Pandemic: Coronavirus Edition

Will lack of government funding disrupt the transition to endemicity, and hope is not optimism

• Dr. Stephen Kissler and Matt Boettger • Season 1 • Episode 98

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Matt Boettger:

You're listening to the vendetta podcast. We equip you to live the most real life possible in the face of these crises. My name is Matt Barker and I'm joined with my one good friend, Dr. Steven Kissler, Napa dealer, the Harvard school of public health. How are you on this incredibly spring month?

Stephen Kissler:

Ish. It's spring down. It's a spring month. Yeah, it is spring it's. I mean, it's actually sort of like raining really hard last couple of days here in Boston, which, which is spring time here. So yeah, it's finally getting warmer and Boy man. It's it? It is a, it always feels like a miraculous thing when you emerge out of the Boston winter. Cause it was just so cold and so long and so dark. So yeah, everybody's feeling it. That's good.

Matt Boettger:

Yeah. I cannot imagine I'm so used to Colorado three days of, of in a year. And those two days, I'm like really angry and life and I, and then I feel bad cause most of the other world has many more times. So, I'm sorry for those who were probably expecting a podcast episode on Monday, a good news for me is I got a job another job. So I've been doing other random stuff, got a full-time gig started on Monday. So the first few days were kind of crazy. So, this kind of, this might be an ever evolving, changing, shifting release. And I know I haven't even told Steven yet, but I'll be gone for over a month. And so we'll throw that out a way from Colorado. So there might be some times where we might not have an episode right on time, but we're still gonna strive hard to be as regular as humanly possible and regular, I mean that on episode wise, not like biologically or like regular, always squarely. I'm always striving for that at 44. So, I don't know whether I should cut that out and I'll find that out. I'll, I'll determine that later on. But before we get going the regular good stuff. If you can leave us a review, we love it. Haven't had one in a few weeks. Just get inspired by those little drops of notes. You can do that on apple podcasts. There's other platforms. You can do that as well. We'd love that. Give us a rating. Also patrion.com/pandemic podcast. As little as$5 a month can help us keep this going or just a one-time. PayPal Venmo all in the show notes. Okay. So it has been a little over two weeks, Steven. I feel like there's a decent amount to cover, which is always interesting. So I keep thinking that at some point in time, we're going to just sit here and stare at each other for 45 minutes and then close up shop and they can hear us breathing. At the still there's still stuff to talk about. But the first thing I want to check in with you is just dealing with the, the variant there's BA too. I just read an article this morning about this I guess a BA three, that's kind of sitting around, not doing much, but who knows, but you want to give us a status of where we're at with B2 because we've heard of Europe having increasing cases. There's been a lot of news articles about expecting a surge here. We've definitely seen an uptick, but nothing dramatic. Is it Is it more than that? What should we be expecting this summer? Felicity?

Stephen Kissler:

Yeah. So, it's, we're sort of in this spot 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 up pretty consistently about a month or so later. You know, why, why that is. Sure, but it's, it seems to have been a relatively consistent pattern. And so, and actually, to a large extent that that is what we're seeing now, we're starting to see 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 more than half of the COVID cases that are being sequenced. So it's now a majority of what's circulating here. And as Europe is to the U S oftentimes the coasts of the U S are to the rest of the country. And so since we're starting to see that rise in the proportion of BA two cases here, I think that we can probably expect that to happen across much of the rest of the country. But the big question is like, you know, how, how big and how long will. B I am not yet convinced that it's going to be a major feature of our spring time COVID experience here in the U S and that's to a large extent, because we've had BA to circulating in the U S for quite some time. We've had introductions of BA to here all the way back since December. And so I think that if we're going to do something really. Huge and sharp and sudden it probably would have done so already. Now that's not to say that we're not going to see a rise in cases because there, there may be some strange interactions with previous immunity and waning immunity. And, you know, the fact that our behaviors are changing quite a bit. Mass mandates are sort of lifting just about everywhere and You know, every, I certainly, my behavior has changed over the last month or two. I've been seeing people more, I've been out and about more. And and so all of that is going to contribute to so I think the most important thing is to to note that, you know, BA two is probably more infectious, more transmissible than the original Omicron variant, but it's the difference between BA one and is nowhere near the difference between. And be a one. So we're going to start CBA to start to take over. But I think that a lot of the surge that we're seeing is actually probably behaviorly driven. And and, and I think we're going to be helped by the fact that this is happening as we're going into the spring, as it's easier to move some of these interactions outdoors. And and so hopefully that'll help prevent this from turning into a major surge. And it'll just be sort of one of those blips that we're, we're probably going to be dealing with for a very, very long.

Matt Boettger:

Yeah, I can imagine. And yeah, you can already hit it already, but it seems like this is not necessarily just a BA to reality when it comes to this uptick in the U S you mentioned the idea of our behaviors are changing. We're going to get into the next part of our little discussion about policies, guidelines and the CDC. And is that a good move of the CDC? Is it, you know, the government funding is starting to go away. So there's a lot of things that are kind of coming in the pipeline that are going to change this summer dramatically. Hitting one more part of this kind of uptick in the us. I've read an article. This is great. Or whatever. Once in a while I hit an article and like, oh, that's Steven, he's actually in there because there was a scene where you quote, you, you were quoted talking about one of the, kind of the metrics is looking at the 65 and older group I've seen, what's going to happen. Can you talk more about that as we begin to venture forward and kind of see how do we plan for any future surges cases? What do we, what things we need to be looking for and monitoring. And this other article I talked about, which is deeply related, I think it was by the Atlantic about this increased desire to look at another metric, which is kind of the immunity surveillance. And so clearly we can watch the 65 and older group as they enter into the hospital. But I feel like that's kind of a little bit late. Are there other things that we're doing preparing to help be a little more preventative to see? Okay. When should we be. The different measures went to, we encourage the 64. And all the group to take the second booster and that becomes available those kinds of things.

Stephen Kissler:

Yeah. Yeah. So, you know, with, with the, with the thoughts about the immunity in the 65 and older age group, it's really basically. A couple of things, you know, first back in, gosh, I don't even remember what year it is anymore. It was when when vaccines were sort of first coming online. So I guess it was like end of 20, beginning of 2021. There was a lot of asking about, you know, who how should we prioritize vaccine doses and should we prioritize it to interrupt, to transmit? Which would suggest vaccinating young adults. We should, we should, we prioritize it to reduce severity of disease primarily, which would, which would prioritize vaccinating the elderly and and sort of prioritizing vaccination by age group that with each, you know, as, as you get older, the more important it is that you get vaccinated. And based off of the modeling and the information that we had about the severity of COVID. By age, it really seemed that it was by far, in a way, the best strategy to vaccinate the oldest people first. And that's really been Kind of supported by some well, and I think we'll probably talk about this in a little while too, but the experience in Hong Kong so one of the really big issues that seems to be in play in Hong Kong is that they were able to keep cases low for a very long time. But there's been a lot of vaccine hesitancy amongst the older age groups, and that has led to a really big surge in hospitalizations and deaths in Hong Kong that really hasn't been. Seen in other countries like New Zealand, for example, where there's higher vaccine uptake amongst the older age groups. But have had a similar experience with COVID previously where it was kept suppressed a very low levels. So both the modeling and the real-world experience suggest that the more immunity you have in the oldest age groups the better you're going to fair as a society overall. I think that it's, you know, this is another one of those examples where it's really difficult to reason. When we're thinking about exponential relationships instead of linear relationships. So when I'm talking about the risk of hospitalization and death increasing with age, I don't mean that it's still linear increase where it's like with each year, your risk goes up by a fixed amount. It's really pretty much exponential, right? So like, as, as you get older the, the risk just increased. So much that if you compare the risk of hospitalization and death for somebody who's over the age of 80, for example that's, you know, it the risk of somebody who's much younger, really, really pales in comparison. And so, so that's really why you know, getting back to this quote in this article why I really think that one of the most important indicators for how communities are going to fare as we move forward is vaccinate. And immunity rates in the oldest members of our population. And I do want to say that this also extends to other groups who are vulnerable. You know, it's not just the elderly who are vulnerable to severe outcomes. In many ways that's sort of the largest and easiest group to identify with a single category. But we can ask ourselves, you know, what is it that makes people who are elderly more vulnerable to severe disease from COVID. So part of it is the immune response that as you get older, your immune system just doesn't get fired up as easily. And so, so of course, that also then extends to people who are immunocompromised. It extends to people with co-morbidities that either prevent them from mounting a good immune response, or that make them more likely to have severe COVID outcomes. Because again, as you're elderly you tend to have more cardiovascular conditions. You tend to have. The rates of obesity increase the rates of diabetes increase. So all of those things independently also affect your risk of severe disease from COVID-19. So we really want to make sure immunity is high in those populations as well. But again, if, if, if you had to sort of say, you know, if I had to, you know, if I had 10 seconds to tell you what my strategy would be for getting communities through this, I would have to, I would have to stick with that oldest age groups because that's that's sort of does the best job of sort of encapsulating all of that together. Yeah. So that's, that's a, long-winded answer to the first part of your question. I know you had another one about immune correlates too, but let me know if you want to dive off on another tangent.

Matt Boettger:

That's great. I think let's go into that because I think just understanding, cause you, you you're setting the stage for this then how do we begin to prep or monitor in. Have immunity surveillance as being a key criteria for us to be ahead of the curve a little bit in a different perspective of monitoring. When these people, I can kind of see how you might be able to do this on a macro level we were kind of already doing this, like, oh, it looks like immunity response decreases around six or seven months, but maybe even getting into a particular response as part of your, in my mind, like part of your, your physical and your physical baby, there's something down the road that encompasses. Where are you at on particular antibodies for veterans? Diseases.

Stephen Kissler:

Right. Totally. Yeah. You know, and so yeah, a couple, a couple of thoughts on that. I think you're, you're absolutely right. That really what we're talking about here is amount of immunity. And ideally what we would be able to measure is a person's antibodies or other immune responses to a given pathogen with. It correlates with vaccination and previous infection, but, but it's not perfect. It's a pretty noisy correlation. Right. What we've seen from studies where people have been looking at antibodies in the blood is that people really do have a very wide range of responses to the vaccine and a previous infection. And while it's very much true that on average, your protection increases with increasing exposures there are some people who just really repeatedly, just don't know how to very good response at all. And and so it'd be really worth understanding. And who those people are and what we can do. Again, like I said, you know, for, for some individuals who already know that they have some kind of immune compromised condition, that makes sense. They have reason to suspect that they 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 be some underlying condition that they're not aware of. And, and that leads to this huge amount of variation between people. So I do think, you know, we're not yet at the point where we can. Do a serology for COVID-19 on sort of a widespread population basis. And then say like, you know, like your immune response, hasn't been very good. You would really benefit from another dose of the vaccine or you might want to take these list of precautions, but that realistically I think that that may be. A direction that we're heading it with immunity to both COVID-19 and other infectious diseases. There are certain infections for which we already do this for people who are working in healthcare, for example. So for, I think it's hepatitis B. If you're going to be working in a hospital frequently, you have to basically get an antibody titer. You, you do a circle. And most of us are vaccinated for 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 already a sort of a paradigm for this. But it's pretty reserved. Really only the groups who need it most. And but my hope is that as we move forward forward, we'll both see the value in this kind of testing. And also the cost of doing these kinds of tests will go down as the interest and investment in them goes back. And so hopefully that'll mean that it's no longer just reserved to the people who are working in hospitals, who admittedly are the ones who really. You know, th they're the ones who need to be getting this sort of test right now. But it would be wonderful to start to see that become more widely available for COVID-19 for other infectious diseases, because it really is that that's really what we're trying to measure here is, is how, how immune you are and not necessarily how many doses of a vaccine that you've gotten. Yep. Great.

Matt Boettger:

And do you expect then this for like the second booster dose or the fourth? If you're taking Pfizer as being like. A common thing that's gonna be in this fall. Like, are we, you know, we were kind of didn't know w initially thinking that, oh, maybe like that initial booster is going to take us far, like maybe a year or two, three years down the road. I don't know where we're at for research with how long it seems like even the booster, some articles say maybe six months, again, it might start to wane a little bit, given the prevalence of homo Cron and this kind of stuff. Are you going to, do you see that this fourth dose being pretty much a. Not required, but are highly recommended things for 65 and older come this fall, or even sooner.

Stephen Kissler:

Yeah. You know, I to be honest, I haven't really reviewed the data very closely on the fourth dose you know, additional booster kind of Another dose in the series. I know that it has been, I think it already has been approved and even recommended for people over 50 by the FDA and CDC. And, but I, I really kind of would love to dig into the data a little bit more because as far as I can tell, it does seem like the booster has provided a substantial and more durable response than the initial series did. And I think there's still some questions as to how durable that responses and also what there is to gain by getting a fourth dose. Absolutely. I think that, like, if you get another dose of the vaccine, it's going to rev up your immune system again, and that's probably a good thing, you know, it will, it will give you more protection. But there are also all of these different layers of protection that we need to bear in mind. It does seem like the booster goes a very long way and does a very durable, consistent job of protecting people from hospitalization and death. I imagined that a fourth dose will probably go even further and help prevent people from getting symptoms in the first place, which is great. And, but it's, it's not clear. Yeah. How much added benefit there will be in a severe disease camp. And part of it is just because I don't know that we've collected the data. And even if we have, I admittedly have not been able to dig into it much yet. So, but that's definitely, you know, that's, that's been a big topic over the last couple of weeks, so it's something I'm going to be looking at soon. So hopefully we, hopefully we'll be able to dig into that a little bit more in in the near future.

Matt Boettger:

Great. Great. Well, let's get an, you mentioned the CDC. Let's talk about that now, because now we're seeing, you know, all the guidelines of the CDC. We talked about this just over two weeks ago and how some of the goods. So the pros and the cons of the changing towel now with the new guidelines, what was considered high risk for a particular state is now low risk and there's different criteria. And now on top of that, we, this layer of funding being removed. So I just want to get your, your insights of where you, where you think, where are you thinking about the direction of the lack of funding? It seems like in my mind, I th I just kinda thought things were like, they're gearing up. We're establishing kind of a new maintenance routine of how to deal with infectious disease. And once this funding goes away, it can go in like autopilot and keep going. But it sounds like. Drop, maybe like things that were installed are helpful. We're going to no longer have funding and they're going to be removed. And where do you see all this going? What would you buy? The biggest thing. But I don't see clearly, as I read these articles about complaining about the funding being dropped, but I don't see too often, these benchmarks of like, well, we didn't read, we didn't reach this benchmarks. We need X amount of more months. It's just more like, we need the funding. And for me it's like, oh, that could go on forever. And we can't do that forever. But do you see like a benchmark that we haven't quite got to, that you would say, oh, we should keep this funding. Or where do you see yourself in the midst of all?

Stephen Kissler:

Yeah. You know, it's, it's hard. And this gets into the complexities of, of national budgets, which I have zero experience. Because you're right. It's like, you know, absolutely. I think we need to be maintaining a consistent and responsive approach. To managing COVID-19 cases in the us. But it, it is one of many priorities as, as a country. And and so it's, it's like hard to know how to, how to weigh those things together. So of course I think that you know, dropping funding altogether from COVID-19 response would be a huge mistake. I don't think that's really what's being proposed. The, what I would really hope to see as we move forward is, you know what I, it does seem to me like we're, we're beginning to move out of a phase and I think this is this is. You know, an accurate reading on the part of sort of the general political mill, you you know, th that we're, we're moving out of this crisis phase of the pandemic and, and moving into a management phase. And some of that has to do with epidemiological factors. You know, we've been through a major wave of cases that actually didn't translate to hospitalizations and deaths at quite the same rate as it had been before. So that's a good move. In cases are relatively low right now. We're going into spring and summer when historically cases have been, you know, nationally sort of more manageable. So if there were ever a time to sort of regroup and evaluate where we want to go forward with this, you know, this, this is it. And so I think that, you know, what it really makes sense to do is to maintain funding in the areas that will allow us to respond quickly and efficiently to new searches. So it's still possible that a new variant can emerge at any time and we'll have to deal with it in short order. Right. And so I want to make sure that we, you know, we have the resources to do that. And so it remains true that like having a Yeah, a stockpile of vaccines makes sense. And that's partly informed by the fact that you know, two doses of an MRN, a didn't help all 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 know for sure, but, but it makes sense to have some amount on hand to vaccinate, especially the vulnerable very quickly makes sense to have tests available. Maintaining investment in rapid tests and making sure that they're available and that you don't have to like go searching through 20 different CVS as to find one like we have in the past. Like that, that makes sense. And those things don't really expire very quickly. So I think making sure that we have a good stockpile of those make sense pharmacy. Again, like those things, we can really stockpile and make sure that we have on hand. And so my sense is that as long as we have enough of those things available to deal with an impending surge in short order, then it's okay to sort of back off of some of the other funding for maintenance. And, and I will say that, you know, there are other areas where the government and the CDC have been investing in sort of a longer-term approach towards managing infectious diseases, including like funding this new center for outbreak analytics. That's going to be doing a lot of modeling, a lot of surveillance. Both for COVID-19 and for other infectious disease threats. So my hope is that some of that funding that is being taken away from COVID specific efforts will also be transitioned to, into sort of thinking about, okay, what's next. And and I think that's probably the best thing that we can do at this point.

Matt Boettger:

I like that. Yeah. Moving things from like an acute allocation for acute crisis to more of a long-term maintenance of, of systems to put in place to, to govern and, and grow this. Okay. The one other thing on this, on this kind of area is my friends. This article, they from airlines America for airlines kind of provoking the airline. To reconsider relinquishing masks and particularly the testing, you know, before you come back home and showing like the economic downtown people, not wanting to go and travel overseas because they're afraid of 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 to weigh in on that. If you could like epidemiologically, is there any. Support the can for continued mass in the airport at this point in time and like testing and, you know, do you have any opinion on where this stands for when it comes to airlines when their next, their next move for the summer?

Stephen Kissler:

Yeah. I think that with with the testing issue, it's, it's tricky because, you know, like you said, it's It does, you know, you're, there, there is this concern of being stuck somewhere. And that, I mean, Yeah. It's like, I don't know, is that better than flying with COVID-19 then going to the airport like that? Maybe so, you know, so I'm, I'm, I'm hesitant to say that like, yeah, we should just sort of drop the testing requirement. But, but I do recognize, you know, that maybe the added benefit of tests. When people are getting on an airplane is not that great when we're not actually testing anywhere else. Most, most of the spread that's happening right now is not coming from travelers, you know, coming from other places. I think that testing makes a lot of sense in the context of a new variant when we're trying to sort of slow the spread of something like Omicron and eh, their, their testing makes an awful lot of sense. Now it's kinda hard to say it's kind of everywhere. And so it's like, you know, spreading it through an era, like you're just as likely to get it anywhere else as you are in an airport or on the airplane when it comes to masks. I think that I like. Honestly, I don't plan to ditch my mask in airports anytime soon. There were times way before the pandemic that I kind of felt like I should be wearing a mask anyway, but I felt a little weird about it, you know? And that's, I don't think the masks are keeping anyone from traveling. I could be wrong, but I, you know, like that's and there, you know, it also, the other thing is that the masks are probably most important while you're in the airport. I had this funny. The last time I was traveling where you know, there's somebody who is like wearing an N 95 around their neck and, you know, while they were waiting in line to get on the airplane. And then as soon as they got on the airplane, they like put on the mask and it's like, you know, in many ways that's kind of the opposite of what you wanna do. Cause it's in the airport where you're not going to have as good ventilation. And you're mixing with a ton of different people. Once you're on the airplane, like you're probably sharing air with maybe the people right next to you. But otherwise, like those things have HEPA filters and like a huge number of air transitions. Such. So it's like actually the risk of spread on an airplane is not huge. And so, so I could see an argument for saying, like, be masked to airports, but then you can like be less stringent about them on the airplane. I think that would also really help. I know that a lot of poor flight attendants have had a lot of issues with compliance with masks on planes. Right. And there's been a lot of, sort of like. Argumentation and even violence. And so like, if it helps with that then great. You know, if we can say like, you know what masks are optional when you're actually on the airplane and if that makes flight attendants jobs easier than absolutely. I can get behind that because I actually am not convinced that masks. Do a huge amount of help when you're actually on the airplane, but in the airport. Definitely. So those, those are sort of some of the things that I'm thinking about as I'm thinking about changing policies with, with, with travel.

Matt Boettger:

Great. Well, the distinction, so let's get into quickly to Hong Kong because it's, you know, total change shift of what's been happening there. We just love to get your insights of like, what happened, you know, and this is a nonpolitical statement, honestly, but I'm like, I felt like when I was reading some of these articles, some of the aftermath of what's happened, Hong Kong felt like. Nick and mini America, many of us like the lack of trust and a vaccine hesitancy, all these kind of similar, similar overtures that we have here as well. But clearly just being riddled with hospitalizations, just wanted to get your reflections on what's going on there. And w w what happened that created to create that situation?

Stephen Kissler:

Yeah. Yeah. So Hong Kong is a really interesting sort of case in you know, thinking about the management of COVID-19 getting into for any listeners who haven't, haven't had a chance to look at, you know, the, the data you know, hospitals like cases and deaths in Hong Kong lately. It's pretty remarkable. I've, I've got it pulled up right now next to me. And you can just type into Google, Hong Kong COVID cases. And it's like flatline. Like all the way up until a few months ago. Like nothing. And then there's this huge surge and that's, you know, driven by the Macron variant. And so, you know, one of the other things I want to pull up here is so looking also at. For example, COVID 19 cases in New Zealand. So in many ways prior to the Omicron surge New Zealand and Hong Kong had actually pretty similar experiences with the virus in the sense that they were able to get it out early and keep it out for essentially the duration of the pandemic up until this point. And then lately they've been relaxing, travel restrain. And so that's, you know, inevitably COVID has been able to spread. But one of the big issues in Hong Kong seems to be the fact that again, the older age groups there's been a lot more vaccine hesitancy amongst those groups. There's been lower vaccination rates amongst those groups than there have been, for example, in New Zealand where despite a pretty big surgeon cases, the number of deaths has remained pretty low. Really an order of magnitude lower than what we've seen in Hong Kong. And and so I really think it comes down to that in, in very large part. And I think, you know, w what a lot of this speaks to is that these issues of vaccine hesitancy of trust in the medical establishment of really just evaluating personal risk and thinking about vaccination as such like these are not. American issues. These are not necessarily like, American and European issues. You know, they, these are, these are really human issues and they look, they look different in different places for sure. But but we we have some really sort of. Deep questions to resolve here. And and so I think that, you know, the, probably the, you know, the, the short explanation of this is really just like differences in which age groups have been most highly vaccinated. But that really points towards a much bigger issue of like, what is it about vaccination that makes some people more likely to accept it on others less? And yeah, just like what. What can we do about lack of trust in the medical establishment? What can we do about misinformation? What can we do about you know, there are many people who have very good reasons to not get vaccinated, but then like, what do we do to make sure that we hear and honor those, those reasons as well? You know, and I think I think those are, those are questions that we don't really have good answers to. And unfortunately in Hong Kong, we're seeing that you know, the lower rates of vaccination seem to have. Had a heavy toll. And I think that just points to all the more than needs to to answer these questions, all the monitored.

Matt Boettger:

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 not to go with the Pfizer one and some other one. And I don't share that. I don't even know if anybody knows the data on that particular vaccine. So you have a vaccine hesitancy on top of the vaccine that was rolled out early and I'm not entirely sure how good it is, right against Macron. Whereas Pfizer in modern are just pretty, pretty good, especially with the booster. So a lot of different threads coming together to form. A pretty big mess in Hong Kong right now. Yep. So next we talk. One thing I wanted to mention just briefly you mentioned this early on, maybe like a month or two ago, who, who says most likely scenario shows, covets, Verity deal decrease over time, which is just another layer of right. As we begin to unfold restrictions and do more things. It's like, this is another kind of. Prosthetic voice, whether it's right or not, we don't know. Right. It's most like it could be different, but again, another reason to, or incentive to decrease the measures by which we funding those kinds of things where Alex metrics, because we were. And to be better down the road, even though it's not necessarily true.

Stephen Kissler:

Right. And I think an important point with that is that it's not necessarily the inherent severity of COVID that's going to decrease over time. I think that that's, that's another element of this story in Hong Kong too, is that there was, 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 a Testament to our immune systems. And I think what we're seeing in Hong Kong is that Omicron is, is every bit as severe. Maybe not as Delta, but certainly as the pre Delta variants of COVID-19 But in much of the rest of the world, we've got a lot more immunity built up either through vaccination or through multiple rounds of previous infection. And, and that's, that's the story there. It's, it's not, it's not necessarily that SARS, cov two is evolving to become. The severe, it could, I'm not saying that that's out of the picture, but that doesn't seem to be what's happened so far. I think what's behind the statement is that the critical piece of this and, and the way in which severity decreases is by increasing immunity. And I think that's useful because that that points to. Ways that we can respond to it. You know, one, we can just sort of sit and wait and wait for the virus to get wimpier, but I don't think that's realistic because immunity is actually something that we can be proactive about. We can think about vaccination and we can think about ways of getting boosted. We can think about, you know, making sure that the people who are immunocompromised are protected and all the ways that they need to be protected and. How do we decrease covered severity over time? That was

Matt Boettger:

great. Thanks for that nuance. That's really that's great. So now when it comes to detecting COVID, I just want to drop this as well. A new PCR tests can identify all SARS, cov, two variants, any positive patient sample. This seems pretty cool. Even going down like even color coding, you know, w whether it's an OMA, Cron Delta, you know, so I'm not sure it'll get to the point where, like, I get my. Let's say you you're positive and you got Delta or, you know, you got an Omicron. I'm not sure I'll get that, but what ramifications this have for surveillance, if this becomes a commonplace, a common way by which we do.

Stephen Kissler:

Yeah. Yeah. So, you know, this is, this is great. I'm going to, I'm going to geek out a little bit if that's all right. If you'll indulge me for a few moments. Right. So, do you know how, like in a computer colors are stored like the little data structures? Usually it's just like a string of numbers. They're like numbers and symbols. So, there are a lot of different ways to do it, but one of the most common ways is a hex code. So they're basically. Six digits that encapsulate a color. And with that, you can encapsulate a ton of different colors. Another way of doing it is by a slightly longer string, that's just binary. So ones and zeros that basically give you, you know, different shades and hues and things. And the longer the string the more, you know, the more binary digits that you have, the more precisely you're able to articulate specifically what color you're talking about. And so essentially what they're talking about with PCR detection of new variants is exactly the same principle, but on a molecular scale. So essentially what PCR is able to do. Is to give you a yes, no answer. If a specific short genetic sequence is present in a sample that you're trying to test. So with existing PCR tests it's actually not just testing a single genetic sequence for SARS cov two. It's actually three different sequences 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 strings of RNA letters and seeing, seeing if they're present in a nasal. And one of the reasons that previously we've been able to distinguish between for example, alpha and Delta or Delta and Omicron is because with each of those transitions, one of those three sequences that we're testing for is mutated in the virus. And so it drops out. And so now you sort of have this binary string where. A Delta infection probably represents a 1, 1, 1 in each of those different things. It's a success like each of those targets has been identified, whereas an alpha or an Omicron infection would be like a 0 1, 1 because one of them drops out the S gene target drops out. Whereas the the other two targets remain. Well, there's no reason why we just have to test her two or three different parts of the virus we can test for 10 or 15. Or we could think more about which three we want to use in a PCR to, to test the virus. And so essentially what you can do is you can identify. Parts of the virus that differ between variants and you can use those as your tags. And so by doing that if it, you know, if one set of those tags amplify in one sample, you can say, well, this was probably be a one. And then if a different set you can say, well, that's BA two, because you happen to include in your tags. A little bit of the sequence that distinguishes BA one from BA two. So to do this, you really have to have a good sense of what the variants are, what their sequence. Yeah. That's, you know, and we actually do have a pretty good sense of that. But once you do that, then you can actually make these, what we call like multiplex PCR tests, where you're testing sort of multiple parts of the viral genome. And you're testing the pieces that give you the most amount of information about which variant it is. And then you sort of read out this binary code and based on what that code is, you can get. The certainty about what variant it actually is that a person is infected with in the same amount of 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 it would allow us to do much better surveillance of what is circulating, where and the relative prevalence of different strains in a given population without actually having to sequence everything. You can just rely on the PCR tests. So this will allow you to detect new. It's necessarily, unless you start to see some really strange Binary sequences that don't match anything that you've seen before. And then you'll have to do the sequencing to figure out what's going on, but this can go a long way towards helping us figure out. What's actually one of the things that we already know of what's what's circulating in a population at a given time.

Matt Boettger:

That's great. I'm guessing this is probably a huge, because I know, I know we used to say that UK led genomic research and that's a separate industry, so to speak. And now if you can build into the PCR, which has already mainstream that's. Almost like exponentially grow our capacity to do surveillance in the U S and I feel like, I guess if it, if it's comprehensive enough, like you said that then new variants that come up, hopefully we'll see it. Anomic, that's weird. And then that weird allows us to like start exploring earlier than, than maybe, you know, so that's, I'm not sure when I'm guessing, is this something that's gonna be down the road mainstream that it's gonna take some, a lot of some checks and balances before we're going to use this as a replacement, or can this be a quick turnaround, like, oh, let's start using these.

Stephen Kissler:

Yeah. You know, we in theory, we could start using these next week. You know, it, it would take a while to sort of like, you know, distribute to them, make all the reagents and figure all of that out for sure. But but changing the set of targets that you're testing for is a pretty routine thing to do with PCR tests. So if you have access to. You could do this tomorrow. And if you know how to do PCR, I don't have no idea how to run a PCR, but but, but, but people do, you know. But, but I think that that is to say 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 resources to sort of update the infrastructure that we already have and update it to this new sort of version of PCR.

Matt Boettger:

Great. Fabulous. Okay. So next part here, we're getting close to the end. Another interesting article I read, and I know this was interesting to you cause you, you read this as well. So the surprising link between COVID 19 and deaths is internet access. Now this, these, this thing, when I read it got me excited, but it also made me a little weird. Like I'm like, okay, can this really be true? The internet access and they, you know, they can get some so, and I'm glad I brought it to you because you say this is a great, maybe a great segue of helping to understand the audience or get people up to speed of how to be able to look at this data and see the nuances behind, you know, what's real, what's not, what's complicated, what needs to be considered in light of this. So I want you to take it away. And what were your first impressions when you read this article and and the nuances behind. Yeah,

Stephen Kissler:

right. So, I think, you know, when you hear a headline like this, the first thing that should immediately spring to your mind is correlation is not causation, right? Like that's like, you know, if that, and I hope that at this point in the pandemic that is just drilled into everyone's heads. And anytime you hear a causal claim immediately those alarm bells should come up and you should ask, like, is this a relationship or is this a causal link between two different things? That said, you know, digging into this article they really did go to great lengths to try to what we call in statistics to control for different variables that could be other explanations for. Difference in COVID-19 rates for people who haven't have internet versus who don't like the obvious ones being like socioeconomic status or urban and rural location. There are a lot of different things that you could say like, oh, well this is just a proxy for this other thing. And that's, what's actually driving the difference. Well, there are ways that you can at least sort of nominally. Adjust for these different factors 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 difference associated with internet access. Now that still doesn't go so far as say, The cause there, you know, the other thing is that there could still be some underlying factors that are not yet perfectly accounted for by the other variables that you put into your analysis, but it does make that link a little bit stronger, you know, where it's like, well, we can't just totally discount this difference in COVID cases, by individuals who have, or don't have internet access at home. And and so, and so it, it begs for a further look. So, so the first thing, you know, I think you know, we can first play with the idea that maybe there, maybe there isn't a difference. Maybe, maybe there is a causal link and we can start to ask ourselves, you know, why, why might that be the case? And you can imagine all sorts of things from like access to information. And I think that's really the main one is like ability to access and to find information about 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 you control for someone who has the same socioeconomic status living in the same neighborhood same demographic characteristics, but one has internet. And one doesn't. You might imagine that the one who has internet is already a little bit more plugged into social services that has helped them get that internet than the person who isn't. And so maybe those social services are actually the things that are helping them reduce their rates of COVID 19 and not the internet itself. And that wasn't really able to be low. Rigorously in this statistical control design. So there could very much be other what we call confounders that are behind this, even though 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, you know, I read a study like this and I go like, huh. You know, like, that's, that's basically 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 giving everyone internet is now going to reduce their chances of getting COVID-19 or future infectious diseases. It could, and there are a ton of other really good reasons to make internet much more widely available. Right. So, so sure I can get behind that. And maybe this is one more reason that, you know, one more thing that could tip the balance in favor of giving people internet, but really, you know, scientifically what this is. You know, begins a narrative in my mind where now, anytime I come across another study that says internet and infectious disease, I'm going to be like, oh, I can put this in the context of this other thing that I've read. And over time, hopefully we can build sort of a scientific consensus where we're looking at this question and a lot of different populations and from a lot of different angles and maybe even some experiments are done. Give people, internet. And then you see if that changes their experience with infectious diseases over time. So it's more of a controlled experiments as opposed to you know, just an observational study and then maybe we can build up an evidence base about this. So the most important thing is that one study never really gives scientific proof. It's sort of a consensus between an entire set of studies. Really that's that's the currency by which science operates. And so what this does is it says it sort of raises an interesting question and does a pretty solid initial attempt to give evidence for, and against the reason why internet access may or may not affect a person's experience with COVID-19. And so really for me, what this does, is it sort of earmarks this, this sort of thread of thought and I'll sort of carry it with me as I go forward in my research. That's

great.

Matt Boettger:

Awesome. I love that. One of the things I wanted to end on is this whole long COVID thing. This is always it's funny because I've read a number of articles and I just kind of been stacking them in a little area for us to talk about. And then we ended up not talking about. And, and, and, and, and because I think you brought it up before 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 these things like memory and concentration problems affects 70% of long COVID patients living with, with COVID long coveted becoming a pediatric public health crisis. So these things keep percolating. Right. And I, and I want to talk about it, cause I know we have listeners who have actually emailed us saying they suffer from Lancome. It's just not, I don't have a care about it. I'm not trying to be empathetic, but I've always struggled with. Into the discussion because I don'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 right back into this discussion as we end this episode of. Yeah. A, have you heard anything about long COVID Dennis have a B I think more importantly is why is this such a complicated topic to topic to talk about when we're talking even about COVID and it's long COVID like, it just seems like an anomaly, even though it's not, I'm not wrestling with a psychological, how do I fit this in and, and, and, and, and, you know, and address it to something that we can actually give valuable information to people who are.

Stephen Kissler:

Yeah. Yeah. So yeah, there's, there's so much complexity here. And you know, I, I also have a number of friends who are still suffering from long COVID effects. 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 of the frustration of the people who are suffering from it and the sense of like, you know, why, why don't we have more information, more answers? Why do I feel like not even being heard? And so I think that, you know, there are so many different aspects to this issue and you know, and, and partly, you know, behind the reason why it's been difficult for us to even sort of like talk about on the podcast, because it is such a. Complex issue. So I think there are a couple of things in place, so, you know, one of them and one that I think that I've been trying to follow is is the sense of first belief in 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 on your Socioeconomic racial and ethnic gender status. You're more or less likely to be believed by a physician of, you know, and and so if, you know, a person of one set of characteristics comes in and complains of, you know, brain fog and headaches one might be believed and one might not be, and that's, you know, not across the board, but it's, you know, it's, it's a fairly well-documented trend. And and so, and so that's part of what may be in play and that like, that at baseline sort of this constellation of symptoms You know, there, there are probably a lot more people suffering from it than are necessarily picked up by the healthcare system than are necessarily sort of, seen and trusted by the healthcare system. And, and so there, there are definitely these issues with sort of the healthcare response, but I don't think that's everything either. So another aspect of it is the sort of scientific structure of our medical. System and it's, I think even that phrase is important here, where it is fundamentally scientific and science is based off of things that you can observe and measure. And when it comes to disease, we have things that are signs and we have things that are symptoms and signs are sort of objectively measurable things. Like I had a fever of 103 degrees Fahrenheit. Whereas a symptom is something like I don't know, I'm feeling like a little woozy and lung COVID It does have signs, but it is principally made up of by symptoms. And one of the things that a lot of researchers are trying to do is to find signs of co of long COVID of, you know, things that you can objectively image or measure that indicate, you know, this is long COVID or this is a person who might be suffering from long COVID. And the difficulty between having a really science-based medical system is that we often tend to, and this is true of science overall, is that we tend to think that things that we can't measure. Don't exist. And you know, that really doesn't do us a very good service either, because clearly there are lots of things we can't measure that do very much exist. But but I think that's one of the barriers here too, is that we don't really have good measurements for what constitutes lung COVID adding on top 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 actually sort of a collection of things that can manifest in long-term chronic effects from COVID-19. And we have a lot of other diseases for which this is the case. You know, I think about diabetes, which, you know, we already know that there's type one and type two diabetes, which manifest differently have very different causes, have very different. Treatments that you need. And even within those, there are multiple types of type one and type two diabetes that also come from different places and need different sorts of treatments. This is true of cancer as well. You know, we have cancer that describes this overarching you know, set of illnesses, but you know, different cancers. Utterly different from one another and again, come from different places and require different sorts of treatment. And I think that may well be true of long COVID here too. That it's actually probably an entire constellation of conditions. And it helps to talk about as a single thing, because it sort of raises the awareness of this constellation of symptoms and signs and effects from COVID-19. There's also this difficulty, which is that when we're studying long COVID, we're actually probably not studying one thing. We're studying a hundred different things and it can be really difficult to sort of find the common threads through that constellation of causes and effects and figure out what it is that we can then do about it. So all of these things are really conspiring to make it really difficult, to talk about lung COVID and. Scientific way and leads to a lot of the really well justified frustration on the people who are suffering from it, because it is a complex problem and it's one that I think deserves much more attention, even more than it's getting. But even inherently it's, it's such a complex problem and it plays on a lot of the weaknesses that are already inherent in our medical system. And so because of all of these things, it is, it is just a complex deal. Yeah.

Matt Boettger:

That's well said. Thanks, Steven, putting that in perspective. And I know we'll definitely try to 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 have suffered from it. And whenever things surface, we want to make sure that people are aware of the resources available. And what's, what's been the leading research on it. But it is a complex reality, you know, we're gonna end on one last thing and we have to go have meeting here in a little bit and we've got to get going and we'll see you in a couple of weeks, but this one article. Steven, I haven't talked about it. I gave it to him to read but I want 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 listened for 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 things in perspective of dealing with a juxtaposition between optimum. And genuine hope. And the reason why I plant this seed is because even as a little bit late to the game cause we're kind of all wrapping this up, going to endemic mode. And I don't think we're seeing the crisis as much as we did even six months ago when we had that peak. But nonetheless, I think it's still relevant of dealing, especially when you reflect back on early in 2020, when things have. About, you know, first this idea of optimism, you know, two week shutdown, this is going to be over with, and you know, everything's going to flatline. We'll be okay. And then realizing this continues to just surface its ugly head and continue and continue and continue. So optimism turns into despair, right? It's not going to end. And now this is going to last forever. Right? So then there's these emotions that evoke with this word forever. And this article did a great job of showing how optimism isn't necessarily the thing we want to cultivate. We want to cultivate hope and I'll leave you with. This line that the author put here, and then I hope you can go into the show notes and read it yourself, said, namely, he realized that hopeful people shared three things in common goals, pathways and agency, although Snyder called these the three components of hope. It may be more useful to think of 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 to live in the context of hope and not optimism as we move forward. It really encouraged me and I hope it encourages you as well. That lands are playing for this episode. Thank you for hanging in there. Thank you for listening. If you want to. Patrion.com/pandemic podcasts as little as$5 or one time gift PayPal, then all in the show notes and as well, please give us a review. You can do that apple podcast. If you want to get ahold of Steven S T E P H E N K S S L E R on Twitter, or just email me, I will forward it along to Steven and mark@mattatlivingthereal.com. Okay guys, and gals have a wonderful week. We'll see you. I'm sure. In two weeks ish and one way or another. Okay. See you soon. Bye-bye.