These Delta behaviors are a little perplexing...

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Things Discussed on Episode:

• U.S. Vaccinations Ramp Up With Shots Passing 700,000 for Four Straight Days
• Pfizer Covid-19 Vaccine Is Less Effective Against Delta Infections but Still Prevents Serious Illness, Israel Study Suggests
• Some COVID hot spots see increase in vaccinations; Massachusetts outbreak shows 'vaccines are working': Live COVID-19 updates
• MA Outbreak of 900 COVID Cases Leads to Only 7 Hospitalizations: 'The Vaccines Are Working'
• 21 of 29 People Test Positive for COVID-19 After Oregon Family Reunion—13 Fully Vaccinated
• Should you be wearing a mask again? Here’s a map of the Covid hot spots subject to the CDC’s new guidance

Transcript

Matt Boettger: 0:00

You're listening to the pandemic podcast week with you to live the most real life possible. Face to face. My name is Matt and I'm joined with my one good friend, Dr. Steven Kissler, a epidemiologist at the Harvard school of public health. How are you doing this? Fine, wonderful August Monday. Crazy

Stephen Kissler: 0:17

there actually. No, it's it's cool enough. It's almost, there've been these weird days lately where it almost starting to feel like fall which has really thrown me for a loop. I know, I know. I know. It's like, it's crazy, but it's, it's one of those days today and I, yeah, it's nice. It's comfortable, but it's also got a weird.

Matt Boettger: 0:33

Kind of weird. Well, that'll be in that might be a really a good theme for today's episode, weird stuff coming on, but I know, I know my wife can not stay here. After the 4th of July, when all the, like the back to school sales begin because she's like, it's not school time yet. It's not fall time yet. Don't, don't put that in my face. I want to do it the summer show. So we saw a couple of leaves look like a little foolish here in the premature. We're like, no, no, no, come on. Hold strong in the late fall. So, man, to the hard problems of the U S. There is a lot going on this week. And before we get into that, the normal stuff. So please leave a review. We've got a couple have been great. It inspires us. You can go on apple podcasts, leave one. We really appreciate it. We'd love for your support financial support in any way possible to keep this going, to help us keep the lights on as little as$5 a month at patrion.com/pandemic podcast, or just one time gift to PayPal, Venmo all in the show notes. You can grab it right then and there. So let's get into it. Steven. We were kind of chatting before we were rolling. We were, I was asking you what what's been going on. You're like, oh man, it's been crazy week. And it depends on what it could be thematic to our podcast, or it could be, it'll be a crazy week in general for you. But this one seems to be very much right in line with what we talk about. And so let's just tip off. What's been going on in your world. What's been kind of put on your lap and what do you guys seen over there with this past week? There's been a lot of weird stuff going on and some big news cycles that have been thrown in my face a couple of times even against kind of what we talk about. So. Take it

Stephen Kissler: 2:11

away on this. Yeah, totally. It's it's, it's been an eventful week for sure. So, I mean, I think, you know, the big thing is we have the CDC stating new mass recommendations for basically everyone who's indoors whether or not you're vaccinated, especially if you are in a area of high transmission They did that citing some evidence that that the Delta variant in particular may be transmissible among people who were vaccinated. Then a couple of days later, they Released a report on the data that they have based those recommendations off of which primarily was this a cluster of infections in Provincetown which is a town here in Massachusetts. So it's just up the road. And Yeah, and we can, I think we'll probably spend some time getting into all the details there, but it's been really interesting because there's, you know, there's been the CDC itself, updating guidelines, and there's been the response from all across the spectrum as to whether or not they should have done that and how they should have done that. And you know, that hasn't necessarily fallen into the traditional camps where, you know, some people who have been generally supportive of recent CDC measures have been more critical and vice versa And then in addition to it all, you know, just the question of, you know, whether it's founded, whether, whether this makes sense to do it, how they did it, whether it made sense to update the guidelines before releasing the data, or if they should have done it in the reverse order. And then all of the new cycles that have come off of that, where there have been articles, reporting, you know, bits and fragments of this report headlines that don't really reflect what's in the articles, but then, you know, cause a lot of concern and confusion around what's actually happening. But it also makes sense because we're all a little bit confused and trying to figure out what's. So, so it's just been a a busy week to be an epidemiologist.

Matt Boettger: 3:56

Yeah. I know. Just when, what, two weeks ago you were telling me, oh, you know, we, things have been slowing down and, you know, our focus is finally being kind of switched from, so COVID focused like right, right

Stephen Kissler: 4:08

back in it again. Yeah.

Matt Boettger: 4:10

Yeah, totally. So let's jump into this because this has been concerning me. And I have another question that I've talked to you about. We'll kind of we'll maybe come back and circle back with that question, but this Provincetown thing has really kind of made me a little uneasy if it, because number one, I didn't even know about it until somebody did a Facebook post to somebody. I don't know. Don't consider a friend, a very large conspiracy theorist throwing it in kind of the public's face. Like, see, this is just, you know, basically if you can get the gist of it, In Stephen, you can get all the dot, the I's and cross the T's and this kind of stuff. But basically that there was a large amount of infections in like 77% of them or 73%, something like that in the seventies. Those who were infected were actually people who were vaccinated. So the majority of people during this timeframe, like on July 7th, the 14th or something the majority of them who were infected were actually vaccinated people, which should just, was it alarming because and we might try to figure out ways by which this could be possible. And then I just read another one. This was, I think this morning or yesterday then it's just, okay. Now two of these is really making me kind of a little nervous of what's going on. There was 21 of 29 people, the tested who tested positive for COVID-19 after Oregon family reunion. So there was 21 of 29. That's one thing and another. 13 of those were vaccinated people, right? So that's, that's, that's that's again, another one that seems to at some level kind to ring true to the province. So, what are you guys talking about? What's going on? Is this a sign that the vaccinations are having a difficult time working or is it actually creating a more havoc with infections? What's how you're trying to make sense of this.

Stephen Kissler: 5:54

Oh boy. Yeah. So, There's a lot of different factors there that are playing into this and I'll try to tick down them one by one. So, so first let's, let's maybe focus on Provincetown and sort of thinking about the context, what happened there? What we know, what we don't know, what we're still trying to figure out. So, first of all, the, the outbreak, a cluster of infections in Provincetown is largely traceable back to the 4th of July weekend. And Provincetown is a place where a lot of people in the Boston metropolitan area, and even across new England go on the 4th of July. It's like a very big destination for July 4th. So a lot of people there, a lot of people. In close proximity with each other it was raining that whole weekend. So a lot of people who might've spent time outdoors were driven indoors. So a lot of opportunities for spread many, many opportunities for spread. So, So that's one thing. So, so if you were to expect a cluster of COVID cases anywhere in the country, over the July 4th weekend you know, I, I might well put my money on Provincetown, you know, maybe I'm biased being a Massachusetts it's resident right now, but but it makes, it makes some sense that there was a cluster there. No I'm still sort of sifting through the data on this, but I know there've been A number of tweets by Shaw, for example who's a very well-renowned epidemiologist and a doctor. And and he's been one of the things that he cited is that, you know, we've had this cluster of cases, which has been alarming, but also it seems like that In his words, it's, it's largely sort of fizzled out where you would expect if a big cluster of Delta cases emerged in an unvaccinated population that it would just skyrocket. But actually, you know, here in Massachusetts, thankfully we have very high vaccination rates and it seems like that might've helped sort of tamp down the fire which is good news. So that's all there. But I think it's worth sort of digging into some of this a little bit further because you know, I think that a lot of people remain sort of confused and uncertain about sort of how to make all of the different pieces line up. And, and frankly, I'm, I'm still working on this too. You know, we, as epidemiologists are trying to make sense of all of the data that's coming out and trying to sort of reconcile everything with each other, because it seems like it's giving us sort of a very mixed picture. So, you know, on one of those, the things that people have found most alarming is that and this was the subject of a lot of the headlines in the immediate aftermath of the outbreak or at least of, of this report that was published by the CDC which is that an estimated 75% of the cases were in vaccinated. Okay. So what does that mean? You know, that, that almost makes, it sounds like the vaccines were actively harming you in a way, right? Because because you actually haven't, you know, more than 50% of the cases that you observer and people who are vaccinated. So it's not a, it's not necessarily that simple it's. So one of the thought experiments that I like to do is that, you know, imagine, imagine you have a community where you have a hundred percent vaccination rates, but we know the vaccines are not a hundred percent effective at stopping infection. So you do have a cluster of cases there. What fraction of those cases are going to be in vaccinated. Oh, a hundred percent of them are going to be in vaccinated people. Right? So if we, if we, if you have a place with very high vaccination rates, you naturally expect greater and greater proportions of those cases to belong to vaccinated people. So that's not necessarily surprising that we're, that we see a lot of cases among vaccinated people, because if there is an outbreak and the outbreak occurs in a highly vaccinated community, then you expect a lot of those cases to be in vaccinated people. One of the things that you know, certainly I'm still trying to sort out here is that you know, here in Massachusetts we have we do have pretty high vaccination rates and it's, you know, on the order of, you know, for people over the age of 18, it's about 75% vaccination rates. So. If you assume that the people who have been sort of infected in this cluster so far were reflective of that 75%, then it is a little bit odd that we would see, you know, 75% of the cases being vaccinated, people in a place with 75% vaccination rates, because that would suggest that maybe actually the vaccine is providing less protection against infection than we initially thought. You would expect that number to be skewed a little bit where there would be at least fewer people, fewer cases in the vaccinated population than the unvaccinated population, relative to the baseline vaccination rates. So that then gets into the issues with so there are a couple of different ways that we could explain that potentially. So one of them is that maybe amongst the people who have been infected so far actually vaccination rates are much higher than the state. That would make sense here in the Boston metropolitan area, vaccination rates are actually quite a bit higher than the Massachusetts average. So maybe they were actually, you know, if vaccination rates were 90, 95%, then that 75% no longer becomes as surprised. There could be a bias in case ascertainment where people who are vaccinated might be more likely to comply with public health officials might be more likely to report their cases, things like that. And so that might also bias case ascertainment towards vaccinated people. And so those are all things that we're looking into. But of course we can't throw out the fact that we might've learned something new about the Delta variant here too, or about some descendant of it where You know, it's it does seem like the Delta variants you know, we've known for sure that it's extremely infectious. And and I think that we were going to talk in a little while about some of the data coming out from Israel too, that suggests that you know, it might be chipping away at some level of the vaccine protection as well, especially protection against infection, even if it remains pretty effective against severe disease. So, you know, as the Delta variant continues to spread We're learning a lot more about it. And I think the big question about this outbreak is that, you know, what, what exactly is it telling us? The trick, when we see sort of a single big outbreak like this is that there are all of these different axes in play where there's behavior during the outbreak there's behavior, after the outbreak, there are a lot of uncertainties as to sort of what the baseline situation was in terms of vaccination rates and who was there. What their age distribution was. And then we layer on top of it, the fact that we're dealing with a relatively new variant that we're still trying to learn about. So there's, there's a lot of uncertainty here. And so I think really what I want to emphasize is that I I've even been frustrated with some of the ways, you know, not only the media has been portraying this, but even, you know, even, even other epidemiologists and experts in the field or at least tangential experts you know, people who have. Sort of weighed in, on epidemiology over the course of this thing, but might not have sort of the full grounding and epidemiology or even people who do who I think are trying to, you know, in good faith to explain their perspective on what's happening. But I think that what that can gloss over. This is a really complex situation and it's okay to be confused. I am a little bit confused and I'm, I'm personally, I'm sort of suspending my judgment as to sort of what's happening in this, in this outbreak. And I don't, you know, I don't want to say that to, you know, so alarm or concern that, you know, we have this like crazy new variant on our hands, but but I do think. It's prudent in this case to say that, you know, there's, this is a new, important piece of information that we've gotten in. It's a little bit difficult to square all the corners on it, to figure out what exactly is going on. That it's still, you know, highly probable. That this was just Delta being Delta. And that it was in a very anomalous situation in a sort of strange community in the sense that, you know, Massachusetts has high vaccination rates and we don't really know who was there, but that said, you know, we're going to have to see sort of how this plays out in the next few weeks and months to sort of see what to try to disentangle some of these different factors. So, you know, I, I love to be able to. Explain things clearly and concisely and to sort of help people sift through all of the, the difficulty here. And, and I think we'll continue to in the coming weeks for sure, but, but I think really what I want to say right now is that this is it it's complex. And and yeah, so it, it makes sense to yeah, to be paying attention to all of this and to To not necessarily have a, have a clear place to stand yet. Yeah,

Matt Boettger: 14:03

no. I mean, first of all, thanks. I mean, thank you for your honesty. I mean, technology that you don't really know what's going on and kind of giving us all the right to be able to feel the same thing. If an epi epidemiologists of Harvard school, public it can be perplexed and we have the right to be perplexed as well. And no, I feel like we have to either go on one side or the other where there's the one side by which I'm seeing that they're using the, the, the Massachusetts study to prove conspiracy theories. And there's the other side, which I think is more, I think, I think more, more pronounced and, and maybe in some sense can be a little bit more dangerous because I think it's so much easier to dismiss. The conspiracy theories, I guess depends on what camp you're, you're a part of. Right. But then there's the other side which I'm seeing is this, this almost even I read it the past week, a lot of articles I felt as if they're going above and beyond to justify that this is normal. This is okay. This is to be. And I get that, but I felt like there was a little sense of artificial reassurance being, say, like, yeah. And, and thank you for just saying like, look, both sides might be kind of erring on the side of like trying to like defend their position. Right. And this is just a perplexed, this is a perplexing case. And so I wanna, I want to kind of encapsulate this again. So I wanna like give a potential reason why this might be happening and then reopen a new door with you. Have another level of complexity that you should. Off the air. So you just mentioned that study from Israel that I saw, I sent it to you, Stephen, the wall street journal. I'll put it in the show notes and it talks about how, you know, before all this happened, you know, when, when the vaccine Pfizer Madrona rolled out, it was 95, 90 4%. You know, effective against infection, right. And that was an incredible rate. And we're really excited about that. And this study presents itself sane because the Delta variant, I'm guessing, I'm assuming, and maybe all the variants together that Israel has shown that the, the, the particularly, I didn't see which one it was. This is Pfizer is 39% effective at reducing the risk of infection. Right. 30 that's a huge dramatic jump. And then 40% effective at reducing the risk of symptomatic disease. So this may feel like we're getting a little nervous going to scare. I mean, the good news is that's still the same level of the vaccine was 91% effective at preventing severe illness, which you were talking about. So I could see this. As making sense a little bit. In my mind, you kind of gave the, some of these situations with Provincetown, you know, me being vaccinated, I'm more willing to go out and quote risk and go do normal things. Right. Because I'm vaccinated. So I feel like almost like a, as a Malcolm Gladwell, the tipping point is there, like this like tipping point, you're like. When, when the vaccine is 95% effective against infection, people going out and doing things, once they're vaccinated, probably doesn't have a dramatic change on infection, but at some point in time, when it gets whittled away, 90, 85, 70, 60 fifth, there's a tipping point by which okay. Now between the combination of, of behavior and it's reduced, defectiveness did like, almost like a just a flood water. Right. When it comes to infection open up, I'm assuming that could probably make sense of some of this. Is that what you were thinking

Stephen Kissler: 17:06

as well? Yeah, totally. So, to sort of break some of that open and just just to be sort of totally precise with my words here. So the the early, you know, the, the trials for the Pfizer and Maduro Nevada the reported efficacy is that 94, 90 5% was the efficacy against symptomatic disease. Not necessarily against infection. So the efficacy against infection was probably somewhat lower on the order of 70 to 80%. But nevertheless what you say, you know, is true that these data coming from Israel are Are really important because as you know, as, as you said, it seems like the, the efficacy against both infection and symptomatic illness are, is reduced to around 40% in the data set that they're looking at. So either way that's, that's a drop-off from from what we had been observing before. No. This study as the authors were very upfront about, and also the article in the wall street journal is very up front about is that it's preliminary, it's relatively small group has not been peer reviewed. You know, we still need a lot of checks and balances on this before we can really conclude anything for sure about this. But you know, that said it does also kind of align with the. Increasing reports of vaccinated people coming down with a symptomatic disease in the face of the Delta. And so these numbers are going to absolutely shift over time, as we learn more about the Delta furthermore, you know, there's not only are we learning more about the Delta, but we're also learning more about the vaccines themselves. So one of the things that was brought up in this article and that I think we need to continue thinking about is that It's very well possible. And in fact, probable that immunity wanes over time. This is a pretty well-documented phenomenon that happens with other coronaviruses. It happens with flu. It happens with many different infectious diseases. Where are the strength of our immunity can decline over time. Part of the reason, the way the Pfizer and Madrona shots are in a two dose series is to sort of help shore up that decline to try to keep it higher for longer. But a lot of the talk about introducing potentially a third dose into that sequence is because maybe, maybe we need it to maintain those levels of protect. You know, that's not unprecedented. There are a lot of vaccines that we get, especially as kids where we have a three or four dose series. And the entire purpose of that is because it takes that many doses for our immune response to go up to a durable level and protect us for life. That way may well be true for for COVID-19 as well. Israel of course has extremely high vaccination rates. But also, you know, they were very quick to the draw. And so many of the people who have been vaccinated there have been vaccinated for a while. So some of this might reflect the Delta variance. Some of it might also reflect waning immunity from the vaccine over time. And so once again, there's a lot of these different factors in play that we can't quite disentangle until we observe. These kinds of studies in different populations at different times so that we can figure out, you know, what exactly is contributing to what so absolutely important information. It's just not totally clear what to do with it yet. Yeah,

Matt Boettger: 20:10

no, that's awesome. That's great. So let's add a level of complexity to this because, okay, so you added another additional level complexity, understanding the situation. We talked about, how, ah, you know, it kind of makes sense if, if right, if these preliminary, the studies are correct and there's a, it's now only 40% effective on maybe S you know, symptomatic disease and people are being a little bit more risky, so we can see these large amounts, however you mentioned. And I didn't, I didn't even know that. Before we started the podcast that Florida is seeing a pretty significant uptick in hospitalization. So that's like another level, you know, so seeing Pfizer being at 91% effective now, I'm not sure what it was beforehand. If it was like 95 or 96, I don't, when it comes to that level, that seems maybe like, I, that that's a hard narrative that I'm not being able to explain right now in light of the efficacy. Of of Pfizer Medina and you were telling me. Florida is a place that's generally well vaccinated. So you maybe wouldn't really expect to have such an uptick. So do you wanna talk about what you've seen with Florida and how that's causing a whole maybe, and maybe in their mess of complexity and perplexity as well?

Stephen Kissler: 21:19

Yeah, so exactly. So, you know, we're, we're starting to see pretty substantial increases in cases in a number of states, particularly Florida, and some of the. Southern Midwestern states like Florida, Louisiana Arkansas, Missouri have recently had among the highest per capita case counts in the country. As you mentioned, you know, so some of those states have relatively low vaccination rates. And so we might not be particularly surprised, but actually, you know, Florida has had it. Has decently high vaccination rates, you know, especially relative to their surrounding community and and even relative to the national average. So, so Florida is an interesting case in this, in this sense where you have relatively high vaccination rates and we do have cases that are increasing pretty quickly and probably most concerningly, you know, hospitalizations are rising there as well. And so it's again, sort of. Trying to make sense of this. So, it's once again, there are a couple of things that could be in play. So. As as before. So Florida was one of the few states in the country that had a larger summer surge last year than their winter surge. And we think that some of that might have to do with the fact that You know, up here in Massachusetts and certainly in Colorado, we think about summer as the time that you spend outdoors and winter is the time that you spend indoors, but that's kind of flipped there where, you know, it gets so hot in the summer that you spend more time indoors. And the winter is actually when it's pretty pleasant to be, you know, hanging out in Florida. And so, you know, some of this stuff. Could be behaviorally driven. We do expect cases to rise around this time of year if it reflects it all, what happened last year? Particularly in Florida, but also in some of the other Southern states. But I think again, you know, the thing that we're trying to reconcile here is that the trajectory of Hospitalizations in Florida is seems to differ from the trajectory of at least the relationship between cases and deaths, for example, that we saw in the UK. So I think one of the things that we talked about last week was this really remarkable difference. In the previous two waves in the UK where they had their winter, sorry. And then they've had this more recent summer surge that was really driven by the Delta variant, where in the winter you can sort of calculate the factor of cases that lead to deaths. And then in this most recent search really in the post vaccination period, that that trend sort of broke apart where there were far fewer deaths per case. That seems to be totally as a result of vaccine coverage, which is great. And so, you know, I was. Expecting to see something much like that here. It may well still play out because it's still too soon to sort of carry cases forward into mortality data. We haven't really had this surge of Delta long enough for it to really cause an uptick in deaths if it's, if it's going to do so, but we're definitely seeing a rise in hospitalizations. So, one of the questions that's remaining here you know, I. I wasn't able to get, I wasn't able to find data on hospitalizations in the UK, which is really what I would want to be able to compare to here. Part of the question is, you know, the vaccine can provide protection at many different stages of illness. It can prevent you from getting infected. It can prevent you from getting symptoms that can prevent you from going to the hospital that can prevent you from going to the credit clinic, critical care, and it can prevent you from dying. It's not really clear, you know, what is the efficacy of the vaccine at each of those stages? So it may, well, you know, there may well still be people going to hospital, but it might be doing a very good job at preventing people from dying. Even if they do end up needing care in the hostel. I think it's still sort of too soon to see if, you know, hopefully you know, the we'll still see cases spike, but actually the, the deaths were remained very low especially in places with high vaccine coverage. But we're again, in this super unsatisfying position where it's kind of too soon to tell what exactly. That's going to look like I'm, I'm hopeful. I'm hopeful that that we will still see far fewer deaths per case in this search than we did before. And I think that, you know, looking at some of the experience of other countries around the world with the Delta variant, there's good reason to believe that that will be true, but I think it's something we're going to have to watch very closely, because if that does not turn out to be the case, then that's, you know, another thing we're going to have to figure out, you know, what is going on there. Is it a difference in. Is it a difference in our behavior? Is it a difference in, you know, the time that it's taken between when we've gotten the shot and when we've gotten infected, all of these things are in play and we're going to have to put all of those on the table when we're sort of reconciling the different experiences that we've had with this particular variant of the virus all around the world. Okay,

Matt Boettger: 25:46

that's helpful. And just a quick caveat. It's one of our Facebook, private groups that ALO hello back. I don't know who you are because I don't think you hit the accept button to know who it actually is. But it's one of our members from the, our private support group. So thank you for watching. It's awesome to have a couple of years right now. Let's continue on to a question I had. Is, it's not quite as relevant as it was maybe last week, but still kind of relevant. I mentioned this to you because I was like thinking in my head, Adam, okay, last week we said, Hey infections are or going up. But hospitalizations are still really low. And we we also kind of saw that at that point in time, we were saying, oh, 99 send to the people who are being infected were, were unvaccinated and only 10% were vaccinated. And so then my mind is initially it doesn't really make sense because. If 90% of the people have been infected yet hospitalizations are low. Then you think they'll only be like a 10% decrease because of in fact, you know, because of those who were being infected are vaccinated. It took me a few minutes to kind of reverse engineer that. And I thought, oh, you know, cause some of our listeners could be struggling in the same way. Like that doesn't make sense. And I want to throw this back to you. Just make sure that my mental gymnastics were obviously correct that. Okay. So it is the fact that even though. Only 10% of the people had left at that point in time. Right. We don't know now because we've got some new studies showing up right last week. We're we're vaccinated, but it's the, it's the very nature of the population of the vaccination because before the vaccination. Everyone was susceptible whatsoever, including the immune compromise. Those who had cormobidities all these kinds of things. And of course those people who signed up for the vaccine, probably the majority of them, those early adopters were those who were at the greatest risk. So that population pool has been taken away largely. Is that how those statistics kind of make, make sense?

Stephen Kissler: 27:32

Exactly. So, I mean, and that's one of the things for sure is, you know, vaccination rates are especially much higher amongst people over the age of 65 who are much more likely to go to hospital. In the first place. And so we have this whole gradient where, you know, if we just look at the average vaccination rates and we look at average vaccine efficacy, we can really miss a lot of the picture because we've so far done a very good job of protecting the people who are most likely to go to hospital in the first place. So, which is a good thing. Yeah.

Matt Boettger: 27:58

Great. So let's let's land here because what we talked about, all the, the, the, the true stuff, the stats, the data we've acknowledged, there's a, there's a large sense of perplexity going on. So what do we do with this? Like, how do we land this plane? Because the CDC has given us some guidelines, right? It's it's up to states to impose that or not impose that. So here we are individuals listening to this, maybe a little concerned of. Coming down the pipeline next week or three. How do you feel like we should be engaging on level of prudence when we're saying, Hey, the conspiracy theorists clearly we think are way off the mark. And we even say those people are trying to radically confirm that everything is normal. Don't worry. All is going to plan. Might be a little bit too intense that we need to hold this middle ground. What does that mean for us going forward in my day to day, grocery shopping, going out, seeing friends, should I change on any level or modify my behavior because of this time of complexity?

Stephen Kissler: 28:55

Yeah. I mean, I think that there's, you know, a number of different principles that we, we need to put in play here where you know, one of them is the, you know, the principle of prudence or caution where, you know, we're, we're not sure what's w w how exactly. Yeah. Or if substantially the game has changed against the virus there's some evidence to suggest that it might have. But I wanted to bring up, you know, on the other hand, it, it remains true that at, you know, as you said, the, the great majority of people who are being admitted to hospital with COVID are un-vaccinated so. That's another piece of evidence that we have to square on the other side of the camp where it's like, it does seem pretty clear that certainly being vaccinated reduces your odds of going to the hospital on this very large scale. So, if you're not vaccinated yet, it does still make sense to get vaccinated. That's remains the best, you know, the best tool that we know of that we have available for preventing the most severe outcomes from COVID and even reducing its spread. I think that continuing to wear masks while indoors whenever possible, it makes a lot of sense. That was something that I've more or less kept up throughout all of the changing guidance. But I think especially now it makes sense because. This, you know, if Delta is going to continue to spread, it's mainly going to be spreading in indoor crowded spaces. So, trying to reduce your exposure to large crowds, trying to reduce certainly your unmasked exposure indoors makes an awful lot of sense, especially if you're in a place where cases are are spiking, right. I do think that it makes a lot of sense to, you know, pay attention to the local to the local COVID weather where that can really adjust our behavior. Because you know, certainly in places with a lot of spread, I would, I would, I would urge a much higher degree of caution. Whereas in places where cases are remaining relatively low, I think that, you know, not a lot really needs to change at the moment. We should continue paying attention to the data that's coming in, sort of suspending our judgment about what's happening and informing ourselves as much as possible. But in places where cases aren't actively searching, I don't think that I would recommend much of a shift in behavior at the moment. But it's all totally contextual. It's all sort of, associated with what your own risk budget is. And and so the best I can do is say, you know, I'm generally wearing a mask indoors. I, you know, still going to the grocery store, but haven't really been indoor dining as much. Outdoor dining is wonderful right now in this part of the country, you know, so, supporting local businesses you know, a lot of people are having trouble making it through this thing. So like, you know, recognizing that, like we have a formidable Infectious disease on our hands. And we all need to make it through this and all of the different ways we can. So I feel like I'm bringing up a lot of things that we were talking about way back at the beginning of 2020, but this sense of like, to the extent that we're able to, you know, maintaining our solidarity recognizing that some of our actions willing to change, but not allowing that to really drive wedges between us, but instead to make sure that we're taking care of each other. And and. You know, living our lives to the extent that we're able. But also recognizing that there may be. Necessary adjustments coming up.

Matt Boettger: 31:51

Yeah. Great. I love it. You know, I'll put this in the show notes as an an article, just talking about the CDC recommendation and they're kind of tears, which seems a little abstract, but they break it down to basically I can read the article. I could be flubbing this and Steven can agree, but you know, basically between 50 and a hundred cases per a hundred thousand, I think that's considered like the, the high level. And then above a hundred is considered even higher. Those areas are, you know, recommend that you wear a mask endorsed even in fascinated. And then there's the positivity rate, which I forgot what it was, but it's in the article and that's a great way to kind of memorize those and use that as a kind of a baseline and just check your COVID weather. Right. I think, what do you use Steven? It was, it was like some of the New York times or New York something. The great one that you can just check.

Stephen Kissler: 32:34

Yeah, so exactly. I mean, I think the New York times does a good job with data visualization. And so a lot of their maps are openly accessible, even if you don't have a subscription. And so, yeah, so I've been, I've been relying on on at least their data visualizations, quite a bit to sort of, do this, but I think the CDC is now actually providing some of these maps now as well, which is, which is good. Great.

Matt Boettger: 32:55

So check that we can put that link in the show notes. And finally, just in, on a bit of good news, because of all the Delta variant, there's been a surge in vaccinations, which has been great just to see a lot of people tipping over I think 700,000 at some point in time for four straight days this has been great. So that's good news hopeful news. And for those of you are. Please consider it. That is a safe way, and it is a great way to protect yourself and the people around you, which is mutually important, so, and help and share this podcast with other people. If they're hesitant, or if they're just having a tough time, make that decision Stephen and mark do an incredible job of just, just showing why it's important and that it's safe. So, share this podcast with people. You think you may need it. Thank you all. For listening once again, if you want to support us anywhere, anywhere that's patrion.com/pandemic podcast,$5 a month, as well as one time, Venmo, PayPal in the show notes. And if you want to get ahold of us or just send a comment or let us know what's going on in your world, matt@livingthereal.com and I will send that on to Steven and mark have a wonderful week. You guys we'll see you guys next Monday, take care and bye-bye.