Variants and Transitioning to the New Normal

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Things Discussed on Episode:

• Delta Covid-19 Variant Is Dominant U.S. Strain, CDC Data Show
• House Speaker Pelosi rejects two GOP selections tapped to serve on committee investigating the Capitol riot. Watch CNN
• Fauci Casts Doubt on Study Suggesting Delta Variant Hit Pfizer COVID Vaccine's Efficacy
• Top health expert says vaccinated people are spreading delta variant
• CDC warns Covid-19 vaccines might not protect people who are immunocompromised
• Going further than CDC, pediatricians group recommends masks in schools even for the vaccinated
  
  

Transcript

Matt Boettger: 0:00

You're listening to the pandemic podcast. We equip you to live the most life possible Caymus hill anymore. It's been too long, like literally the faced with this crisis. That's out of my name is, but couldn't join with not one, but finally, two of my good friends, Dr. Stephen Kissler and epidemiologist, the Harvard school of public health. Drum roll, please. He came out of his cave at Dr. Mark Kissler, a doctor at the university of Colorado hospital. That was phenomenal. How's it going guys, guys.

Stephen Kissler: 0:32

It's great to see you. It's been a long time.

Matt Boettger: 0:34

It's been for ever a mark. What the heck have you been

Stephen Kissler: 0:37

doing? I asked myself that too. I think, I think it's it feels like life has just accelerated in in all sorts of domains. And so a lot of work I've been at the hospital a lot which has been good. And and then a lot of home stuff too. So it's just, yeah. Yeah. All

Matt Boettger: 0:55

over the place. Yeah. Stephen, your neck of the woods, like what's been going on with you.

Stephen Kissler: 1:00

Alright. Yeah. Slowly transitioning back into some of the work that I was doing pre pandemic. So I'm starting to think about things other than COVID. Even though we still have some COVID related projects going. So, but I like, it kind of feels like in many ways, the summer has been a bit of a reprieve in that cases are a lot lower here. I've gotten to just see more people even do a little bit of traveling some good friends got married this past weekend when we got to go to the wedding. And so it was just, taking advantage of some of these things that it's been a really long time since we've been able to do so. I'm grateful for that. Yeah, that's still a strange world out there, but just trying to transition back into something that reflects a little bit closer to what what life looked like before.

Matt Boettger: 1:40

Yeah. And I'm, I think this is going to be the theme of today's, mark was talking about this, he was talking about it before we started recording. It's been a while for, it's been two weeks. I think we just lost mark there. So when he gets back, we'll we'll chime him back in but it's been two full episodes that we've been away from the pandemic. And we, we want to kind of check in, talk about how things are going for us. And it's been just unusual because it's the summer and. A sense of feeling like things are meant to be normal, but then we have Delta and gamma and Lambda and Epsilon. I'm like the good news is I'm being reacquainted with my Greek alphabet, which is, I think if there's going to be a win, that's a win right. For anyone. So, I there's so that's, that's been a really big, I guess, good thing going on, but behind that is a lot of questions of like, what does normalcy look like? Should we be doing. And then there's like the, I think the sub narrative of like, okay, well there's people who are single and adults and some are vaccine and some are un-vaccinated. And then for me, the complication is when you have a family and it's summertime and, under half of us are vaccinated and the other half are still waiting to be vaccinated. And what does it mean to live a normal life? And so I just want to chat about this for you guys. Like, what does it mean for you guys to, because in my mind, as we were kind of going from may to June in the summer, sorry to rev. We were kind of asking ourselves as a family, what do we do this summer? What do we want to do this summer? And we didn't, it was hard to know what to do because there was a sense of like, well, let's just wait. I want to start with this because that was a hard question. I'm like, well, if we're waiting, what are we waiting for? Because I'll have Stephen, I might have you just chime in for a second year, starting with this because. If we're looking for an into COVID, as we've been saying for months now, I don't think that's going to happen. So that kind of wait, I think you're stuck in your house forever, right? On the cover. It's always going to be at some level part of the population. And so this idea of moving to normalcy needs a different kind of measurement. And so in light of what what's going on with your discussion, Stephen, what you guys have been talking about, what does that look like? What he has been talking about this idea of like moving towards a sense of normalcy in the. Of this kind of unknown of these new variants now with Delta kind of dominate in the U S

Stephen Kissler: 3:52

yeah. It's really tricky. And I think we can, and I'm sure we will, over the course of this episode, tackle it from, an epidemiological and a clinical. And then also just like a personal perspective, like what all of this means, it's, it's really tricky because. So one of the ways that I've been thinking about this, right, is that early on in the pandemic, one of the big reasons why we were really emphasizing physical distancing, flattening the curve was the big thing. And, and there were two reasons for that. One of them was just to reduce the strain on hospitals. The flatter, the curve, the fewer people get infected overall. And, you, you prevent, huge surges from going to the house. And we were trying to delay as many cases as we could until we had a vaccine. And until we had effective therapeutics, right? Like we're, as you really gain a lot by pushing off infections to a later date the landscape has changed a lot and that's not to say that, physical distancing, flattening the curve is no longer important, but you know, we, we now have a vaccine we've gotten a lot better at dealing with COVID in the clinical perspective. And so, and so you're right. We're transitioning. A period where there was this very clear sense of a finite waiting period to a sense where, COVID will be here with us for the foreseeable future. And that's, that's a really tricky reality. I know it's one that we've been talking about throughout the entire time we've been talking about this But that, that's almost certainly the case at this point and we can talk more about epidemiologically, why that's true. But yeah, we're transitioning into a time when, when we, as individuals, we as societies, we, as epidemiologists, as doctors, as teachers, as whoever we happen to be are thinking about, what, what is our life going to look like now that SARS, cov two is going to continue spreading. It's going to be with us. It will probably be a wintertime respiratory virus. And that's going to mean different things for different communities. It's going to mean different things for different people. And for those of us who are thinking about the epidemiology and the clinical side of things, we're going to have to keep innovating, trying to figure out how to make this less and less of a burden, but then also for individuals, just like, how do we navigate this? As people, how do we renegotiate our risk of going out into the world? That was a very intuitive thing and the pre COVID era, but now there's this new risk that sort of layered on top of everything else. How, how do we. That we haven't really developed the intuition to have a feel for what that means. And I think the story of this next year or two is going to be reintegrating this new risk into our intuitive sense of, of, of what we're able to, to manage as people. And that's going to be a really difficult thing to do cause we're all going to go about it at a different way and in a different speed.

Matt Boettger: 6:21

Yeah. That's great. Mark. How about you? Like w. Dealing with idea trans she's a normalcy in the context of your clinical work, but also as a family man and working with kiddos and that kind of stuff. How's that been for you? What's that look like? Has Delta change anything what's going on in your neck of the woods?

Stephen Kissler: 6:37

Yeah. It's kinda I just want to echo a lot of what Stephen said. I had a funny conversation with a colleague of mine, just as a sidebar outside the elevators the other day, who has been really involved in our COVID response. Essentially what he, here we are here we are, we're starting to see this kind of cyclical thing. That, that old article, the road was right. And he was kind of bummed about it and we bonded for a moment a bit like neither of us are really all that happy to admit that Stephen's right. And, and yet I think there's this sense of amongst clinicians is what does this mean? Do we integrate COVID into our regular medicine teams, just as we take care of all sorts of respiratory viruses at the time. And how do we, how do we start to think about COVID now that we know a lot about it and we know more or less that it's probably going to be here to stay? Yeah. Was there anything from a personal standpoint, tricky one. We've been doing a lot more, we've been out some traveling, we'd go out, I've been, going through our local stores rec center and all these things and feeling pretty good about it. I think post vaccine with sort of a sense of how do we keep each other in general? And not being overly cautious. I feel like there's a really good return to a certain what I call maybe a local normalcy, certain ways. And so that's, also there's, taking the kids out and they're doing things and they've been going to school even during parts of the pandemic, just mask up. And and that seemed to go pretty well too. We were fortunate that even though we all got COVID at one point. I think we we've been kind of in a, in a fortunate state where we've been sheltered from some of the severe complications, at least as a family. I think it's tough. I think for me the, as we figure out what, what do we do and how do we get back into things? There's this combination of what's our ideal state. And then what's kind of the reality that we face, and we, we, we just have to kind of flex and know that sometimes we have to do things just because we. We need to do them, we need to get out, we need to reconnect with family and, and those things. So there's, this they're very much sort of a reality check in the midst of all of this that's that's just constantly going, the back of my mind.

Matt Boettger: 8:51

I've been in the same way. Like, just kind of transitioning, talking as a family of what, which we should be doing hesitancy because all this, this E over a year of like secluding ourselves in a house and then the light switch comes on at summer. And it's just, what I was hoping for is just like black and white, we're switched on. We're ready to go. And just not that way, we're trying to transition back into normal, seen what that looks like. And it's been, it's been kind of, it's been harder just to, in, try and encourage our family and my wife to be like, if there's one time to begin transition. It is now, right? Because if you're looking for a measurement, if you're looking for some kind of quantifiable metric to make you feel as if this is a safest time for me to try to like get back in the normalcy now is the time we're talking. I think off the, off the air though, waiting until November, if your skin is not going to be probably the ideal situation, because come November, there's probably going to be some kind of resurgence of COVID nothing like last year and that's going to probably. Raise some hair in the back of your neck and re you know, the trauma of the year before and the summer is a great time to be in the transition. So for us, it's been as of recently of slowly getting back into the pool and go into the pool. And it's been amazing. We, one time we went to the pool, we got ice cream, like, oh my gosh, this field. Amazing. I, I it's just to be with my family outside, going to a store, getting ice cream, go into a pool relaxing last week we went to a restaurant granted we were outside and it was just really wonderful to just kind of begin the transition. I know it's hard for the family and wife. Cause right now we're, the little ones are unvaccinated. I want to throw it back to you, mark, of just like, about dealing with your kiddos and the future and with a Delta variant. Is there any concern for you, in light of that and when it comes to the fall and the winter in light of what you see with the vaccine, the vaccines and its efficacy, and some of them may be the rare responses of heart inflammation with kids and that kind of stuff. Where are you landing right now in the process come fall or winter with the kids about getting them vaccinated or not vaccinated? Where are you at on that?

Stephen Kissler: 10:51

Yeah, I I think there's a couple of things. So, one of them is that it's really helpful for me to keep in mind what Stephen was mentioning at the beginning, which is what's our, what's our big picture goal here. And really, yeah. Hopefully we've stressed this throughout that of course, part of the goal is to avoid ourselves from getting COVID, as much as possible, but really there's this secondary goal, which is a bigger picture and a little harder to grasp intuitively, which is we're trying to avoid being major vectors in a dangerous and vulnerable time period, because. As the evidence has shown time and time again, that there though there are very severe insignificant manifestations in kids in general, compared to all comer respiratory viruses, this is a little bit less of a there's less morbidity amongst the younger population. And I think that's important to remember because, what's, what's our goal here. And so as we're thinking about. I think relative risk of reentering life and, having our kids be able to do the things that are important for their development. Not just like recreation, but just like be involved in, in our community, in important ways. I think that that's helpful for me. Does that make sense? think it, because again, I think that we can get into it replace. If the number one goal is always just to avoid like me getting infected and it's a little bit freeing in certain ways as we kind of think like, okay, what's the, what are we trying to do here? And where are we at in the overall pandemic in terms of our need to flatten the curve? Our concern for these vulnerable populations to, to what degree are they being protected by? The things that have been put into place up until now. So as I think about, I, I think that I'm going to make the same, use the same kind of paradigm around decision for vaccinating, my kids as I did, with myself and as I recommend with my patients, which is, we're gonna look at the evidence which. So far to date has not shown a tremendous downside to vaccine. And in younger people, there have been, there have been a lot of reports and a lot of certain media coverage of like a myocarditis or vaccine related my carditis and younger people in particular. And I think that's probably due to the robust immune response that young people have. And anytime we see things like that, we always always have to. Hold that up against, what's the risk with infection, natural infection too, and there's, there can be I think a false sense where, oh, it's better to get, like, if you're going to get myocarditus, it's better to get it from the natural infection. Cause it's not. Yeah, sure. And then like this artificial vaccine or whatever, and a lot of suspicion around that. I, I'm more of a mind of let's just look at overall what's our relative risk relative risk of serious complications and morbidity, and also bearing in mind that there's still this component. With COVID of asymptomatic spread and presymptomatic spread, which has always been one of the distinguishing factors and made this kind of a tougher thing to get epidemiologic hold on. And so there's this benefit to having more people vaccinated because of that that component, that that's going to continue to help to protect our communities. It's a long winded way of saying, I think I, I don't. Severe, significant reservations about getting my kids vaccinated. And I think globally, as we start to think about, is this a good thing? Epidemiologically. It's probably a good thing for the vaccine age to March down a little bit. And again, I think we just have to be really conscious of our messaging around that. And the way that we talk about it, both in our families and communities, and then professionally, because this is just such a highly charged issue and it has been for years and it's just going to continue to do. Yeah. Super, super supercharged going forward.

Matt Boettger: 14:24

Yeah. No. Great. Thanks mark. Yeah, let's get into this a little bit about the variants, because I think this is on a lot of people's minds. We see, we saw, we're seeing a little bit of resurgence of the spread in the U S Dow. Particularly like you just said, mark and unvaccinated areas is where we see the highest, which kind of goes back to this idea of like really trying to. Do our best to talk about it with our friends and our family who aren't vaccinated to help encourage them to be able to get facts. And if they're not vaccine already, because yeah. It prevents yourself, but also the community at large to have a resurgence and those kinds of things. Steve, I want to go back to you and just looking at the Delta variant, where we've seen it right now in light of its it's spread it's a couple of things that come to mind when I saw here with the Delta. There were some questions about parents and unvaccinated kid at the Delta variant. If there's anything that we know about, if there's any difference when it comes to kiddos. And the biggest thing I saw here, we talked about this off the before we started recording is an interesting, Israel had a resurgence and and so there was this one study, small study. Presuming that maybe Pfizer or the, the, the vaccine doesn't work as well against the Delta variant. So like only like a 64% protection against infection. That's different though, of course, against hospitalizations, still on the upper nineties, those kinds of things, the dangerous parts of, of COVID that kind of stuff. Also Fowchee re said that, that. That's really true. So in light of what you're seeing, where are we seeing with a Delta variant right now? And it's spread in the us and in anything that's looks more dangerous for us whatsoever.

Stephen Kissler: 15:55

Yeah. So the, the Delta variant in many ways is kind of changed the game. Not, It's not, we're still dealing with COVID, it's still the same virus that we're dealing with, but it, it really has affected how we're going to live with it in, in the next months, two years. And so, The Delta variant right now makes up the majority of cases in the United States. I think it's now over 80% of all new cases are associated with the Delta variant. And so it swept the the viral population pretty quickly. And we saw this with the alpha variant to the The one was originally detected in the UK. That also happened where it very quickly made up the majority of. New COVID cases. And as soon as it started to do that, then we started to see cases rise again. And that was because it was more infectious. And so the things that we were doing that were able to suppress the previous variants of the virus were no longer effective and know no longer as effective. And so the alpha variant started to rise and now the Delta variant has replaced that one. And so we're starting to see cases of that go up again, too. So there's, there's a lot of different things going on here. So first. So we have the Delta variant, which is more infectious that starting to cause rises in cases, especially in communities where vaccination rates are low, but it's also spreading in locations where vaccination rates are high. Why? Okay. So, we ask ourselves, we got, we got the vaccine to prevent clinical illness for sure, but also to prevent the spread of disease. And there are some places that are verging on the, the thresholds that we were talking about for her to immunity. Why are we. See the spread of Delta, even in places that should ostensibly have gotten some degree of herd immunity and that that can be largely traced back to the fact that the Delta is so much more infectious. Right? When we were talking about SARS cov two originally back in beginning of 2020, we were talking about reproduction numbers on the order of three whereabouts, one infected person would infect three others, all th all of the things being equal. By the time it jumps to the alpha and the Delta variant, the Delta variant now has a closer to a reproduction number of around six. Right. And that's a huge, huge difference. It's like twice as infectious as what we'd been dealing with before. And some simple calculations suggest that with It's that infectious you need about 85% of people protected from infection to get herd immunity. Now, the, the vaccines are probably only on the order of 70 to 80% optimistically effective against infection. So even if you have the entire population back, You would still be able to see the spread of the Delta Varian. So that's one big reason, this there's been a lot of suggestion that like, well, why are we getting vaccinated in the first place? They clearly don't work because the Delta variant is spreading in highly vaccinated populations. And to some extent, that's true, but that's just because this virus is such a formidable foe in terms of its transmissibility. The good thing about the vaccines is they are preventing people from getting symptomatic illness that preventing people from going to the hospital and preventing people from dying. And that's true for the Delta variant as well. Even if the Delta variant is actually more severe as well, which it seems to be the vaccines still do a very good job of preventing against the symptomatic illness and the onward, hospitalization and death. So that's all good news. But again, it's not, as we've been saying. For a very long time to these vaccines are not the magic bullet that we hope for them to be always, they're not a hundred percent effective. They don't protect everyone. And even vaccinated people sometimes do get hospitalized and some of them die too. And we, we don't want that. We don't want that. But that's happening in, in much smaller numbers amongst the vaccinated population. It's really complex. Right. And and it's difficult and the voltage Delta variant will continue to spread. And so, and so that's kind of the situation that we're in right now where it's spreading, it's spreading mostly and unvaccinated populations are low vaccination populations, but it's continuing to in highly vaccinated populations too. And so that's where we're at.

Matt Boettger: 19:39

Okay. Kind of reminds me of like, Groundhog's day for us. Like it's like kind of dealing with the same questions in the same concerns, over different cycles of different variants. Kind of like when the very beginning, when we were doing unlocked down and we were doing social distancing and there was accusations, see, it's not working, it's not working. It's not working. They're still infected still growing because it's, it's, it's so hard when you don't have anything to compare it to. Right. You can't compare the same thing to the same stand in the same way, because you're actually dealing with that variable. And it wasn't until, for us, at least for me, maybe not for everybody, but it wasn't until we saw, oh my gosh, flu cases are non-existent this year. That comparison help me realize, oh, could you, so if that affected the flu that dramatically, could you imagine if we wouldn't have done what we did? What if COVID would have done the same thing now? It's like, oh, vaccines, aren't working. Lord help us if we didn't have a vaccine right now and what it might look like, and like on a geographical scale with a Delta variant going crazy, right. That it's so effective. And the fact that we're still seeing a rise in cases, we should just be counting our little blessings that we have it, that it could be so much worse, right. So much worse. So, no, thanks for that comparison. There really appreciate that. That helps make sensitive, these, these articles that I read that it's kind of hard, cause I'm not. This niche, this area of expertise. So when they start with titles, like called a top health expert, and like, I have no idea whether there's actually really is a top health expert, that's the title. So that's the magistarium, that's the must be the truth. Right? So top health expert says vaccinated, people are spreading Delta variant, and that helps now you put everything into restaurant. Of course, it's going to at some level, because of the extremity of, of the spread. Of the virus. Mark, do you wanna add anything to this conversation?

Stephen Kissler: 21:21

W I love that. I just think not to put too fine of a point on it. I think you guys said it exactly, but that's the sense of anytime we resort then to, jumping to this conclusion, Oh, the vaccines don't work or this absolutism around that. Especially when, with, when that's kind of retreating into a sense of kind of fatalism about, it's like, well, nothing that we do matters. Yeah. Let's just go back to doing whatever we feel like, I think there's a, there's just this real draw sometimes to say, I just want my intuitions to be validated and I'm going to kind of follow the evidence until the point in which my intuitions are validated. And then I'm going to stop. And that's just it's so hard and I feel like that's, those are some of the conversations, that we ha have been having and are having continually about some of these things, because we've got to push through to that level a little higher resolution and it's helpful. I find that just really helpful to situate what is really going on with vaccines, Delta spread, and then, and then that makes a material difference in what I feel comfortable doing. With me and my family, so I appreciate it. Great to kind of, oh yeah, no, I was just one of the things that I've been thinking about linking all of these things together. I really appreciate that, that point, mark. And is that like, like how, how I feel myself tempted towards a sort of fatalism in the other direction that like, we're never going to be able to understand. To, to, to accept the sort of behavioral changes, the sorts of acknowledgement of the complexity of the world that will allow us to engage with the world in the way that it exists, as opposed to the way that we wish it would be. But then again, I think that there's when, when I'm tempted towards those moments of sort of fatalism on, on the other side of the spectrum I think it's like, it's always helpful for me to remember that. Then times when actually our collective behavior has changed profoundly in response to different risks or different threats that we've faced on a population scale. For example, putting on a seatbelt when I go into a car, right? Like I, I never drive without my seatbelt on. And when seatbelts were first introduced, there was a lot of rules. Against them. People actually thought they would be harmful. And it took a long time to you know, for, for that to integrate now, it's, it's second nature. I don't even think about it when I get into a car. More to the point of infectious disease, as we think about navigating this transition I think a lot about the experience we had an actually especially the gay community had with HIV in the 1980s, going into the nineties and two thousands, right? Like HIV is still spreading. Right. And it's still a threat to Two people and it's it causes disease. And there had to be some vest, behavioral changes different ways that people thought about the risks of certain activities, different ways about the risk of interacting with other people. And yeah. A lot had to change. And in many ways, a lot has changed and that's been integrated into culture. It's been integrated into the ways that people lead their lives. And so I think in some ways, what COVID is forcing us to do is to do those same sorts of things on a more mainstream, broad scale population level. But there are things that we, or at least different parts of. Society have done before. And so I do think that there is hope and there's actually even like roadmaps that others have gone through previously that we can look to and draw for inspiration for very clear practical guidance on how to do this. And I think that that's something we're going to have to really, we rely on in the coming months and years to. Navigate this, this ongoing sort of simmering crisis. Yeah, I think and just, maybe it was kind of my, my last contribution to this particular point to bring it back to our conversation at the beginning of, what do we do now and how. Think about recalibrating our risk. It feels to me that one of the big conversations that's going on amongst different different people in different communities is the sense of, to what degree do we value safety in relationship to other goods. To what degree do we value our protection against infectious disease in relationship to other things that are also important. And good. And I think there's, there is a way there's of course there's, absolutisms on every side, and there is potentially a way to prevent, a huge amount of infectious disease by never, ever seeing anybody again. And, by doing all these things that are otherwise damaging. To, to other human goods. And so I think there's, we don't, I don't know if we always have that conversation on that level about like, okay, what are the, what are the underlying things that I'm wanting? That I'm shooting forward for my self and my community. And how do we talk about the, just real granular details about how, how the, our number affects? Yeah. My sense of, whatever, communal integration and, and, social justice or whatever, like that's, that's a complicated calculus, but there is a sense, I think that we're transitioning into a period where making that conversation a little bit more explicit, could be useful. And and I think could also bridge a little bit of these different communities where that have reacted to COVID. Different ways, if that makes sense that there's the, I think that lots and lots of these different reactions have been deeply motivated by some different underlying assumptions about what is important and what is worth protecting. And And I think if we can start to think about that a little bit and and recognize that we're in a different phase right now, in which some of those other concerns may be rising a little bit on the priority list, how do we then react? You know our conversation so that we're not quite so siloed and just continue to be siloed and moving in the opposite directions from here on out.

Matt Boettger: 26:46

Yeah. I don't want to make this sound like exaggeration, but you know, up until this point, I felt like, fundamentally we were. Rational animals. I think we're kind of fundamentally irrational animals and like, everyone, like, I think, I think we, because I think there is stuff beyond rationality that we consider as part of our importance and that kind of stuff. And it's it's, and I've learned this the hard way of like, I have things in my own life that I put prioritize. I prioritize in my life. That anybody on the outside look, that's fundamentally irrational. It doesn't make any sense why you'd prioritize that over this statistically, that kind of stuff. But helping people guidance into normalcy through statistics, I've learned that does not really work that well. Like, just constantly hammering the idea that, oh, now the summer it's June, it's July, it's going to be August and statistically, you have 103 chance, one a hundred, three chance to get in a car accident and have some failures and versus one in a million chance too, die of COVID and you're like solved. It didn't really solve any problems. Statistic doesn't really matter right now because I feel scared and it's a bit of a big hard year and there's been a lot of things that's happened and they have a narrative and I've got to find my way and my way to transition into it. So combining rationality and irrationally as a hard quest to move forward in normalcy. But my biggest, my biggest PSA. Now is the time to do that transition because it's a time, at least in the U S where it's one of the safest times to be able to, Hey, and if you're in, yeah, you can be outside, you can go to the pool, you can do all those kinds of things begin to, to reintegrate those things that you value that you've sacrificed for over a year now. But you know, in relationship to other things like, so now there's other variants there's Lambda there's Absalon as well, any contributions to that, Stephen on this stuff. Besides. Alphabet I know Landa looks like that's hitting south America pretty intensely. And it seems to be pretty aggressive, I guess Peru was hit and they have one of the biggest, mortality rates per capita. So I'm not sure what Lambda is in relationship to Delta. We have Epsilon, which I guess is a California variant. Right. And so I have a couple of questions. So just these two ones. So if you can maybe get us up to speed on these two, where, where they were in a relationship. And then my other question, just to throw out you and your you're at Harvard, you can hold these intention. Right? So, in that is the other one is how has variants in general changed over the course of vaccines? So, before the vaccine, this was spreading all over. Is there a, has there been like a change of rate in it that's been noticeable in the amount of variance because of vaccinated people? Is it, is, has that changed or are we seeing them still come on the scene roughly at the same rate as before the backseat?

Stephen Kissler: 29:23

Yeah. So, first the overview of the variants that we have so far, right? They, we do have a number of different variants and it's been interesting as time has gone on, they've shifted between their different classifications of how concerning they are, how interesting they are, or, how suddenly they are, right. The classification. And so, So it's hard to keep track of. Even, even as an epidemiologist, who's looking at these things all the time, but I think the upshot of all of this is that there are multiple variants spreading. In addition to the Delta, there are others. And even within those, there are different, different subjects. Sub lineages within those variants that have different attributes. And so, but really the broad picture is that, the key three things that we're interested in when we're looking at the variance is their transmissibility. So their ability to spread their ability to evade our immunity and their severity. And those are the three axes that the virus. Moving around the evolutionary space and and trying to figure it out now, now the only one that the, that it's really being well. So, so the virus will naturally. Evolve to be both be more transmissible. And when it's spreading in communities where immunity is high, if a variant emergence that is able to get around that immunity, it will naturally spread more easily too. And so we'll start to see more of that variant as well. It doesn't necessarily try to become more severe. In fact, sometimes it tries to become less severe. It just depends on sort of these other axes and how they're all linked together. So each of these variants that you just listed off kind of differ in how far along they are on each of these axes. The big concern with the Delta is just how much more transmissible it is. And that's usually the real concern, because if you're more transmissible, you can just infect way, way, way more, many more people. And so you get sort of the, the effect becomes much larger. So that's the issue there, but yeah. The variants of different, some of them are able to get around to some amount of natural immunity as well. And so they make both immunity from previous infection and immunity from vaccination a little bit less strong when, when faced with that variant. So there's the question of, how does vaccination play into all of this? Well, it's pretty well established now that on average, the immunity that you get from vaccination is stronger than the immunity that you get from natural infant. And so, it seems to last longer, it seems to be more durable. It seems to be, more effective on a, on a challenge by challenge basis when you're exposed to the virus. As far as we can tell there's of course, we have a lot of vaccines too, so it depends on which vaccine we're talking about here March. That seems to be the case. So that's all good. And so there's, there's been a lot of speculation, like. So we, we now have vaccines and now we're hearing a lot about these variants. It's very easy to say. Okay, well, let's draw a causal link between the two vaccines, therefore variants vaccines, or maybe the reason why we're seeing more and more variants. I'm not going to be able to satisfyingly say that. Absolutely. No, that's not the case, but I don't think that it's nearly that simple. And I think that we would be continuing to see new variants emerging regardless of whether or not the vaccines were there. And in fact, I think that the vaccines are probably helping to suppress the development and spread of variants rather than to encourage them. Why is that? When we're thinking about the evolution of a virus the the, the, the sweet spot for evolving something that is a worst variant in terms of either getting around immunity or being able to spread more easily is these intermediate levels that we can get into. So I'm thinking about like intermediate immunity where either, yeah. Only small fractions of the population are protected, or the people who are protected are only protected at a middling level. So one of the good things about vaccinating with a very good vaccine and vaccinating very hard really getting the vaccine distributed to many people is that it moves you from that middle area where protection is on the on the middle scale to very high levels of protection, where many people are highly protected. And what that does is that that drives cases down. It prevents the amount of it keeps the amount of virus that's spreading in the population low. And that just gives us statistically fewer chances to develop new variants in the first. So really the worst scenario that we can be in is when we have half of people being naturally infected with this infection that sort of gives you a middle level of immunity. And that really allows the virus to to explore the space of possibilities and be. It's come up against people who are partially protected, but not fully protected. And so it can get around these evolutionary barriers a little bit more easily. So of course, in places that have a very good vaccine, that sort of middling vaccination. That can contribute to some amount of the evolution of variants, but that's not to say, that the vaccines are causing the evolution of the variants. This, this is the virus doing what viruses do, and all viruses do this to some degree. All biological organisms do this to some degree they're following the same rules and the same patterns. And so we would be seeing. Whether or not the vaccines are here and I'm, and based off of all the evidence that I see, I think the vaccines have actually probably helped us keep some variants from spreading that would have spread otherwise. That's my rough take on, on, on, on the interplay between all of these different complex

Matt Boettger: 34:21

factors. So you were talking about how there is speculation that somehow vaccines could actually bring about more variants in what situation could have, could a vaccine actually bring about more variants? Is it that somehow people are carrying it? There's the assumption that people are carrying it. It's stain in the body. And then, and then, or the vaccine itself is making it, what's the name? Contributes to that theory.

Stephen Kissler: 34:44

So it would be really it's. If the vaccine provides, maybe only partial protection, like very low degrees of protection, basically the more the vaccine resembles natural infection, the more likely it is for it to to contribute to the development of variants, basically. And so, So, yeah, roughly speaking, that, that seems to be the case. Yeah. We were predicting, predicting evolution is as just an incredibly difficult thing. And it's something that we're still scientifically very in the early stages of doing so. So that's why I'm hedging so much about these things. But you know, it really, really, it is that like, If you one sort of general rule in the evolution of anything, but especially, do variants of a virus and the evolution of resistance or the evolution of greater transmissibility is that if you give the virus sort of a low hurdle to clear, if, if you give it many low hurdles to clear, it's able to evolve new variants more easily than if you give it a very high wall. And so the vaccines are our high wall and natural infection these low hurdles in, in some sense, roughly speaking. And so that's why that's my intuition behind why the vaccines helping prevent these variants from spreading. We want, we want to present it with high walls as frequently as we can because the low hurdles are what allows it to incrementally change. And then eventually, we, we get something that's really new and is able to spread through the population.

Matt Boettger: 36:02

Great. Awesome. One of the things hitting the vaccine Pfizer, we've been hearing about booster shots coming up like boosters or B. I think Pfizer has got one coming up and it's been available. And I don't know if he has no information about this. To what extent are we going to need a booster? I saw an article here, a very exciting study indicates MRN vaccines could provide here as a protection. Against COVID-19 they'll have any clue where this is true, but is there at this point in time, is there any indicator by which we might need a booster in a year or so? Or is this looking like the evidence is showing that, Hey, we could be rocking it for like 2, 3, 4, 5 years with the, with, with, with, with one good vaccine.

Stephen Kissler: 36:41

Yeah. We have no idea. As far as I should. Check that off. Yeah. I mean, it's one of those things where right where you, you only know, well, how long immunity lasts by following people until the immunity fails. Yeah. That's the only way to know for sure. The immune system is so complex that we won't know for certain, until we start seeing people who got vaccinated early on and start to get reinfected. And hopefully that doesn't happen for a very long time. And, and that's something we're absolutely watching closely, but it's unfortunately, one of the. You can't really know until until after you would want to have known it until after, after you're able to really do something about it. That's not entirely true, they're working on boosters so that if, and when it becomes clear that boosters are needed, we can just deploy them immediately. And, and that's a very good thing, but there's been a lot of speculation of how long immunity lasts and if we're going to need booster shots, and frankly, there's just. Not only does the evidence not exist, but it couldn't exist at this point to know that question. The answer to that question, for sure.

Matt Boettger: 37:37

Yeah. Yep. Okay, great. I saw a couple of things here. I'm trying to look it up here. CDC warns COVID 19 vaccines may not protect people who are immune compromised there. So there's been a little bit of a guidance on that quick question though. What does it mean to be immune compromised? Because I get the. And there's no. And I'll get to like, well, maybe I'm immune compromised who knows maybe have it, like, I'm guessing this is like, I'm gonna throw this to you, mark. I'm guessing this has like a real. Definition. It's not like, oh, I have allergies. And so I might be immune compromised.

Stephen Kissler: 38:06

Yeah. I think that's that's exactly it, that I would not worry about somebody with seasonal allergies or general kind of general medical conditions as being in that category. That means a very specific set of things. And it's true. We have seen. Where I've cared for patients, or I know people who have really good example of this is maybe somebody has rheumatoid arthritis and is on an immunosuppressive medication, which part of the role of that medication is to tamp down the immune system. So you're not creating these auto Antabuse. To make your arthritis worse. Well that also works with the same processes that your immune system needs to do to respond to a vaccine. And so, there have even been, folks who've been fully vaccinated and then checked a few months later to see if the antibody response and it's been there. Largely as a result because their therapeutic is working as it should. And so then there's a few, they're typically more rare conditions when there's, isn't medication-related it's more rare for someone to have an immune deficiency to the degree, to which they're not going to respond to the vaccine, but that also happens. And we do see folks like that in the hospital as well. We have some different considerations. In terms of our therapeutic approach to those patients. And so things that we might do to help support them in the case of an infection. And I think that typically that's more often than not, that's going to be something that you know about. It's not going to be something that you just discover as a result of getting COVID after the vaccine. So it's definitely not something I would incur, encourage people to really worry about if it's not something you already know. I do think if you are, what, on one of these, these immunosuppressive medications are not necessarily rare. There's some of the conditions that they treat or have a reasonable prevalence in the community. And so I think if that's the case for you, then having some conversations with your doctor or being really thoughtful about what additional. Risk reduction, methods. Should I take in the, and so does that mean that I'm one of the people who, even though I'm vaccinated, I'm still wearing a mask in public or, being thoughtful about the time when I go to the store or things like that, just knowing that my own personal risk is still a little bit elevated compared to other vaccinated folks. Yeah.

Matt Boettger: 40:16

Okay. T and a to advance a cause for people getting vaccinated to help those people who can't quite get the full benefits of vaccination as well we'll land on this. I read this article. There's a lot more stuff. A lot of talk about this our first and back in weeks, we'll catch up over the coming weeks. Hopefully we'll have mark back a little more often. I saw this a guideline kind of, it kind of surprised me, mark. I don't know if you've read or saw this America American academy of pediatrics recommends masks in schools, even for vaccinated going further than the CDC. Any, any reason for that? Or is this just over caution or. Did you have you

Stephen Kissler: 40:50

any, I haven't, I'll have to read it, then see what their what the evidence base is that they're using for that? I don't know, Stephen, if that's something you're familiar with, I actually just, there's been a conversation at my kids' school about mask or no mask in the fall. And they've gone actually back and forth. On this. And so it's going to be interesting to see where this lands. I suspect personally that a lot of it's going to have to do with where we're at on that saw tooth curve of up and down infection. And and again, kind of treating this in a more chronic season. And almost, the metaphor that Stephen used, it's like the weather report, there's like a weather report and then there's kind of a COVID infectivity report. And we may have to ma minorly alter our behaviors as a result of where we're at on that curve. And then we can relax them in times when that's less less of an issue I'm interested to see. I'll have to, I don't want to come in yet, but I'll have to take a look and see what the American academy of pediatrics is drawing that recommendation. I think it's interesting. I think it's interesting too. Cause it just highlights yet again, this complex interaction between based statistics, expert opinion and our social response to expert opinion, each of which has a lot wiggle room. So somebody interesting to see but I'll take a look. Good.

Matt Boettger: 42:02

My last thought here, before we go on, as I keep going back to what you said, the very beginning mark, about how am I, right? You said you guys were thinking as a hospital, but how to thinking about how taking the COVID war to the patients and basically integrating them into the whole normal respiratory illness, basically wing or area. So think of it, not as siloed reality, but it's just. One piece of a bigger puzzle of respiratory viruses. So that's part of the conversation right now. Mark. I want

Stephen Kissler: 42:30

to make it clear. That's not I'm not involved right now in any of the operations conversations around that. So it's not as if we're having at least that I'm privy to. Conversations about physically moving patients or re-integrating on the teams, different hospitals manage this in different ways. So far, we have siloed our COVID patients on a particular one, too many COVID teams over the course of the pandemic, depending on how many folks we have at at the time. But what I do know what more I'm saying. From a conversation standpoint, as we're thinking about it, just as physicians caring for these patients. I do think there's a sense that at a certain point, there, there may be, there's just maybe a tipping point at which that makes a lot of sense. And so we have had some of those informal conversations, but nothing that I know of in terms of like formal operational changes, Sure.

Matt Boettger: 43:20

Well, I'm just thinking of landing the plane with this kind of metaphor of just seeing that, how our lives are, trying to work that, that string of COVID and refabricate it into our life versus seeing it as a siloed reality. And to seeing that hospital's like as a metaphor of like, we're all working with taking this siloed reality for a good point. And how do we. The string and now fabricate it. So now, instead of looking at separately, it's part of the life that we live with. Right. And that is the hard, but I just, that imagery that you said early on, just maybe like that struck me. Yeah,

Stephen Kissler: 43:51

absolutely. I think re-integration or integrating any illness experience into the story that proceeded it and follows it is a major part of how humans cope with disease. And so I think that as absolutely we're at this funny, we've talked about some of the, the narrative structure of life and disease over the course of this pandemic and talking a lot about illnesses is an interruption illnesses causing chaos or an UN UN narrator. Sort of state, and that at a certain point, there's an opportunity, I think. And of course we don't want to force this and we don't want to be too prescriptive about it, but there's a certain point at which a type of integration becomes appropriate or possible. And I think we're starting to maybe turn the corner into that phase with COVID.

Matt Boettger: 44:35

Yep. Yeah, I agree. Well, this is great. Great to end on that thought. And I just hope that we all can try to begin to kind of take that metaphor and how we begin to make those steps of refabricating that, that big part of a siloed life into the normal part of our life which is for the overall wellbeing of all of us. Well, thanks so much guys for coming back. It's great to have both of you Steve and mark on it. Good to see your faces. Can we see in person we'll be done. Regularly as best as we can weekly bi-weekly, we're striving for weekly until we feel like we might provide more value bi-weekly so, we're here. I got a couple of emails, like, did you guys leave? Do you guys drop off? Please come back, but we're that was just a little break. We'll be back for the foreseeable future. Thanks so much for Katina. Listen to us and subscribe to us. You can always do that to give us a rating. Give us a review, keeps us inspired. Keeps us going. Do you want to support us? patrion.com/bending podcast. One time a gift of Venmo people all in the show notes. Thank you again. Have a wonderful week. We'll see you guys all next Monday. Take care and bye-bye.