenomenal. This is really hopeful. Really helpful. Yeah. Mark, I went through it too quickly, cause I know that you may have to leave around nine 30 or so. And before I get the vaccine, I know I'm dropping this on you right now. So I don't know if you but we haven't talked about treatments in a long time and I want to get your update on what your experience when treatments cause everything's vaccination. Right. Right now that's a bit, but. There's just a lot going on. And I saw two big things show up on the news. I don't know if you even heard of this. It was in the notes. There's some Ellie Lily's combo therapy for COVID-19 cuts, serious illness and death in large study. It said like up to 80%, I didn't know if you were even aware of this, if this is something that's on your radar at the hospital. And then the other thing is this a new coronavirus drugs set to be 80%, 80 times more potent? I don't know what that means. Then the antibody drug Trump was given. It was some GlaxoSmithKline, something for. I don't know what it was for, but these two things came up in the news recently didn't know, first a what's treatment like in the hospital and are, have these two things, serpents, everything in discussion or treatment in your hospital.

Mark Kissler 30:35

Yeah. Good, great questions. So my understanding is this the Eli Lilly combo, is that an it's an ant, another antibiotic combo. Susan, do you

Stephen Kissler 30:43

know? Yeah. I don't know much about it.

Mark Kissler 30:46

Yeah, I don't, so I don't, I haven't looked at the study myself yet. I'll have to look at it. I think when I think about these often these antibody drugs are used and are most effective really early in the course of illness. And so they're often things that are, that are best used kind of initially after somebody presents before they get super sick. And a lot of times in the hospital, we see folks days into illness, into weeks into illness and start to see sort of that peak of symptoms later on in their illness course, after which time the virus was already. Replicated, and it's kind of run rampant through the body and it's at that point that we want to address the hyper inflammatory response. More so and so, yeah, I do think that the I'm, I'm interested, I'll have to look at the study before I comment, officially about about that. I think it's good. I think it's interesting. I, my, my overall feeling is that these sort of therapeutics are really important and great. It's really gotta be our bread and butter prevention. And, and just a sense of like, how do we do, prudent, social distancing. Let's get the vaccine uptake, and, and worry about those things. Because again, overemphasizing therapeutics I think actually can can be counterproductive in a global societal sense as we deal with something like a pandemic. We want to get to a scenario in which We're able to engage with our, our communities and our neighbors and our friends and families again. And and I think that the best chance of that is going to be through these things that we've been emphasizing, all along from a therapeutic standpoint on the, in the hospital, we're still using a lot of dexamethazone. We, we use Ramdev severe, at our institution. The, again, the, the data on that In terms of its mortality benefit and, and all of those things, there's there's room to, to have a conversation about sort of the, the efficacy there, but that is pretty common practice in a right now where I'm working is both dexamethazone and rum does severe for the COVID patients. And I think that's kinda, that's kind of where we're at and it's, it's again, it's one of those strange diseases where it's really a lot of very attentive, supportive care really high quality nursing cares that are one of the things that helps these patients the most rather than a wonder drug,

Matt Boettger 32:56

Yep. All the more reason why you don't want hospitals over run because that, that, that, that part it's, it gets chipped away. The first thing is chipped away. When you start getting overloads, right?

Mark Kissler 33:06

That's right. Yep. Yep. Time and attention. Yeah. Yeah.

Matt Boettger 33:09

Great. Thanks. Thanks Mark. Let's see here. Let's get into the vaccine. I want to set the stage for this. The reason why now I know we're 36 minutes in and we're just now talking for me about the vaccine. We'll go as long as we can here before we have to head out, I want to set the stage. So this is the stage by which I want to enter into it. Initially, there was just Pfizer with Madrona. There was like excitement. And then, and then Jonathan Johnson came on the scene that made life complicated. And so there was this initial reaction towards, Oh my gosh. If I had to, Madrona is better. Stay, don't do Jonathan Johnson get in quickly or you're gonna lose out your time. And then you started seeing news outlets being presented about how no, no Johnson Johnson is just as good as any, any, any any vaccines, a great vaccine. And so I feel like they sweep, they kind of went the other way and, and kind of glossed over the nuances. And now we're kind of finding the center balance of, okay, the vaccines are good, but they're nuance. They're different. They have different advantages. And as we roll this out further, they're going to have more, the reason why I bring this up is because it reminds me of. The complications of the mask, right. Were early on, it was, don't wear a mask. Now, again, it's complicated. We, we explained this at the part of the reason why is because we were, we were trying to say that no, the mask only protects you. The one who's wearing it and it's complicated, blah, blah, blah. And we realized, Oh no asymptomatic transmission and all this kind of stuff. So then mass became a popular reality. But there was a sense of did you. Tell us not to wear masks because you wanted to save them for the hospital. Right. There was another alternative motive was it was a complicated motive. And so is the vaccine and other kind of complicated motive because we just want to get to a vaccinated. So let's just make it sound really, really good. And it's not really, maybe as good or maybe it is. I don't know, but I want to start with just kind of. Where are we at with the vaccines? I think right now we can just safely say for the U S anyway, I know, I'm sorry for those people overseas. There's there's many other ones being populated around here, but Pfizer Medina and Johnson and Johnson. Can we first give it like a small understanding the difference, because if, from what I gather also from an article, I read Johnson and Johnson. Might've been the only one among most of the vaccines that studied a particular way by which it was effective. That other ones didn't. So at first I thought all vaccines are just different in their measurements, but it sounds like Johnson and Johnson is the outlier in the way they tried to measure things. Which is making things a little more complicated to compare apples to apples, Stephen, start with you. Is that correct? And where are we at with these, these treatments?

Stephen Kissler 35:34

Yeah, so you're exactly right. I mean, I think that it's really important to just be totally upfront about all of these things. Right. And I think the. I think it's very clear to many the epidemiologists, at least that I know that like it's, it's both Ineffective and also just like wrong to like mislead people, that's like not what we're in the business of doing, because not only it's, it's just it's just wrong, but then also, it's, it never, it never works out. Right. Like it's just, it's, it's a poor strategy and it's just not something that you want to do anyway. And so I think that, certainly like messages, can be emphasized. Incorrectly or miscommunicated or, whatever, all of these things. But I think really what I want to try to do is speak as clearly as I can, about what I know to be the case about these different vaccines. So, the, the vaccines differ, they differ in how they work where the Pfizer and maternal vaccines have very similar modes of action. And the Johnson and Johnson vaccine is somewhat different. And I think that part of that is reflected in the, in the numbers that we see for the efficacy of the Pfizer and Madonna. I mean, they're like just right in lock step. Like they're very, very similar vaccines in terms of, of the F the reported rates of efficacy. Whereas Johnson and Johnson is, is, is different. So it has first a lower baseline efficacy, which is the, the ability of it to stop symptoms altogether, basically. So, So that's one thing. And, and the, but the trials measured them in slightly different ways. Most importantly, they measured them in different populations at different times as well. And so, and so it does get difficult to totally compare, you have this number of efficacy, but it's also. You're comparing different populations with different underlying, there were different variants spreading it at the time and different sorts of amount of spread as well. And all of this can sort of affect the th the certainty in that final number that you report. So all of that said, I mean, I think that it's What it seems to be the case for me is that, is that I do think that probably the Johnson and Johnson vaccine has a lower efficacy than the Pfizer and the return of vaccines at preventing symptoms of any sort. The ability of the three vaccines to prevent severe illness and particularly hospitalization and death is extremely high and is so with these numbers, those events are, are rare. They're relatively rare compared to two infections. And. When you're doing statistics, it's really difficult to get very good estimates of very rare events. And in all three vaccines, those events are rare enough that the efficacy of all three is basically overlapping the estimates of the efficacy of the three. So there's, as far as we can tell, they're equally efficacious in terms of present preventing hospitalizations and deaths. And part of that is because there's still a little bit of uncertainty about that because those numbers are relatively small compared to the other ones. But the important thing is that even though the numbers are small, and though they overlap between the three. The protection is very high amongst the three of them. It is very different than the non-vaccinated population for sure. And we know that for sure, in all three cases and that's ultimately why they were given this emergency use approval. And so I think that's, that's the main thing to emphasize is that when, when we're talking about that, these vaccines are all very good. They're, they're good at preventing hospitalization and death, which are, are really the things that we're most after trying to prevent Increasing evidence suggests that they're actually pretty good at preventing transmission too, which is a huge bonus. And so I think that there's very good reason to be. Confident in all three, even though there might be differences in in uh, in their individual efficacy. So the last thing is that, of course individuals are also going to have a lot of variation in their immune response, with Pfizer and Madrona, there's 5% of people who may still get infected and show symptoms after the fact. Right. And so it's, it's impossible to predict like what my response is. Perhaps my response to the Johnson and Johnson vaccine would be better than my response. Yeah. To the Pfizer and Madrona vaccine. And we're, we're playing, probabilities here all over the place. But yeah, it's, it's, it's sort of difficult to suss any of this out, but I think, and that's, that's why with all of this complexity, usually the answer is that we, and I agree with this is that we have three. Very good vaccines. It makes a lot of sense to get the one that is available when you're ready to get the vaccine because they seem to be comparable at least in terms of preventing the most severe outcomes. And they all seem to be doing a pretty good job so far preventing infection as well. So that's, that's sort of the bottom line and that's how it gets distilled into that single message from all of this complexity.

Mark Kissler 40:04

Okay, go ahead. Yeah. I like that. Just to underscore that the sense of don't, let's not let the microscopic optimization question. Out, overshadow the macroscopic optimization. So the micro is which of the vaccines when and how, and, and at what interval and that sort of thing. But the big picture is we have three very efficacious vaccines and on a population level, this is very, very important in terms of. Where we're at in the overall picture of the pandemic. So looking to that bigger question, I think is, is the key. Yeah. Great.

Matt Boettger 40:39

And there's a nuance though, because not to throw a wrench into things, but then you have Pfizer coming out saying that Hey. That's what it showed that it's effective across all age demographics, even the elderly equally as effective. Right. So then in my mind, I'm like, okay, then I want my mother-in-law. If I can get her, I want her to do the Pfizer one. Cause these sets shown to be equally across demographics. And this is where I think someone who wants is, and I know that, like you said, it's, it's still complicated because. It may be the case right now, but six months from now, we might find that all of them are equally because I just heard that, because these are rolling out at different times, then we can't treat them as being equal in their statistics and that, so now we have to do another round of study, which we put all in together and do a trial all at the same time, in the same locations for the same day. Now we're getting a similar Apple to Apple comparison, but that's not going to be for. I don't even know, and then more vaccines get rolled out and we can add them to the flame. Right. So this

Mark Kissler 41:34

is, and I'm just, yeah. And I'm just not sure that the variability between these three particular vaccines matters that much, to be honest with you. And I don't know, Stephen, if you want to add, it may be, you may disagree, but I just, I, even if we did that kind of head to head study, I'm not, I, I'm just not convinced with the data that we have, that it really is going to be. Meaningfully different. And so I think, again, it's, it, this is more a question of kind of participating in the rollout of the vaccines in general making that decision for yourself holding together all of the evidence and lack of evidence that we have making a good decision, that's very personal, but at the same time I think it's, it's, it's more a question of, to vaccinate or not to vaccinate rather than. Which of the three is, is my kind of my take on that. Stephen, do you agree with it? Yeah, I do. I do.

Matt Boettger 42:25

Okay. Great. I want to frame this quickly because we talked about ethicacy. I there's three tiers of this, right. There's ethicacy, but then there's safety. And then as Mark, you were talking about before we got on there's a systematic transmission, right? These three areas are all important here to talk about efficacy is one and my sub domain of my personal life and my family. Oftentimes the is less efficacy and more about the question of safety. Now I know this is a little more difficult. I know we had a. Episode about this. And I want to bring in right now that that whole email I showed you guys from this natural path that we have dealt with in the past, that kind of helped to her, her subscribers to get an understand and grasp of, of the vaccine, the pros and cons. And that I think, as we talked off the recording, that there was some misleading stuff in that, in that email, because either a, like you said, that even just the language itself was not precise enough to be able to convey the real message. And then even some of the stuff, the, the side effects, like the Goulian, I don't want to say Jillian bears. I don't know how to say it. I'm not French. Keon,

Mark Kissler 43:23

Gian,

Matt Boettger 43:23

bearish. He embraced. So I completely, I got the gut and the, and the bow. So that was, I nailed it. I nailed it. That's good. You got to

Mark Kissler 43:32

start, you got to start with the hard consonants. That's what

Matt Boettger 43:35

so I, it says a framework because the question of safety and her principal thing was well kind of safety, but she mentioned a lot of things that were kind of like, okay, is that really true? Talked about how, the vaccine is just once you get it, you're just a silent spreader, which that leads to the second. The third, big question of asymptomatic spread. So let's start with that. So she talks about him that if you get the vaccine, the problem is that you're just a silent spreader. Is that an accurate assessment of where we're at with the science when it comes to the vaccine, Stephen?

Stephen Kissler 44:03

No. I mean, thankfully we, for a while, we were unsure of the extent to which the vaccines might reduce transmission. And so the recommendation was basically, we have. These high numbers of efficacy, but we don't yet know how much it prevents transmission or really if it does, although there was good reason to believe that it did, but we weren't sure by how much those numbers are, are, are starting to come in and, and they do seem to be pretty high, they're, they are seem to be pretty good at blocking asymptomatic transmission, which is measured by basically doing weekly swabs of people who have. Gotten the vaccine versus those who haven't been measuring the rates of infection in those two groups that also there's again, all three vaccines seem to be pretty protective against that as well. Hovering between 60 and 80% is what seems to be the case, at least for the Madonna and Pfizer ones. So that's good. I don't think that by vaccinating people, we're sort of introducing this huge pool of, of asymptomatic silent spreaders.

Matt Boettger 44:53

Great. And, th th th this goes to my other question then. So this is related. So I was thinking in my head yesterday about this idea of the, the idea of asymptomatic spread, and it was still a question we don't know it wasn't get the vaccine. Could you spread it? And I kind of allowed that question is to stay in my head as like a legit question question. And then after a while, I'm like, wait a minute for me, this is not a legit question, and I'm not a scientist. I know nothing. This is just pure intuition. But we've talked about in the past, this idea of the parade of principle and how it actually was pertaining to the spread. We realize that there were these super spreaders and we explained why we don't actually pigeonholed them, that we talked about the circumstance instead of the actual person. I can go back to previous episode, talk about that and that how it's 20%. It's really contribute to 80% of the spread. So these 20% are having extra amount of viral load. That's actually causing a lot of spread. So I'm thinking, okay, you talked about this before, Stephen. That how, like the norovirus, it takes one, I think that's right. One, like it takes one particle, maybe on average. Now, granted, this is getting art and science blended together, right? So roughly one particle to infect someone. And then you said like COVID, which is much a higher degree of particles, so hundred ish or something like that. Right? The current. So it's all about not just a part of it, but the amount that's being spread and you get a vaccine, you're clearly reducing the amount by which you're going to probably be replicating. That's the whole point of the vaccine. So even if you do it by half that 20% and we're, we're nailing. Right. The spread of the virus in my mind, this is like a no brainer. Just logic of how COVID works. Am I off on this? But is this are we going to see even higher numbers probably intuitively once we kind of get down further down the road, do you expect?

Stephen Kissler 46:30

I sure hope so. Yeah. We've, we've done a little bit of modeling around this. That's it's hard to pin it down enough to really get clear numbers, but, but you're right. That Super spreading is probably most likely when you have, when you're producing a lot of virus. And and so if the vaccine reduces that, we have these average reductions in number of transmissions or number of infections, but like you said, the vaccine is probably chopping off that tail, which is going to have a lot more effect on the overall spread in the population. So even if a single person might still spread on average to a couple of others, if we, if we can effectively eliminate super spreading events or cut the size of those and a half or a quarter, that's good. A huge, huge, huge role in transmission overall. So again, that's, that's one of the, the little Easter eggs that's hidden in the in the numb, the efficacy numbers.

Matt Boettger 47:14

So, yeah. Yeah. Okay, great. And Mark, I want to throw it back to you on this, this, this because I know I don't want to get the details of this, but it's, it's symbolic gesture of this. When this email talks about I'm gonna call it GB, right? That's for sure. Whatever. Right. I'm so hip I'm so cool. I call them just by their, by their, their letters. So yeah, you take GB for example, right. And this idea where she kind of burst, she kind of

Mark Kissler 47:41

just. Just for the sake of it or less. Thank you, sir. Thank you very much. Thank you for that great

Matt Boettger 47:46

Britain. Oh yeah. Good. Thank you. That great Britain. But you take this right. And she kind of exposed this, which I thought it was interesting because she talked about how it increases the cost of getting this from the vaccine, but then it, but then explains that it's not the vaccine, which is, it feels like a little bit misleading. And then that it's just the antibodies from the vaccine, but it's not just the antibodies from the vaccine and the antibodies from just COVID in general. It doesn't matter whether you get the vaccine. So this is a moot point. Yeah. But what, what is this about? And does this really have any impact on the discussion of the vaccine?

Mark Kissler 48:16

No. I mean, I think so. Couple of things, the, the way that I read that that section was largely, I think, I think that there, there were sections of this that were really precise and well-intentioned, and I do think that the way that I read it was yes, there is a risk of. Guillain-Barre associated with, vaccination. And that also there is a potential risk of Deon brave coming from natural infection. And that it's just getting the vaccine, that that alone is not a reason to not get the vaccine. That's how I read it. And I'd say that's a pretty reasonable glass that, we Canberra is a neurologic condition that has auto-immune. Roots and it can be triggered by vaccination. We've seen that before with including the influenza vaccine and also can be triggered by infection with the virus and the immune response, from, from a virus. And so I think in some ways I found that actually to be a helpful, helpful expert, explanation of what one of the things that may cause people to be more hesitant, again, as we go back to it There are also risks of just getting. Yeah, but the virus itself, and that may level the playing field a little bit in terms of the risk benefit calculation of, should I get the vaccine or not? It's very different from saying, is the difference just getting the vaccine and never getting infected, that. That sets your risk a little bit

Matt Boettger 49:38

differently. No. Good. The reason why I didn't bring this up. So I think this is a great illustration of the complexity of a situation where it's not just a black or white switch but that, that by taking the vaccine, not taking the vaccine, but I think this is encouraging because this is a naturopath who does want to look and explore at the possible side effects and safety. And this was probably the, one of the biggest ones by which it's more complicated than that. So going back to the question of safety for all those people out there who are wanting, if it's safe, is there anything. Currently out there by which we're seeing that showed that it on any level it's not safe anywhere at this point in time. Stephen, has there been anything surface? I mean, from what I've read, there's the rare things, but there's nothing that's really shown up on the radar to show that that there's anything to be concerned about.

Stephen Kissler 50:20

Yeah. That's, I mean, that's my reading of it. It seems to be as safe as any of the other vaccines that we have available which is pretty good. Yeah.

Matt Boettger 50:27

Yeah. And I don't know much to say about that. It's hard because there's really not much to talk about because everything has come up so far has been good news. Besides the side effects. I know there's spend some on the, on the margin of things, some, some really strong reactions, but it's so rare fits into the general population of, of what you would do if you studied. So I'm really in the end, hopefully encouraging that. We all just try to take part of this. And I know the one thing that I, that the nuance to this is what Mark and Stephen really did a great job of framing back in, gosh, the spring and the summer that in this email from the naturopath, it was a really a question of here's all the situations, here's all the nuances. Here's where we're at. Now you need to make the best information. You need to make the decision, the best decision for yourself and your health. Right. Your personal health and that's kind of where it landed. And then she can offer ways by which to navigate that terrain. But then, Mark and Stephen you've really opened my eyes because that's the way I have seen it, but it's, it's a much bigger perspective. It's not just, okay, here are some side effects. Oh, I don't know if I want those side effects. You know what, it's just, I don't think I want to do it. Great, but there's a bigger picture because it, because it takes a much bigger population to be able to bring safety to other people. And then he'd be a huge consideration and a fever for two or three hours or a headache or some swelling or some tingling of fingers, maybe worth it for the greater cause. Not just for yourself, but what it gives to the community as well. And it would keep that in consideration. Great. I think, and I think we nailed it. We talked about the efficacy. And that that was really encouraging to see. And by the way, just talking about how, when it comes to hospitalization, that they're really kind of on par with each other, and it's encouraging to anyone who's considering this fact that the vaccine, now we talk about its safety in that really there's nothing to be concerned about. There's nothing on the radar. And then the great news about asymptomatic transmission. And now my last question, before we head out and leave. Is that across the board. You think asymmetric, admission. I know Madonna and Pfizer have been out for longer, so there, but do we expect, we think that that might be similar intensity of prevention with something like Johnson and Johnson and other vaccines that are coming out.

Stephen Kissler 52:24

Yeah. We're, we're still, still getting the data and that I think so there's going to be some variation for sure. I'm sure. Yeah. Okay. But again, like it doesn't have to be perfect and then you get these population effects that really help a ton.

Matt Boettger 52:36

So, great. Okay. We're going to end on this. I just saw that the CDC came out with good news about vaccines, about how you can hang out with people, with other people that vaccine, or you can hang it with someone, to somebody else who doesn't have the vaccine with one household. And that's it. That's not at high risk. Now. I know that some scientists are kind of a little bit leery about that particular prescription. That's the nuance, but as the CDC provided as a helpful kind of hopeful reality, For those who are getting the vaccine, that's it. I wa I hope you guys have a wonderful week. If you want to get in touch with Stephen S T E P H E N K I S S that's on Twitter and check out his list. It's awesome. You can follow it. As well as he would get ahold of us mad@livingthereal.com check out my podcast, living real about the six or seven things that I've learned so far that are still unraveling. One, which is hit me like a ton of bricks and it scares the heck out of me. Okay. For that's it for this week, have a wonderful week. We'll see you all next week. Take care. And bye-bye.