Pandemic: Coronavirus Edition

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• Dr. Stephen Kissler and Matt Boettger • Season 1 • Episode 76

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Matt Boettger:

You're listening to the pandemic podcast. We equip you to live the most real life possible in the face. That is crisis. My name is Matt Boettger and I'm joined with Dr. Stephen Kissler in a very different environment. He's in epidemiologist, the Harvard school of public health, but you are not in Boston right now. Where are you? My friend.

Stephen Kissler:

Hey, I am back in Colorado, currently in my parents' basement

Matt Boettger:

flashbacks. Yeah. Good. Yeah. So

Stephen Kissler:

my first trip in out of state, really since the start of the pandemic, so it's been ages and it was. It, I'm glad to have the experience, it's interesting. And certainly, one, one more reason why we're being vaccinated has helped a lot, really helped reduce. I think a lot of the anxiety that I might've felt and knowing that a lot of other people around me were also vaccinated, people were wearing. So I flew and people were generally wearing masks and Yeah, so just super interesting, but the plane was packed. It was definitely like the most people I've been around for a prolonged period of time for a very long time. So I think, this is like one of those things where step-by-step, we're going to start re-integrating into things that we were doing prior to the pandemic. And I know some people have been traveling for awhile and some people maybe haven't yet. And it's a new experience. There were things I had to relearn But and I think we've talked on previous episodes about like the safety of travel and how airplanes have so many air exchanges. So they're almost as safe as being outdoors, but like real risk is like being in the airport and all of these things. So we can rehash some of those things, but it was really helpful to put some of those ideas into practice and, really think about where, how wearing my mask. Am I being distanced within the airport? How is all of that working together? Just a totally different context. And I've been in, in awhile, so

Matt Boettger:

sure. All these big questions should I not shower? Cause I'm leaving the house and a shower at the PJ's do I have to dress up? How do I pack my bag? These are big things. You have to come back to

Stephen Kissler:

things,

Matt Boettger:

you guys are listening and you're probably thinking, we haven't talked about the fact that we haven't been on an episode in weeks since I think May 10th and it's been forever and it's not because we wanted to stop this. We enjoy our time together with Stephen and mark and we enjoyed being. Part of the greater community. So I think it's just good to just put a bookmark and just say, okay we're still here. There's been a couple of big things. My life took a big turn just dramatically affected my family and everything like that. So that had to be put on pause while address the meanings of my family and then Stephen left and he went to Colorado and one of the things he wanted to give him some space to do is be a little bit COVID free, not so much physically, but just mentally write your whole mind.

Stephen Kissler:

Totally. It's I know it's been, I think that I hadn't even realized just how non-stop it has been until I got this chance to take a quick step away. And it was just, it's been immersed in it for almost 18 months now. Crazy. It's way

Matt Boettger:

overdue for you to take a break. When was the last time you came home? Was it like Christmas in 2019 or. Yeah. Okay. That's what I figured, man. I'm glad you could be home with your family. See your brother. It's crazy that you've been here for well over a week or two or whatever. We haven't seen each other physically. That's our life, our craziest Ben. So we're hoping that happens at mark. Steve. I can actually get a brief Hugin before you go back to Boston, but we'll see. So we'll still, we have a decent amount of stuff to cover. A lot of things have happened. A lot of great news, before I talk about what's going on in your world, just a big thing to celebrate. I saw this morning that under 6,000 cases in the U S yesterday, I that's like unheard of low, right? I This is

Stephen Kissler:

absurd. Yeah. It's great. It's like the lowest. By many metrics it's like the lowest the cases have been since we did enough testing to know how many cases there were. This is back below what we've seen, even at the lowest points last summer. And of course there's a lot of variation between different places in the U S still. So the picture varies from place to place as it always has, but it's It's encouraging, this is what we've been hoping for a

Matt Boettger:

long, long time. Absolutely. It's been great news, at least for the U S my life's been a little bit crazy, so I haven't been able to check about, around the world, how has it been going, how India has been fairing, but I know at least you S most. The U S is doing pretty well, except for we have, Washington, Colorado, where you're at we're at and Florida and Wyoming seem to be for generally hotspots. And I think at this point in time, that's a relative term and led to where we were even four or five, six months ago, those kinds of things. But yeah, let's get into a couple of things. You've done a couple of things that I want to do. You talk about the op ed that you did. About that, when you you mentioned about the idea of the future of testing that you wrote about in light of now vaccinations and how is that being going to unfold as well as this idea of absolute and relative risk? I'm not sure. What was that? Was that another article or was that in the interview?

Stephen Kissler:

Yeah, that was an interview. Basically like a verify fact check team that was looking at some interesting Misinformation or stretched information that was going around about vaccine efficacy and surprising

Matt Boettger:

whether you're on top of that one. You're amazing. Let's start with, let's start at the future of testing and then, what's what, how did this come about? Why was this kind of like an impetus to write about this?

Stephen Kissler:

Yeah. So there's been a lot of talk about what the role of COVID testing should be in places where vaccination rates are getting high like the United States, for example. So I was approached by one of the editors, the opinion editors at the hill who asked if I would write them something about, about what. I, and my colleagues believe the future of COVID testing might hold in places like the United States what do we need to be doing? What should we be paying attention to? And it was really interesting. It gave me the opportunity to talk to a few of my colleagues who have also been thinking about this. And one of the things that really struck, one of the questions that I asked to these colleagues was what's. One thing that you would be absolutely horrified to read in an op-ed on testing, just to make sure that I didn't really stick my foot in my mouth. I didn't want to say anything that would make me pause scandal amongst my colleagues. Unless I really believed it and felt like that scandal was necessary, but I thought it was really reasonable, but it was interesting because two of the people I asked, one of them said, There would be absolutely horrified if I wrote that we need to do COVID testing for everyone. Always just ramp up testing, just do as much testing as we can always and forever. Yeah. But the other one said, they would be horrified to read that we should just stop COVID testing, but it's just done. We don't need to anymore. So clearly there's this sense of a middle ground. And that's kinda what I was trying to communicate through this piece is like what does that middle ground look like? So one of the things, we've been trying to distinguish for this entire pandemic is COVID versus the flu, there was so much at the beginning of the pandemic, like COVID is just the flu. It's very clearly not just to the flu. Right. But. By some metrics, the flu is a realistic hope for the sort of things that COVID might become. And it's not there yet, but it might be eventually, which is, and hopefully, hopefully even less so, but. Yeah, we don't test for flu all the time. Like I, when I, prior to the pandemic, when I got the flu I might get a flu test if it was bad enough for me to go to urgent care or something. And they just wanted to rule out other things that they might give me an antibiotic for, I might get a flu test, but I'm not, not going to run to the fairgrounds here in Pueblo and get a flu test. Like I ha like I got a COVID test, And so the question is, what should we be doing? So basically the idea in this op ed is talking about, that we're still going to need pretty regular testing for certain communities like nursing homes, places where people are going to remain vulnerable. And in fact, remain vulnerable to things like other coronaviruses and the flu, w we should actually be testing for those things more frequently to the nursing homes. We should be screening people before they come in. So they don't cause huge flu outbreaks because that causes a huge amount of mortality. Amongst people who are in long-term care facilities where their immune systems might be compromised. But the other places, schools, I think rapid tests remained really valuable there. Because at this point, I really don't think that that there's any need any longer to shut down schools. We, in the United States, we have opportunities for vaccination. We have testing, we have masking, we have the summer to help improve ventilation, with, we have the resources to make schools, various safe places for kids to be, and, so that they don't bring infection home. To their families and put them at risk as well. But tests will probably play an important role there too, because schools can be a place where cupboard can spread and permeate into communities. And you know, those are really the two main things. And outside of that, we can really begin to probably start relaxing how much COVID testing we're doing. We don't necessarily. Needs to do this really high level of, constant surveillance of everyone. Yeah. And that'll help us direct those resources to other places whether they are still needed to help control COVID and other infectious diseases that we need to be paying attention to as well. So I think we're in this odd transition period where we're the nature of testing and the nature all of the things we've been doing are really starting to change. But what I wanted to do with this op-ed is to just lay out some very specific ideas and strategies that we can hopefully follow to make sure that we relax in the right places and maintain our focus in the others. Hmm. That's great.

Matt Boettger:

One of the things that I think it's a difference between I think flu and COVID, and maybe you can help. It brings to shed some light to this is that flew in my understanding that you got it and you have it right. Or you're sick as a dog, or you don't have much of a, but you get it. Whereas COVID has this weird thing with long haulers. So then does that feel like you want to increase the chance of being tested or maybe am I, again, this is a hard world Stephen to be in because we're moving to a different world and I'm like, oh, not that much testing being more like, that's kind of like, it's, it feels a little unnerving, not so much because the evidence, but just cause I, I kinda was my emotional blanket. For a long time, then now we know we can let go of it. Now as a coping mechanism, it's no longer needed as intensely as it was seven months ago. And then, but then when I think of a long haulers, I think of, cause I keep thinking of my kids, I'm like, oh, I'm gonna get them tested if they're sick, because what if they do have COVID then I'm gonna have to start looking in my mind. Are they going to have long haulers? That 10% chance does that change? Is that part of the equation for testing or is that something that's more of it just made me an emotional tie that I have. I just can't let go of ah, it's not that much different than the flu mat. They're similar in their effects with children as well.

Stephen Kissler:

Yeah. By many metrics for young kids, like flu is as severe and even for young children might be even more severe than COVID. In terms of, the risk of severe disease and even mortality, which again is low, but is there from the flu and. It's you're right. I think that there's a lot of the, this question of law and COVID is one of the remaining sort of mysteries and something that we're going to have to do a lot more work on. It may well be that, and it is certainly true that other infectious diseases, including flu can cause these sort of longer term chronic syndromes as well. Anytime they cause the immune system to go haywire or an infection, isn't perfectly cleared. I mean it does seem like it. That's especially true for COVID, but there may well be things that were missing from flu too. For example, there's this great piece by one of my colleagues, Michael Mina, who studied measles for awhile, which was a very common childhood infection and people thought it to be this very acute childhood infection that you then. Emerged from, but he showed that having measles increased your like childhood mortality rates for a person who had been infected for two to three years after the infection, because basically measles In some ways kind of like obliterates it it, it hits almost like a wipe button on your immune system and you almost have to start fresh. So you're like re susceptible to a lot of things that you might've been immune to before. And that, that, that's a very long-term effect as well. So we're, and we're still discovering these things about a lot of different infectious diseases. So that's one thing is that. This might be a factor in other things too. And then, currently, the question too is okay, so we have high rates of long haulers related to COVID. And the question is, does it, is it helpful to know whether or not. Those syndromes are from COVID or not. If you're feeling chronic shortness of breath, the question is like, how do we respond? What do we do to treat those? And at the moment there's not really much, that's, COVID specific about those, but we do have things that can help you treat shortness of breath. We do have things that can help you treat fatigue and brain fog and these kinds of things. And so it doesn't really matter so much, eventually it might eventually it very well might matter, but at the moment, It's hard to tell. And so that's another reason why the testing may or may not be as important even, granting that long COVID is still, really important issue will remain one for time to come.

Matt Boettger:

Yeah, I think that's a point I wanted to get to. I'm glad you said that the idea that we're, I do feel like as emotional tied to this, because in the end, whether my son or myself or my wife, or my friend gets long COVID that test has no change in its treatment because Lisa, at this point in time, at this point, there was no like insert in certain medicine here at three weeks out, and then you're prevented from Lancome, but there's nothing like that either have it or you don't. And if you do have it, you just deal with the resource available to be able to treat it. That's not covered related. So in the end, the tests still are advantageous to let go of a little bit. So then the other thing you mentioned about at this, or I'm really intrigued about absolute versus relative risk. We've talked about this in different circumstances, even very early on in co and in COVID in March of 2000, the difference between the absolute risk of something and the relative risk of something. How did this come about for you when you do this interview, what was the purpose of it and to what did we get from this.

Stephen Kissler:

Yeah. So this was another request from the w USA team, which is a station out in Washington, DC, but they've got they do a lot of sort of national programming with their group that's called verify. It's like a fact checking team. So they've been doing a lot of interesting work during the COVID pandemic looking at pieces of misinformation and doing these really nice sort of television segments explaining a. Yeah, pretty involved epidemiological concept and making it really intuitive for their viewers. And I think they did a great job with this one, as well as some others that they've done. And the way that this came about is there was an article that was published that th that was looking at the vaccine trials for the Pfizer and the majority of vaccines and measuring the relative risk of disease. Which is the thing that we usually hear for vaccine efficacy. So the relative risk reduction for the Madrona and the Pfizer vaccines are like on the order of 95% straight. But what they were arguing is that you can also calculate a difference in risk in terms of the absolute risk reduction. And if you look at the data from the trials, that ends up being a much, much smaller number, like on the order of a half to 1%. And they were like, well, what's going on here? Like, why are we giving this really high number when in fact the absolute risk reduction, this other statistic is very, very low. And that was picked up by a lot of the authors themselves seem to have been trying to, so I'll explain in a moment why the, some of the statistics that they did were actually flawed for they didn't measure absolute risk correctly in this piece. But nevertheless, They this got picked up and so they were trying to subvert this narrative of effective vaccines. Then it was picked up by anti-vaccine outlets who really were like, ah, see the vaccines aren't effective at all. Which is, just not the case at all. And so my role was to explain why why we have these two different ways of measuring risks, what they each tell us And and it was interesting. I wasn't, we were talking for a long time and yeah, it was it was funny. I there's like a point where I'm like scribbling down on a piece of paper, this contingency table to try to describe the statistics on zoom. It's really ridiculous. I was like wearing a t-shirt cause I didn't know this thing was going to be televised at all. It's all good. So this is the life of the epidemiologist share and a half into a pandemic. Loosen the shirt. All right. Sounds good. So the idea, without belaboring it too much, is that, relative risk basically tells you how much less likely am I to get infected to get symptomatic COVID after getting the vaccine than I was prior to getting the vaccine, what's the percentage reduction. Relative to what I was doing before. And that's 95%, that's great. I like going about my life now, if I was behaving the same way that I was prior to the vaccination, my reduction in risk is on the order of 95% for symptomatic disease. And so that's the relative risk reduction and that's a pretty intuitive measuring of vaccine effectiveness. And that's why we've been using it. So the absolute risk reduction. Instead factors in, what is what was my absolute risk of getting COVID prior to getting vaccinated on what is it now? And that's why the absolute risk tends to be much, much lower because actually, especially for someone like me who was living in a very cautious life, like my absolute risk of getting COVID, like basically what was the probability that I got COVID prior to getting the vaccine symptomatic code. We're still relatively low, the guesses that about 30% of Americans got covered prior to the rollout of the vaccines or so. So even if I was just an average person, my chance of getting COVID was about 30%. And maybe the vaccine reduced that down to, I'm not doing any mental mastery directly here, but maybe 2%. So the absolute, the risk reduction is that 30% minus 2%. So it becomes 28%. That's a much smaller number. And so that, that sort of takes the wind out of the sails, right? It's that's much less but the issue is that you're comparing it to, th the problem with this is that it's hard to know what the absolute risk of getting COVID is. At all. And the reason why the piece was flagged was because they were measuring the absolute risk of getting COVID just during the vaccine trial, which only lasted for a couple of weeks. So that made that number very, very, very small. They weren't looking at people who got COVID after the trial or before the trial, they were just looking at that tiny slice. And so that made it, these like really minuscule numbers, which was not at all reflective of an person's actual risk of getting COVID. That's another reason why we use the relative risk is because you can measure the relative risk with a very short vaccine trial. Whereas the absolute risk. You would need to follow people for years should know what their overall risk of getting COVID. We don't have that sort of time, nor is it the most relevant statistic in the first place. So those are the sorts of things that I was trying to talk about in this piece. If not that absolute risk is. That statistic or that relative risk is a bad statistic. Both of them give you useful information, but we have to know what we're talking about. And so often these things just get reduced to a percentage, right? 95% is good. 3% is bad, but there's, it matters, what are we comparing here? What do these percentages actually mean? And that's the important thing to walk through. And maybe

Matt Boettger:

this is me and my layman's terms, but isn't the relative risk. Just a much easier thing to calculate because it is relative to everybody's lifestyle. Cause it's 95% of. So if I was as person going clubbing every single night, going against the law, I'm 95% of that exaggerated, but you right. You're 95% of being in your little Boston cell, never moving. So to me, I don't think you could ever get an absolute. Everything's relative.

Stephen Kissler:

It varies so much from person to person. So the relative risk yeah. Counter-intuitively from the name is actually more consistent between people. Yeah. Then the absolute risk reduction, which varies depending so much on your behavior. Right. So that's

Matt Boettger:

why we use it. Yep. That makes complete sense. Thank you for sharing. That was really, really good. And a little mind bending for me. Okay. So let's talk about this. This came up a few weeks ago, Steve, and I want to get your thoughts on this and it's come up a few times sentence, but this, all of a sudden, this idea of COVID coming out of a lab, which initially in March of 2000 dismissive, no way seems to be resurfacing as being a credible or at least something to look at. Have you guys been talking much about this concept and how did this reawaken to being something to be brought back on the table?

Stephen Kissler:

Yeah. Absolutely. We have been talking about it and really been talking about it on some level throughout the pandemic. There, there's some interesting sort of things to bring up here that I'll try to bring up each in its own place. One of the main questions is like why now? Like, why is, why are these ideas surfacing now? Like they're clearly gaining a lot more attention. Some of it is just happenstance, but I think part of it is just that, at least here in the United States, We're finally getting a chance to breathe. Like we, we started off this podcast talking about how cases are lower. And so now we're transitioning into this period where we can begin to take stock and not so much worry about the crisis that's at hand, well, what happened? And what can we do to prevent this kind of thing in the future, which is. When I'm at their best. I think that's what these questions are about. Like how do we prevent something like this from happening in the future? And part of that is knowing what happened this time around at its worst, it's it's mudslinging and, trying to cast blame and and so that's part of the difficulty here is that simply raising the question you run the risk of of. I hear from every different direction where it's how could you possibly even suggest that such a thing as true? Or, how could you, whatever but it's, part of the question is like why are we asking these questions in the first place? Nope. The risk of a pathogen escaping from a lab is something that, again, we've been thinking about for a very long time. One of my one of the professors who I've worked closely with mark Lipson has done a lot of work. Arguing for basically pauses on certain types of laboratory experiments that people were doing with influenza strains called gain of function, experiments where basically you would w in the lab, you would try to evolve strings of flu experimentally that had. Different attributes that might be more infectious. That might be more severe to try to understand how many evolutionary leaps are we away from a strain of that kind of pandemic potential, which is useful information to have, right. But it's also very dangerous information to get, because if you do engineer a more transmissible strain and it does happen to get out of the lab, then you've created a pandemic that didn't need to happen. And so a lot of his arguments were that we'll use these experiments are actually. More risky than the benefit that we get from the information that they could provide. And he was successful in having this multinational sort of moratorium on these experience, experiments for a period of time, which made a lot of sense. LA Pathogens do escape from labs from time to time, this has happened and this, this isn't just something that happens in over there, like this has happened right here in the United States, many times, and there are also a lot of near misses that we've had where, we thought that there were, neutralized strains of smallpox that were being transported from place to place in a vial broke. And actually it turned out that it was not neutralize, and that could have caused a huge problem. This is not like. This is not a Chinese problem. This is not like a developing nation problem. Like this is, this is an international problem. And this is something that we've been thinking about lots. So that now brings us to the question of COVID-19. So where are we? So part of the reason why we haven't been thinking as much about, where did this strain come from yet is because we had a crisis on our hands. We it didn't really matter where it came from. The fact is it was here and we needed to do something with it. And so no matter where it came from, we had to do the things and no matter where it came from, our response needed to be the same to, to figure out what to do next. And so that's, that's part of why we haven't been digging into these questions as much until recently And but now one of the questions is, again, in epidemiology, we're always thinking of, we want to gain information so that we can do something. And the question is, if we knew where this came from, would it change anything? It doesn't change the fact that we still need to do a better job securing labs, where this research is being done, thinking about what kinds of research is being done, right? If we attribute it to a specific lab in a specific place, Does that help us? I don't know. Maybe and I think, I do think that some of these investigations are probably worthwhile, but the question is then what do we do with them after that? And that's the real question. That's not an epidemiological question so much as it is a political and a ethical question as well now within all of this as well. So within this, this story of lab leak implicit within that are a lot of, sort of, Other factors that we need to make sure we're keeping straight as well, because so if it is a fact that labs around the world study infectious pathogens. Now some of these things have been collected from bats, from wildlife, from humans, and they're stored in freezers and they're these experiments and research are being conducted under very, very, very high level of security to make sure that the risk of an escape is very, very low, which is great. When we think about a lab escape, it does not necessarily mean that the thing that escaped was engineered in any way, it could've just been circulating in the wild. Anyway, it could have easily crossed over from a bat. Or escaped from a lab freezer, but it might've been exactly the same thing because it was pulled from the bat in the first place potentially. And if it escaped from a lab that also doesn't necessarily imply ill intent, right? Like we do have all of these precautions, but clearly accidents do happen and we need to do everything we can to make sure they don't. This is risky. Business to some extent, and we need to be really thoughtful as a global community. And certainly as scientists to make sure that everything we're doing, every virus that we're restoring, every experiment that we do is not incurring a greater risk than the experiment itself will potentially give us information for it. And that's something we need to do a lot of work on. But again, that's not just a question of COVID, that's a question of all sorts of different pathogens that we do research on right now. And I think it's something we need to be very cautious with. All that is to say, is that I, many of them it's been interesting because I think many of my colleagues have been Sort of agnostic about this question of lab escape. And it's been generally people on the outsides of that central core of researchers who have been like, oh no, like this is a crazy conspiracy theory because it sounds like a crazy conspiracy theory. But the fact is like there's really solid research suggesting that this is a possibility and something that we need to take seriously, but also that. All of the available evidence suggests that there's no reason to believe that it was anything other than a crossover from wildlife, which has happened time and time and time and time again. So in terms of just raw probabilities, chances are, it was just a crossover from an animal into humans. This happens a lot. It will happen again. And that's probably where it came from. I don't think we can. And I don't think we ever probably will be able to rule out the possibility of some sort of lab escape. And that's a really uncomfortable spot to be. Like we might never know the answer. We probably will never know the answer for sure. And that's unsatisfying ambiguity, but I think, but again, I think the most likely scenario is crossover from wildlife, but I will not, I can't say that, like this theory of lab escape is totally implausible. And it's important to be really clear eyed about that. Because if we say that, no, no, no, he couldn't have been that. He couldn't possibly have been that then we might lose an opportunity to make ourselves safer in the future from other pandemics. Even if that wasn't the case here. Yeah.

Matt Boettger:

That's great. We've said this time and time again, but this pandemic has just really. Put a spotlight on so many, either direct dysfunctions, broken systems that need to be fixed. And this is the greatest opportunity right now. So I'm thinking of this. I was like, what policies did he put in place to help ensure that this does not happen? Whatever it is just to safeguard us for the future. And then going back 10 minutes ago, talking about the flu and how. Look, all this intense research being put on COVID and then from that, the fruit of seeing long COVID and then wondering, wait, just, she says your, one of your friends, your peers, was it polio? I don't know which one it was polio or measles. And how. How this may unfold other areas where, which you know, who knows, like you said, the flu we put this much concerted effort into studying one thing as a worldwide phenomenon. What, what might we see in reveals consequences? So it's just amazing how this pandemic has unearthed so many different dimensions of complexities and brokenness that need to be fixed and corrected for the sake of, of global health. For sure. Speaking of, just this whole craziness, one of the big things we've talked about over and over again since maybe April, may of 2000, is this concept of herd immunity. And we've talked about it. We've talked about it, we've talked about it and now I'm starting to see these articles and this isn't the first time we've seen it, but it seems to be growing a little bit more of a pitch. This idea of like herd immunity is not possible. A one article here from NPR says America's herd immunity. Taxation should end. And I just wanted to ask you, what do you think this is talking about? I heard a national geographic came out with some big article about herd immunity is not even possible. Not sure I haven't read it. So I had it. Can't frame it for you, what it is, but if you get behind this, what might be at the center of these this is question about herd immunity, particularly in COVID.

Stephen Kissler:

Yeah. So here to be an idiot, like you said, it's something we've talked about on this podcast many times, and I've certainly spoken about ad nauseum since since January of last year. Yeah. So it's a deceptively new idea which fits right along with the theme of this podcast as always. But the idea is that for For certain diseases. And measles is actually a good example here because measles spreads like wildfire, but usually you only get infected once, once you get infected or once you get the vaccine that immunity lasts you a lifetime. Yeah, just great. And so in the case of measles herd immunity is a relatively more simple idea where basically, the idea is that if you vaccinate a large number of the population, but it doesn't need to be everyone. The fact that there's, that sort of. Underlying amount of immunity in the population protects the people who aren't protected either because they haven't been infected or haven't been vaccinated because there's just not enough Tinder for the fire to burn. There's, it just the, even if a person, an unvaccinated or unexposed person did get infected, the people they would bump into during their infectious period, th the probability that any one of them would also be susceptible is so low that it's an epidemic just won't be able to take off. That's the idea behind her immunity. But the problem with that is that immunity is a constantly moving target. We know that certain met like certain measurements of our immunity for COVID decline over time that they vary between vaccinated people and people who have been naturally exposed. We're actually, people who've been vaccinated tend to have a much higher B cell response than people who have just been naturally exposed. But that all of those can decline over time. And we're not really sure where that will settle out to. The virus is changing. We have new variants that can get around certain parts of the immune response as well. So that chips away at this idea of herd immunity transmissibility of a virus varies depending on time of year because of our changes in behavior, potentially because of the weather. So herd immunity. During the summer might not be herd immunity during the winter enough to, and that's the situation where we're in some ways, given our baseline behavior, given vaccination rates given the time of year that we're in, we, we do have a certain type of herd immunity in the United States. But when we think about herd immunity, what we want is basically a level of immunity that will allow us to behave as we always have. Perpetually into the future with no, no risk of future outbreak, but that's not realistic. Even with something like measles, newborns are still susceptible, you still have to be exposed or vaccinated to be protected. And so even over time, we have herd immunity in most places to measles right now. But if we stopped vaccinating for 10 years, we would lose it because people are just getting constantly born into the population. So immunity is a constantly moving target. So therefore herd immunity is also a constantly moving target. And so while it's something that's really worthwhile to shoot for right now, like we should be shooting to get to herd immunity as quickly as we can so that we can bring cases down and prevent the development of new variants, these kinds of things. We're going to have to keep, it's something we have to maintain. It's not just something that you achieve and then it's done forever. And that's a really important concept. So I don't think that like herd immunity is, like something that we should lose our fixation on. But I think we need to learn more about what that actually means and that it's, it's Yeah. Like anything, it's something you have to maintain over time.

Matt Boettger:

Yeah. I'm thinking like herd immunity is Ana is an analogous to cleaning our house in the midst of like our boys. Like we clean it, we get it. But if you don't really keep it really straight, a really solid system in place, by the time you turn your back, it's obliterated. Right. It's not a one and done kind of thing. So it does, you got a family and kids. I think that's a biggest analogy to herd immunity. When it comes to the flu, is this, again, do we ever talk about herd immunity and flu? Now I get it. I it's like seasonal right in summertime. Cause I feel like herd is like more like it follows the herd, whereas like C like flu is follows the season, it's a little tongue in cheek, a little looser, but they seem to be more like seasonally driven, but we don't really talk about herd immunity as a common practice. Right. And

Stephen Kissler:

flu. Right. Yeah, exactly. Because in some ways, every flu season, we reach some level of herd immunity and that's why it trails off in the summer. Then we lose it. If there's something new evolves and our immunity declines. And so then that, and that's entirely why we have these seasonal outbreaks and yeah, I think that's what we can probably expect from COVID as well. But you're right. We don't talk about it for flu. And I think that's why these articles have been out. Because it's just not. Is that concept in the way that we understand it now is just not really the right paradigm to think about COVID with it's a much more probably will be behave epidemiologically and a lot more like the

Matt Boettger:

flu. Yeah, absolutely. Great. So let's okay. So I'm going to frame this now. It's like people like us. Who sit on TV and watch the bachelor and the bachelorette. And we're just drawn to it. And we're just fixated on it. I think who discovered the epidemiologist version of the bachelor and bachelorette. And that is this article, the name game for coronavirus variances has gotten a lot easier. I feel like this is like your bachelor. We were like, oh my gosh, what just happened? A real scene where most of us were like, what. Who cares, but I, what you said off the recording, this actually has some heat behind it, between the names, alpha beta gamma. It sounds easy for me, but what's the deal with you guys? How are you guys perceiving this new naming nomenclature for the variance?

Stephen Kissler:

Yeah. So it's interesting. So the names of the variants up until this point have been flawed in two different ways. So one way colloquially, oftentimes the way these variants are referred to are the places where they were first detected. And so we have a UK variant and a Brazil variant, and an India variant. Which is something that we've been trying to avoid for the entire pandemic. Because attributing a disease to a specific geographic location can lead to all sorts of cultural and political badness, like things that we just don't need to be dealing. And because that's not their fault. But it seems like it like it's and so it was back

Matt Boettger:

to, this goes back to when you were even, we're talking about a super spreaders and you were saying like, we don't even like to characterize a w. What a super spreader might look like in light of a person, because you don't want to single out a person. That's why I kept pushing. Like I don't get it. People talk about super spreading and how you can stay away from it. We'll talk about events, but then actually the person, even though, so it's got the same kind of concept that just staying away from pigeonholing and just training. Exactly.

Stephen Kissler:

Exactly. And, in the same way as that super spreader example that you brought up it's also more accurate to refer it in different ways, too. And more instructive because as with a super spreader event it's not always a person, like a person always has a context. There's always an opportunity for spread. That goes beyond just an individual person. And so a super spreading event takes into account that entire context. Similarly, if you say like the UK variant, for example, well, but that is also because maybe it was first detected in the UK, but maybe it first emerged elsewhere. And and it, it also certainly doesn't mean that it's only a problem for the UK anymore, nor that, All of these things get mixed up. So it makes more sense also scientifically because the language we use is very powerful for these things that shapes the way we think about them. So being precise is not just a way of being like anal about these things. It's a way of thinking clearly, right? Like that's why, that's why we try to be precise with our language. So then, but then we have this other naming scheme where we have B one, one seven and B 61 seven B one six one 7.2 and P two. And to be one, four, two, nine, it'd be one 49.2 0.1, and that's what are we doing here? Part of the issue with those is that those names are actually, they're useful for those of us who are immersed in this every day. Because the acronym the letters that we're using and the numbers that we're using, actually give you a sense for how related or just how closely related the variants are. And that's why those numbers are what they are. They basically tell you what. Viral family do each of these things belong to. And so when you tell me, versus I can tell you how those things are related to each other, just by hearing their names, which is super valuable. Yeah. The, for a lay person, that, that doesn't do well at all. Like how are we going to keep all this alphabet soup? So the world health organization comes in and says, all right, so we're just going to collect these things. And once there is a variant of sufficient concern, we're just going to give it a name, like a hurricane, alpha beta gamma, and we'll give it a name. And so I think to some extent that's fine and good. But some of the criticism that I've heard leveled against this is that okay, so we're using Greek letters. How many people, Matt, can you give me the first 10 letters of the Greek alphabet in order? Oh my gosh.

Matt Boettger:

I was a beta gamma Delta.

Stephen Kissler:

That's as far as I can go to, I use these things all the time. So it doesn't really work. Is it actually that much more user-friendly and at some point you do need to combine these letters too. So is the ADA theta variant actually better than the one, one seven? I don't know. I'm not convinced that it is. So what I fear is that, we've replaced a bad system with a. Maybe marginally better, but potentially equally bad system. And now we have two bad systems, which is worse, one bad system. And so that's the fear that I have about this is that I think it's true. It's rooted in the spirit of we do need a better way of referring to these things. Yeah. But I'm not sure that this is the one.

Matt Boettger:

Yeah. Yeah. Well, good luck to you on that one. Thankfully, I didn't have to worry about too much about it, but that's so, okay. Speaking of variants we've talked about India before in the past, it's been such a terrible devastation. There's a lot of been variants of income from it. I seen a few articles referring to the black fungus from Indian found outside the country. I don't know too much about this. Is this like something that's anecdotal to COVID the disobedient association is directly tied to COVID. Can you give a little background of this?

Stephen Kissler:

Yeah. So this is an interesting thing. Basically what these fungal infections are. Is there an opportunistic infection that are generally coming in after a, person's been infected with COVID and has been treated, using a certain types of steroids treatments. And so steroids are interesting because they frequently they really depress your immune system. They basically make you for a short period of time. Your immune system lowers. And that's why, back when we had mark on early in the pandemic, while he was saying we don't give dexamethazone to people who are early in their course of infection, because it could actually be worse for them because it dampens your immune system and you need your immune system to fight that off. What the steroids do is they reduce your inflammatory response, which happens, well, after you've become infected and you basically fought off the virus as much as you can, but you're dealing with these extra, basically your immune system is going haywire and that's what you're trying. To dampen down. So the issue is that when you do that, you do still leave yourself at risk to other types of infections that might be able to come in behind and take advantage of that. And that's what this fungus is. It's it's actually a very common fungus it's found on vegetables. Many people carry it in their air passages. Okay. That's totally fine. There are all sorts of infectious diseases like this that usually pose us no problem until our immune systems take a big hit and then this thing comes through. So probably the prevalence of this fungus is higher in regions in India. And so it's. We're just seeing these opportunistic infections coming on, following along for people who have been treated with these sort of immunosuppressant drugs to help, deal with their COVID better now in dealing with this really severe fungal infection. So that's, that's basically it. So the important thing is that The, this is very much related to having COVID being treated with a specific thing. And then also having been colonized with this thing that then comes in and causes an infection. So it's not like there's this huge outbreak threatening the world of this. Like I'm going to come and, doom us all, but it is still a really big problem. These things are really difficult to treat. And it fits under this broader question, which we've also talked on previous episodes about the intersection between climate change and infectious diseases. And one of the things that happens with climate change is it actually makes the environment more suitable to the spread, to the proliferation of certain fungus's. And usually when we think about infectious pathogens for humans and animals, usually as viruses and bacteria, There are fungal infections too, but those are a lot more rare. You don't hear about them as much, but as our environment changes as the whole, the entire ecosystem changes. That might begin to change as well. And it's still early days for this, and I don't think that that's necessarily the reason for what we're seeing with these fungal infections in India, but it does play into this thing that like our world is changing. The way that we interact with the world is changing. And that might well change our relationship with certain types of pathogens, to the point that things we never imagined could be pathogens do become them. And that's something that's, as we're thinking about sort of our 50 year plan as infectious disease epidemiologists, on our radar,

Matt Boettger:

Yep. And that makes sense. I think in general just change in general. It's like when we think about climate change, it doesn't matter which direction it goes. Just so once you have a stable environment and then it begins to change then new things happen and there's now it's a new game. There's a new terrain. There's new variables. It's just different things happen differently. This helps by the way. I don't know if we ever did this on a recording. But this was a great example of Stephen. I think I was talking about one time. We were all locked in for a couple months and we still got sick and we're like, how on earth can this happen? Sound good. How long there's could this actually happen? And you kinda explain how, yeah. There are actually things that live within our own bodies. They're just passive. And then someday, either your immune system gets low for some odd reason, and then you just get sick. It's not, you don't have to go out and do something. You can have a living within your body. That's just inactive and then becomes active. And I think this is a great example of a black fungus where if it's in your body, but yet normally it's no big deal. But if you really went to a really super immune compromised area, it could, you know, make you sick. So like that. Yeah. So thanks for that example. Okay. Before we close off a couple of things I found these two articles back to back. That was interesting. This is now in light of the vaccine. This is the so COVID 19 breakthrough infections among fully vaccinated. People are extremely rare. The CDC says, and then I found another article just in the following day from a different place from NPR saying CDC approach to breakthrough infections, sparks concerns. So we have this optimistic news that the breakthrough is extremely low, but now there's be apparently people looking and questioning their algorithm for. Coming to this conclusion. Do you know much about

Stephen Kissler:

this? Yeah, a little bit. And I'm not going to be able to like, perfectly quote exactly why this has been an issue but basically the what this comes down to is a difference in recommendations for who gets tested depending on whether you've been vaccinated or not. And so the issue is that, currently, if you're unvaccinated, it's recommended for you to get tested no matter what, and to get tested, even asymptomatic people to get tested and sort of like, what do you call a breakthrough case? Or what do you call an infection? If you're just looking at infections amongst anyone, you might imagine somebody who's asymptomatic, but turns positive should be considered the case maybe. But if you're vaccinated, they've really only been counting people who are symptomatic and who have gone on to get tested. So if you're vaccinated and you're symptomatic, it's still recommended that you go to get tested right now. But they're going to be probably some asymptomatic infections that are missed by that because that's what the vaccine does. It prevents symptoms. It also prevents infection, but like really what it's good at is preventing symptoms. And so what you end up with is since the recommendations are different between vaccinated and unvaccinated people, you're dividing by a different number in some sense. And so that can make comparing the risk of breakthrough infection versus the risk of regular infection. Feel a little bit skewed. It's tricky about this because, at some point you need to make a decision of how you do your testing, who gets tested what number you divide by, what other number, and what's going to be the most useful. And if you're really asking about rates of symptomatic breakthrough infections, which is really what we're curious about, because that's the thing, you compare it to the relative risk. That we were talking about before we measured the relative risk of 95% in vaccine trials. And now we're measuring these breakthrough infections to see, to what extent that number holds up. It seems like it's holding up pretty well so far. But if you're trying to compare to risk of infection among unvaccinated people, then that doesn't, the comparison doesn't hold as much, but because we're collecting these data. For a different purpose. And actually we're collecting all of the data, but the things that are publicly reported, then there gets to be some confusion. So the problem is that, And this has happened with the way that the CDC for example, was counting COVID related deaths. And there was all of this fear about how, w what are you counting as a death from COVID or a death that is, associated with COVID and all of this argument back and forth. And part of the problem is that, we have to measure and report this information in some way, and decisions need to be made about how to do that. And there's going to be ways to. Criticize anything that we do with respect to this stuff. And so it's good to criticize it. I'm not saying that we should just, be quiet and accept what's given to us, like th this is important because each of these articles is giving us useful information, raising a flag and giving us a point of caution that when we're interpreting these numbers, we need to do so carefully. But again, As we were talking about with the lab escape theories, that doesn't necessarily imply that there's ill will behind any of this either, that these decisions need to be made. And usually they're made thoughtfully, sometimes they're made arbitrarily, but rarely in my experience, are they made with an intent to hide anything or to confuse anyone? Not to say that doesn't happen. There are science, science is a political pursuit, just like everything else is a political pursuit and there will be both explicit and implicit attempts to skew information. But part of what we are trained in as scientists is the ability to at least do our best to avoid implicit. Opportunities for that bias to arise. Like that's, that's the scientific method right there, right? Like it's really a psychological technique to try to avoid that kind of bias. And when we're acting in good faith, we're doing the best we can to do that. So it's not to say that everybody's acting in good faith, but I think that there's good reason to assume that they are until there's very good reason to get up.

Matt Boettger:

Great. Dang. So you're say it's not, you're what you're saying is that it's complicated and it's not this grand evil plot of really sweet manipulation of numbers and a very cunning and very. Slow dripping way. It's more competent than that. That stinks. That's that

Stephen Kissler:

it would make for a much better, like a paperback novel, but totally.

Matt Boettger:

Oh man. We're good. That was helpful. Thanks, Stephen. That closes up shop for this episode. It's a long overdue Stephens. Good to see you, buddy. Yeah. And hopefully I'll see you in person if it works out in next few days, if not, when you're back in Denver again in a couple months, but for all these are listening, thanks for holding in there. And it's been a few weeks, we're trying our best to come back to regular episodes, whatever that may look like. Do you want to support us? You can always do that at patrion.com/penn dunk podcast has helped to keep us going, leave us a review. It's just good getting feedback, or just email us mad@livingthereal.com. I always share those with Stephen and mark. When we hear the feedback from you, I think that's all for today. I hope you guys have a wonderful week and we'll see you hopefully all next week. Take care and bye-bye.