Pandemic: Coronavirus Edition

Are vaccinated people as likely as unvaccinated people to spread COVID-19, and the complex cause of COVID hot spots

• Dr. Stephen Kissler and Matt Boettger • Season 1 • Episode 90

Share episode

Can you Rate and Give us a Review in Apple Podcasts?

Please consider financially supporting us for the monthly upkeep and helping hand off some of the editing responsibilities. You can give a one-time donation or become a Patreon member for as little as $5 a month. See the links below. Thank you!

  • Give a one-time gift through Venmo at @mattboettger
  • Give a one-time gift through PayPal here.
  • Give monthly (as little as $5 a month) on our Patreon Page.

Things Discussed on Episode:

Support the show

Matt Boettger:

You're listening to the pandemic podcast. We equip you to live the most real life possible. And the face, these crises. My name is Matt Boettger. I'm joined with my one good friend once again, Dr. Stephen Kissler, an epidemiologist at the Harvard school of public health. Good morning. Fine, sir. How are

Stephen Kissler:

you doing? Hello? I'm doing all right. How are you

Matt Boettger:

doing? I'm doing pretty darn good. Fall is still doing, doing well for us here in Colorado. It hasn't snowed yet when you say super cold cold days. So, I do hear that winter. Might be a chilly day, but I'm loving it. I'm loving it. So

Stephen Kissler:

how's your weather? You know, we finally got fall here too. It was a lot later than it usually is, but yeah, the leaves are gorgeous this time of year. So, yeah, but I'm glad you guys have been getting a good one. I know that sometimes fall last about two minutes out there. So

Matt Boettger:

it does. And we, the older I get, like I said, the warmer, I like it. It's I'll I'll take it. I'll take it. So we have some great stuff to chat about today. Before we get started, we got the usual stuff. If you can leave a review, please do. It's so helpful. It inspires us, keeps us go and you get an apple podcast or some other place as well. You can do them. I have no idea what it is as well as you wanna support us, please do it. Helps us keep this going and keep the lights on that is patrion.com/pandemic podcast, or just a one-time gift PayPal. Then Mo those are all in the show notes. Speaking of reviews, there was a review. So here's the deal. People who listened to us across the waters and different countries. We don't really see them because I think apple like put silos around different countries and their reviews. So we don't see them. So I found one. From Canada. She basically emailed me directly. Let me know that I probably did not see the review left a wonderful long comment. I have yet to send it to mark and Steve and I will, but here is a big thing. I take full responsibility if that's from Canada. And I just don't talk about, we don't talk about Canada that much. And there's been times by which Canada was suffering on a level, very different than the us and probably. It's own guidance and I completely blew it in failed. And I apologize cause I'm the one who brings up the news articles and you know what? I just didn't do it in a week. We definitely want to draw attention particularly to our neighbors, you know, all around the world to, to, to where we can do this, but at least our neighbors to help them out. So I apologize. Thank you for still listening to us and giving us a second chance and we'll, we'll keep that more greatly on the radar. And also here's a great thing. I only have so many hours in the day. This is just kind of a passion project for me that if you are in a different part or a different country, and there's something going on, if you email. Matt@livingthereel.com and kind of say, Hey, this is going on. Can you give it some attention on your next podcast? That makes my life about a thousand times easier and I will definitely bring it to the surface. So here's a tip matt@livingthereel.com. Okay. I think that's all the good stuff let's get rolling. So, let's start with this. This is an easy one. Stephen, I'm going to plant this. I read this article this morning. I had a breakthrough COVID. But this is the article. It was a logistical nightmare from the Atlantic. And I loved it. It was by a gentleman who actually was part of the whole John Hopkins project with the tray, the tracking of COVID. So Amanda takes it incredibly seriously. The reason why I highlight this article, Stephen for the listeners is because not to create a fear factor, but just to the complexity of actually getting COVID because this guy took every precaution was going to go to a wedding and chose not to at the last minute, went into the wedding, into a new Orleans or an N 95 mask in the airport. But of course went mask list to the actual wedding because everybody was vaccinated, even though we know breakthrough cases have been. It gets covered when he gets home. That's not actually the worst part because yeah, he was sick, no big deal. He got over it, but he just explained the logistical nightmare of having now his kids, having to stay home now, having his wife, having to stay home now in quarantine now having to contact all the people he had remote contact with, right? Because he took a PCR test and an antigen test over and over and over, and it was kind of negative, negative, negative. And then finally he started getting the sniffle. And then just when you thought, okay, there's no way I've had so many tests and then bam positive. Right? So it's just the idea of like, I'm just trying to throw this out here that we're all in this together. And man alive is this complicated. It's not just about my own dang health. It's about. 80 double hockey sticks for other people around me.

Right,

Stephen Kissler:

right. Yeah. That's, that's exactly it. I really enjoyed that article too. And I think that it really brings up something that a lot of us have been feeling and thinking, or at least know somebody who's been through a situation kind of like this. No, there, there are two things that come up for me with this with this particular article. And one of them is that that really struck me as interesting is that, so this the author of this article is very well versed in COVID-19 knows an awful lot about the pathogenesis of the disease, about the way it progresses. One of the interesting things to me is that he nearly stopped taking his tests. Before you would expect to turn positive on a rapid antigen test. So, in the sense, you know, the article was saying that like, you know, I'm really glad I took that last test on day five or whatever, because it finally turned positive and it's like, of course, because that's, that's usually the amount of time that it takes you to turn positive. So I think that there's sort of one word of caution here, which is. You can test negative after a potential exposure for a couple of days. And that's, that's kind of expected because this virus takes a while to ramp up in your system. So if you decide to do something similar, if you're going to take frequent tests after you've had potentially some kind of exposure, I would say, try to do so for at least a week. And in this case, you know, if you have a limited number of tests, I think he might've been better off taking one every other. For eight days, rather than taking one every day for four days and then stopping after getting four negatives. And so just, just sort of a bit of practical guidance for these kinds of things. If, if you decide that you're going to do something similar, because I think that's, you know, it's really important. We have the tests now, but there's, there's this real lack of information about how to use them. And so I think that this is one of those key things that now that there are enough tests to do multiple tests after an exposure we need to think carefully about how to use them. And then there's the second point, which I think is really the topic of the article itself, which is, you know, what happens when you test positive? There's one of my colleagues. Somewhat crassly that taking a COVID test to sort of like picking your nose where you have to have a plan for what you do with what you find. And so, and so that's not to say that you shouldn't be taking the test, but you should have a plan for what to do once you figure out what you find. And so a lot of us assume that we'll test negative, but then we test positive and all of a sudden our life is thrown into chaos and rightly so, but it doesn't. A little bit of thought, you know, what does happen when we test positive? Do we have the plans in place? When that happens. And I think that this, you know, this is part of this shift towards having, COVID be a part of our day-to-day lives, where you know, we take all sorts of precautions against all sorts of different, rare, but possible events, you know, we've All of us do or should have a tornado plan and a fire plan. And you know, like what happens in the event that our smoke alarm starts going off and we smell smoke in our apartment. You know, that thankfully it hasn't ever happened to me, but I've thought through what I would do so that, you know, when something like that, I'll know what to do. And I think that this is no different. It's a COVID is still relatively new. So not all of us have thought through that, but I think it's worth having our COVID test positive plan for ourselves and our families because it can happen at any.

Matt Boettger:

That's great, Stephen, and that's kind of what he concluded. Like he didn't think that the whole process of what happens when he gets, when he, when he gets the positive result. Now full credit goes to his wife on this because it's his wife that pushed the things that last engine test. And it turned out positive. Now, a couple of questions. Now I'm out of the loop. I'm in the house. First of all, are the air. These antigen tests clearly readily accessible. Now I haven't bought one yet. And I know what eight months ago we talked about them being like$25, a just one test. Are they much cheaper now or are they going down in price? Are they accessible for the regular

Stephen Kissler:

person? So. Accessible as far as I know. So I actually just went to the Walgreens here in Brookline, Massachusetts the other day, and they had a shelf full of Binaca nows and I bought two boxes, so four tasks. But you're right. Those two boxes ran me almost$50, which is running in my mind a crime. You know, it's like, it blows my mind. Just, you know, gosh, we've talked about this in other episodes, so we don't have to rehash old territory. So they're they're accessible in the fact that you can pick up a box and hold it, but whether or not you can actually afford to buy the thing is a whole different story. So I think that that's an area where. You know, I I don't, I don't have any political influence whatsoever, but I think that, you know, if, if we could find a way to subsidize these tests in any way and distribute them more proactively, like that would be so great. But we're not doing that. So they are, you know, if you have the means they are accessible, please do. If you're able to have them on hand, this is also really helpful for things like Thanksgiving, which I think we'll talk about in a little while. Yeah, but yeah the, the cost is still too high. I hope it will come down in time, but that's what we got to deal with right now.

Matt Boettger:

It came up. I'm sure this exists out here. Well, I know it exists, but I feel like we need to create like a little cheat sheet of a plan of like what to do. When you turn it, when you, when you get a positive result or what, or when you were fearful of, of being exposed to COVID, we've talked about a lot and we've had some great in-depth discussion, especially early on like last March, 2020. We were really trying to figure out how to do this. But even me, it's like, I, we do this every couple of weeks, but I don't have a plan. I'm probably because I have three little boys that keep me so occupied. It's just so crazy to even think about it. I'm just trying to be in survival mode, but it might even be nice to have like a small checklist or.

Stephen Kissler:

Yeah, I, you know, not that I know of. And I think, you know, this, this might be a nice little point of homework for our listeners. I'd be actually really interested to, for people to think through this with themselves and their families. And if you're willing, you know, let us know what you come up with because, you know, I, I'm an epidemiologist. I, I think about these things a lot, but I also, you know, just have my own context. And mark has, you know, young kids, but I don't. And so a lot of the intuition behind sort of what this would actually mean for people in different life stages for people with different family structures, for people who are caretakers for people, with different jobs, you know, there are all sorts of things that I can try to consider, but I'll, you know, it totally fail thinking about all the different cases. So I'd actually be really, really interested to see what people come up with if they think through this. So. Send some along. Maybe we can bring up some of the greatest hits the next couple of weeks.

Matt Boettger:

That's awesome. Okay. You heard this, everyone. Who's listening. We're going to crowdsource this. So let's do matt@livingthereal.com. L I V I N G R E a l.com the in the middle. So I brought that into real, I didn't know how to do my own living the real.com. Check it out. The link will be in the show notes. My email send us your plan. If you have one and we'll crowdsource this, it'd be awesome to see these. Now, Stephen, you mentioned how we've gone from a pandemic and trying to think about how we live with this. There was an article about this idea of question of when does it move from a pandemic to an endemic, can you help guide us as conversation of what is an endemic and how is it from a pandemic? And are we close to that or not even close to that?

Stephen Kissler:

Yeah. So. The difference between a pandemic and an endemic in some cases is an arbitrary choice. So the unsatisfying answer, we can think about this on a lot of different levels. So I think probably the most scientific way to think about it is that a pandemic illness like COVID-19 becomes an endemic illness. Once it finally settles into something like a consistent long-term pattern. So that's why we don't normally think of seasonal flu outbreaks as a pandemic disease, even though flu spreads around the world on every continent every year. So in some senses it is a pandemic, but it's settled into this very regular, fairly predictable pattern. And so it's helpful to have a different term for that kind of thing. So it's steady, it's regular. So for flu, we have seasonal, you know, annual, usually wintertime outbreaks in temperate regions of the globe. And so I think the expectation is that we'll probably have something similar for COVID where we'll have this fluctuation in cases probably higher during the wintertime in temperate parts of the globe. And once it sort of settles into something that is more predictable or at least more similar to other respiratory illnesses, we can say that it's transitioned into its endemic state. But I think there's still some questions to answer there. And this is, this is actually something that we're beginning to look into right now in our modeling and sort of what does this off-ramp to some extent look like I'm so sorry. Kofi two is it is a respiratory virus. It's a coronavirus. We have other Corona viruses around, but it is also kind of odd. It's it's very infectious. The Delta variant is. Super infectious relative to a lot of the other respiratory pathogens that we have around. And my hunch is that it might be infectious enough that unlike flu, where we see very, very low levels of transmission over the summer and much higher transmission over the winter, it's possible that We may actually see sort of sustained transmission over the summers and probably increased transmission of the winters. But it might be a lot more sort of constant over the course of the year, just because the seasonal effects doesn't really have as much power against something that's so contagious. But we haven't crunched the numbers yet to see sort of how likely that is, but that's, that's something that we're working on now. So all that is to say that there are sort of some ways to get an intuitive sense for how the transition from pandemic to endemic looks. But really ultimately it comes down to sort of a semantic choice for when we've decided that that we're going to start changing our treatment of COVID-19 like a Sort of a one-off crisis to treating it, like something that we're living with for the long-term. Yeah.

Matt Boettger:

Now curious, going back to way back March, 2000 with your famous publication, right? Sorry, everyone that everyone's reading, everybody was reading. Now you gave different models, you know, did one of those fit this particular scene or was this one of these where like, oh my gosh, this was now with Delta. This kind of threw off some of the modeling of what we see now, kind of the next, I don't even know if your model went beyond, you know, four or five

Stephen Kissler:

know. Yeah. So, so the first part of the model did go out about five years and and actually sort of the last and what we thought was going to be the most plausible situation. It turned out be a pretty good reflection of what we're seeing right now, where we sort of have this sporadic transmission for roughly two years. And then after two years, it's likely going to settle into sort of a more seasonal kind of winter. Thing. But Delta did really throw a wrench into this thing. You know, when we were building that model, we were thinking of things with a reproduction number of three, or like heaven forbid maybe up to four. Now Delta is easily up to six, you know? And so, it's like far more infectious than frankly I ever expected this virus to become. And so despite the fact that our project. I have held relatively accurate up to this point. I do think we need to rerun the numbers for Delta. And so that's, that's the situation we're in now. Yeah.

Matt Boettger:

Now, speaking of which, now this, this other article, I don't know if say the name Dr. Gottlieb or leave or whatever. He in this article says coronavirus pandemic could end in the U S in January. That was a startling title, especially now we're in talking about it in the second being in Colorado right now, where cases are just really high. And mid November is seeing the pandemic ending early January seems unfeasible to me in my state right now. What do you think of that article? And what's being talked about of the pandemic. Ending relatively soon in the U S particularly.

Stephen Kissler:

Yeah. So, full disclosure, I haven't read Dr. Gottlieb's article on, on this, but really I think that like the, the answer can be sort of yes and no, where, I could see it making sense for practical purposes to say roughly around January, I would actually put it a little bit later, but maybe by the end of the, you know, by early spring to say that we're okay, we're out of this pandemic period, and we're now treating, COVID-19 like an endemic illness, but I think that really has a lot more to do about our orientation towards the virus than about something inherent about the virus and its spread. Now there's, there's some caveats to that in the sense that you know, by that point, Many people, at least in the U S We'll probably have gotten a booster vaccines if they would like them. Many other people will have been exposed multiple times. So by that point, we also will have built up a decent amount of population immunity that will probably protect us from having the same sorts of surgeries on hospitals that we've seen. And in fact are currently seeing in places like Colorado, unfortunately So, so I think that that is largely what's behind it is that there's sort of this two-fold sense that first population immunity will likely protect us from the high rates of hospitalizations and deaths that we've been seeing. Although there will still be those things to contend with just maybe not at the same rate and second, that it will probably make sense for us to shift our own orientation towards the virus, towards these long-term sustainable things that will help us live with the virus rather than sort of these more acute measures. That made a lot more sense when we were thinking about a short-term crisis, but not when we were thinking about sort of our longterm.

Matt Boettger:

Great. Great. Well, let's talk about Colorado now because we're kind of segwaying into this. So Colorado, the hospitals are really getting to the point of being nearly overloaded. The last I checked, there was an article about over 90% occupied in many hospitals. I wish. To chime in, sent him a text last night. Don't think he's been on the COVID rounds too recently, but he did mention on the texts that there were constantly talking about what to do when they get to the threshold and what are the, what are the different options alternatives? So this is definitely something in the forefront of even Mark's mind right now. So thoughts and prayers for Colorado, the hospitals and all the care workers there. We really appreciate it. Now, one of the things I want to chat with you about is governor Polis. One of three states because of our crisis right now, because of what's going on and because of the infection, really getting out of control in many areas. And this is where I want you to talk about what you talked about, me off the air about this other website and how it's connected and seeing the Chinese waves being percolated in different places and where they, where they started. But first, before you get into that first mentioned, Governor Polis gave this emergency order of offering boosters to everyone 18 and over only three states have done this think California and Colorado. And I don't even know what the third one is. He may know. First of all, what do you think about that? It's kind of going against, I guess, FDA and CDC guidelines. I know this is probably like a fourth down in punt and to, to help our, our state. What do you think about that? And then just talk about how you're seeing. Your perspective, a lot of our crisis in light of the history of the kind that this, this, this, this fourth wave or whatever number we're on at this point in time.

Stephen Kissler:

I have no clue. Yeah, I know. Yeah, so I think that this, this makes a lot of sense. There's, there's this interesting thing. With infectious diseases like COVID-19 where preventive measures, interventions It matters an awful lot when you use them. And so right now, you know, Colorado is in this sort of state of emerging. I don't know. I don't know if I want to call it crisis, but definitely, you know, there's, they're thinking about crisis measures at hospitals, you know, they're trying to figure out where to put people because there are so many people coming into the hospital. So, So I think that it, it makes an awful lot of sense to respond to that. And and one of the best ways we can do that is by recommending vaccination. So we know for sure that booster doses can increase a person's antibody levels hugely in the short term, and also cause them to be more sustainable. And we're coming into a time of year. Would we know respiratory diseases are a lot harder to manage anyway. We know that Colorado's cases are increasing. And in fact, cases around the country in many places are increasing. And so, you know, now is the time if we wait too long to do this, we will have sort of missed the boat. And a lot of those infections that could have been prevented will have already occurred. So I think that there's a lot of latitude, especially given all of the evidence about the safety and efficacy of these things. You know, the reason they haven't been recommended yet is not. We don't think they're necessarily safe and effective for everyone. Otherwise we wouldn't be giving them to the more vulnerable groups already. It's just that we want to make sure we have the doses for those people. But in places where cases are really surging, we really want to build up population level immunity as much as we can. So, you know, so definitely thoughts, prayers, masks, and vaccines altogether, please. That's, that's what we need for our healthcare workers right now, especially in places where cases are rising now. So there's this interesting point where like, okay, so, so we're in Colorado right now. Cases are spiking. Y what's going on there. You know, in fact, you know, there've been a lot of reports about Vermont, which is the most highly vaccinated state in I think they're the most highly vaccinated state in the country. And certainly in the lower 48. And there's seeing a major spike in cases right now, too. So, you know, what, what gifts So, so let's take a step back. And so I guess it's kind of Storytime now, but you know, so we've been hearing an awful lot of recent months about cases in the Southeastern us. We've been talking a lot about Florida, about Louisiana, Alabama, Missouri. And there was this really hot bed of cases, especially in July, August sort of leading into September in those states. And there were a lot of, there's a lot of commentary that frankly made me pretty uncomfortable saying like, ah, you know, vaccination rates are so low, these states are sort of seeing the outcome of, you know, low vaccination rates and open communities. And, you know, this is sort of the way that things are, you know, that that's, that's the consequence of these decisions that these places have made and, you know, yes. Yes. Like, of course the more susceptible people there are in the population, the more likely you're going to have cases, Florida has the especially difficult problem. If that their average age is just a lot higher than the rest of the country. There's a lot of older people living in Florida. And so by nature, they have higher risk of people going to the hospital. And it's true that that many of the Southern states have had sort of more open policies and less masking than many other places, but that's, there's this real, real danger in making an observation and then providing a post hoc explanation for it as if it were, you could sort of. In for a causal relationship between X and Y in this really nice, nice, neat way. And what this is getting at is that, so I've been spending a lot of time with this brilliant website. That's called COVID estem.org. That's COVID E S T I M dot Oregon. Maybe we can at, in our show notes. Yeah. And so essentially what it is is it's a team of researchers who are doing what we call an epidemiology. Now casting. So we know about forecasting. So you can forecast the weather. You can look slightly into the future to sort of understand what's happening, but in the context of COVID. Just looking at rock case counts, doesn't actually give you a super accurate picture of what's going on. You need to apply some amount of interpolation and mathematical analysis to account for differences in testing rates and for differences in behavior to actually infer what's underneath the surface. How many cases are actually there given the cases that we observe? And that's the question that now casting aims to answer. And so what this group has done is they've done now casting at the county level. Across the United States since the beginning of 2020. And so what you can see is there's this, this nice figure where there's this timeline with a little bar that you can sort of scrub back and forth, and you can see these waves of infection spreading around the country. And one of the really remarkable things to me about this is that you can see these very clear waves. They look like ripples in water that are spreading and especially these things happen in the winter. So last year, We have this very clear ripple of COVID-19 infection that started basically in the Dakotas and spread outward. So that was really where our winter wave got started. And there was just this very clear wave of spread this winter. It looks like we have the same sort of ripple phenomenon, but it got started in the Southeastern states. And now it's just spreading across the entire. Now, this sort of phenomenon is not unique to COVID-19 either. This was, this was actually the subject of my PhD dissertation, where we were looking at exactly the same kind of spread patterns for the 2009 H one N one flu pandemic. So this seems to be the case for especially transmissible wintertime, respiratory viruses where we've seen this phenomenon happen again. And again. And so the difficulty here is that at any given point in time, you can apply this post hoc explanation for why this given community is suffering high cases at this given point in time. But really, I think that that's, that's a pretty sort of narrow sighted explanation because it doesn't account for the fact that infectious diseases spread and respiratory infectious diseases like COVID-19 spread in this really curious geographic way, such that anywhere that has high cases now, Yeah, it may well be that it's just their turn. It may well be that Delta was just introduced into the Southeastern states earlier, and maybe it was able to gain a foothold easier because of some of these things. But now, you know, we're in this context where a lot of people were saying, you know, okay, well, it's, it's vaccination rates and it's, it's open societies, but now how can we reconcile that with what's happening in Vermont, for example. And the fact is that part of it is just that it just took that much time for the disease to spread that. Now, all of that is not to say that the vaccines are not effective because one of the really good things about Vermont is that these cases are not translating into hospitalizations and deaths at nearly the rate that they have in many other communities that have lower vaccination rates. So definitely vaccines are preventing a lot of the worst outcomes from the virus, but there's still an awful lot of spread. And I think that that's a really important thing to bring up because. It just gets at this complexity of that we really just can't draw these clean, clear narratives of why a given place has high cases at any given point in time, because this is just the, this whole situation is just far too complex for that kind of simple. Excellent.

Matt Boettger:

That was great. That was incredibly helpful. Yeah. That's, it's kinda like one of those things where it, so it just, it's incredibly infectious disease. It's going to land somewhere and it's going to be in this spread. It doesn't mean that wearing masks and, you know, distancing when you need to is not always, it's a pointless operation. It's incredibly important. And it's just that when these things happen, how much do you want it to flare up? Do you want it to just overcome it and golf and entire state, or just maybe, hopefully. Have some collateral damage and we can have some level of helping this thing. So thanks for that. And we'll put that in the show notes as well. This leads to the next issue. Would you kind of already talked about this and this is the idea of, okay, so Colorado is a perfect example. We're in kind of this mode by which we're in, we're seeing a highly increase in infections and infection and hospitalizations. And so the response. Let's get a booster. Right. And then you have these wave of articles saying here and there that vaccines aren't any different when it comes to the spread. Of the virus then being unvaccinated. Now there's lots of research on both sides. This article really helped me. And I want you to talk about this because it was probably two or three episodes where you talked about this and a little bit more detailed to help us out. So you can make, pull from that and bring this in. And I'm going to go back and says how easily can vaccinated people spread. COVID-19. And so there was a lot of great things about this, this article, but basically what it started with is that there are a number of articles that show in research that show that, okay. It seems as though vaccinated people and unvaccinated people may have the same viral load. So then, then the logical conclusion is okay, well then they spread it. The same, but we see evidence. It's not the case that, that unvaccinated people in vaccines differ that there are still, even if they do have the same viral load that vaccine people still spread it less. Can you help in light of what you talked about a few weeks ago, helped bring this into full focus of why that might be. Yeah.

Stephen Kissler:

Yeah, so this was something that I, and, you know, my close colleagues had been thinking about a lot. And in fact, our, our study is one of the ones that documented those equal viral loads between vaccinated and unvaccinated individuals. So, so here's the way that I understand it. Right? So there, there are multiple things that have to happen for SARS. COVID two to spread from person to person. So imagine. One of whom has the possibility to spread to another, but currently neither of them are infected. So person a and person B. So for a person, a spread person, B person, a first has to get infected. They then have to interact with person B while they're producing enough virus to infect them. And the virus that person they have met has to be healthy enough to infect a person B it has to sort of be. You know, high octane, SARS, cov two, it doesn't want to be living along, you know? And so all of those things need to be in place. And the good thing is that vaccination helps reduce at least, I dunno, how many of the things that I said, but I'm going to say that there were four, it helps at least three of the four things that I meant to mention just then. So I'll, I'll go through that. Right. So, so first vaccination definitely reduces the probability that you get infected in the first. Which is great. And that's one that I think doesn't receive nearly enough attention because we can really only look at transmission between people who are already infected. But the fact is that vaccinated people are a lot less likely to get infected in the first place. And so that is sort of the first first barrier that goes a long way towards reducing spread among vaccinated. But vaccinated people do get infected. You know, there are plenty of breakthrough infections that are happening, especially with Delta. And as I mentioned, you know, our study and many others suggested that people who are vaccinated can produce just as much virus as people who are unvaccinated. So what does that mean? Well, first it looks like people who are vaccinated clear the virus more quickly, so they're probably not producing that level of virus for quite as long. So that means that They're less likely to come into contact with another person when they're producing that high level of virus than if you were unvaccinated. So that reduces the probability of onward spread, just because there's a shorter window of time when you're capable of spreading the virus. In addition to that, there've been other studies that suggest that in vaccinated people, the virus that they do produce is less viable. It's less likely to spread an onward infection because. Either it's coded in antibodies or it's already sort of like broken down. I think the important thing to point here, point out here is that usually when we're measuring amounts of virus in a person who's been infected, we're not actually measuring amounts of virus. We're measuring copies of viral RNA. And so. What can happen is that the immune system can be effectively attacking the virus, which basically means, you know, chopping it up into little pieces, but there's still going to be that viral RNA, that genetic code circulating in your body that is correlated to the amount of virus that was there, but isn't there anymore because your immune system is giving this effective response. And so we can say there's similar amounts of virus, but really what we're saying is that there are similar amounts of viral genetic material in your. And just because there's similar amounts of viral genetic material doesn't mean that there's the same amount of viable virus and that's something that's been pretty well established that if you actually look at whether or not that virus is able to grow either in culture, in the lab or to cause onward infection, it's, it's substantially less likely. In a vaccinated person then in an unvaccinated person. So there are all of these throughout the pandemic. We've been talking about these layers of protection, right about distancing and masking and ventilation and vaccination, and you know, all of these other things. And the nice thing about vaccination is that it is in itself, this multi-layer approach towards preventing onward transmission. So at each stage, it sort of introduces this extra barrier for virus to spread and that makes it so that vaccinated people are less. Of course, they can still spread the virus. We see that all the time, but definitely at a lower rate than unvaccinated people for all of these reasons. Great.

Matt Boettger:

That was awesome. So succinct, incredibly helpful. And let's get in then let's land the plane with Thanksgiving because this is probably on the mind. This is related and. Are my family vaccinated and how what's the chance of having a breakthrough of coming. But before we get there, I want to share, I'll put the link in the show notes. I copied this image, so you're going to get it like a link. That's my own link to see it. But I'm going to come back to this in a couple of weeks. It was a great image of basically how airborne illnesses can be prevented in our home, which I think is something we're thinking about when it comes to the holidays or having people over, because I've been just thinking about this for over a year now, off and on about like, how can you measure to what extent your house is healthy. As bad as much as you can see, clearly the caveat is there's no way to have a hundred percent free error and transmission inside of a house, right. Or even outside, but within your control, is there a way you can measure? And I loved this image and you can speak to it briefly as well about this idea of like, I didn't know that an easy measure is CO2 level. So if you have something to measure your CO2 level in the house, that there is a, there is a correlation between the level of CO2 and the amount of inhaled are particles of somebody else's exhalation, right? And the more you can reduce the CO2 level, the closer you get to outdoor air, which makes it healthier. So this is ice to me. I love this image. It's helpful as we prepare for things. To think about whether you have something like this can measure about how to achieve something in like an outdoor air ether. You're going to have a large amount of people in your house who may or may not be unvaccinated. So is that this CO2 level, a good measurement for helping to see whether the house is a little more conducive?

Stephen Kissler:

Yes. Yeah. Yeah, exactly. I think that, you know, CO2 is really the the best, the best measurement that we have available for measuring Recirculated air in an indoor space. And you know, people in industrial design and home design, I've been doing this for, for a very long time. And it's really been picking up through in a public health perspective with researchers like Joseph Allen here at the school of public health. Who's, who's really sort of thinking about how do we make our built spaces healthier. And so he's been thinking an awful lot about these kinds of things. So I think this is, this is great, you know, CO2 levels really do help us give a sense of, you know, how. Eh, how much air is being rebreathe within an indoor space. And so, you know, if, if you happen to have some sort of CO2 meter it can, it can help you see, you know, how, how your indoor air is being research-related. And I think, you know, I wouldn't necessarily recommend everyone to go out and buy themselves a CO2 meter before. But yeah, I think that like, keeping this in mind that like, you know, that that's sort of the target, you want your indoor air to be like outdoor air to the extent that you can. And and I think that that's a really good target for ventilating, and we know we can do that by cracking windows by about six inches. I know it can be chilly in some places, but it really does go a long way towards clearing that air out. And that seems to be one of the single most important interviews. That really makes spaces a lot more safe together. For for Thanksgiving, I've really been recommending that people you know, first, if you can take a rapid test in the morning of before you see people and second crack your windows by six inches. And I think if you do those two things, you're going to really reduce the odds that there's a major outbreak among the people who you may be hosting in your home. Now one caveat with the CO2 measurement is that you know, a lot of people I know have purchased these HEPA air purifiers. And so they have you know, the, the things that sort of clean the indoor air those things aren't going to remove CO2 from your air, but they will remove the droplets and the particles that contain SARS. COVID two virus. So. If you have one of those things running, your CO2 levels might increase and that might be alarming. But that doesn't mean that those things aren't doing their job because they're doing something different. And so that's why the CO2 levels are a good proxy, but they're not, they're not perfect for understanding exactly how much virus containing air or potentially virus containing air is circulating in your household, but it's still.

Matt Boettger:

Sure great. That's helping yet. We just started getting a couple of air purifiers ourselves in our house just to have on hand, just in general distill we have people over. We can have it on. It's definitely not going to be a cure all, but just, just a, and they're not that expensive. I'm surprised you can get a HEPA filter for a hundred bucks that can really do a great job for a decent little room. So,

Stephen Kissler:

I think you mentioned there too, you know, as. As a Colorado native, another thing that these things can really help with is wildfire smoke. So, if you buy these filters for COVID, you'll be able to use them in the summer to, for, and for cleaning your air as well. So, it's a good purchase. Yeah. I feel

Matt Boettger:

like that probably rings on the ears about, about everybody in the Western us, just given, given, given this past summer how bad it's been. Great. Thank you for that. That was so, we talked about the Thanksgiving, you know, this is like a hard decision because I know friends and family, there's invitations being put on, it'll put all over, you know, what would you say to someone who's like, okay, you got the invite from aunt somebody, or uncle somebody or grandma, like, by the way, you know, Somebody coming over and they're unvaccinated, or they're flying in from X, Y, and Z. They're going to be unvaccinated and they're going to be unmasked and feel free to come over. If you want to. And these tricky situations, what do you propose in these? I know this is probably a bomb put on you because it's a very gray, gray area, but what do you kind of begin to propose in these difficult situations?

Stephen Kissler:

Yeah, I think that it. The way that I like to think about it as in terms of a risk budget. And so, you know, it's easy to get into this mindset of saying, you know, this behavior is safe and this behavior is unsafe. So, you know, I will only interact with people who are vaccinated or I'll only interact with unvaccinated people indoors when everyone is masked. And that's, you know, that's admirable. But I think that we can be a little bit more flexible with ourselves. So depending on, you know, your underlying risks your own vaccination status and to the people who you regularly interact with I think that there's this opportunity to think about risk on sort of a weekly or even a monthly basis and say that like, you know, I, for example, I don't have a lot of close encounters with people indoors. I just haven't been doing that much. And I haven't really missed a lot of the things where I used to do that. I have, you know, I, I definitely am having, you know, so I, you know, I've been going to church and so their encounters with people indoors, wild masks, we still have a mask mandate here in Brookline. And so that's part of what we've been doing. I go into the office sometimes again, everybody has masked there and vaccinated And so essentially, you know, from my point of view, I'm, I'm living a pretty, pretty cautious life. And so essentially what that does is in my risk budget, that can kind of buy me a little bit of slack, where for a day, for example, on Thanksgiving, I might be able to interact with relatives who are unmasked and VAX unvaccinated, and who have been traveling because I've been sort of counteracting that risk in so many ways over the different parts of my money. And so, you know, it's, it's not perfect, but I think it is a helpful way of sort of thinking about how to be a little bit more flexible with ourselves and to recognize that there are some times, you know, these one-off things where the ability to have community and to be with people in a setting where there are fewer barriers to our communication. It can be really helpful. It can be really valuable, especially on days like Thanksgiving. And so I think that there are ways where we can sort of step a little bit outside of these strict boundaries that we've set for ourselves in our own behavior and recognize that we can be a little bit lenient with ourselves. Again, to the extent that we feel. Safe. So again, you know, the things that can sort of complicate this, of course, as if you yourself are immunocompromised, or if you're caring for a very elderly relative or something like this, I think that that forces you to sort of, you know, maybe you have a smaller risk budget then. But you know, that that budget is just something we all have to sort of assess for our. But I think really what I want to communicate here is that there's the possibility to be sort of lenient with our behavior and to use different rules at different times while still sort of under this umbrella of sort of this overall sense of how much risk I'm spending.

Matt Boettger:

That's great. That's really helpful. Now I'm going to go back to booster for a second because I didn't didn't which is, again, we mentioned Colorado is one of the few states that can have a booster. So this is probably a luxury question given that this, this podcast is all around the world. People listen to it and maybe somebody who's not even not even accessing. First I know. So I feel really awkward having this conversation, but we do have the opportunity to have a booster. Now, the question is when do I get it? Because it's like, I'm clearly over the six month window. So technically I'm available, but there's decisions that are going into my, in my mind. I'm like, okay, so I can get it now. And then I feel good, right? That there is a surge going on right now. The winter seasons on the rise sounds like a good time. But what if we decide to go on a vacation in June or something like that, and you know, that's like another six months away and should we like balance this act of waiting a little bit longer? Just so that, to ensure that that booster is still has its prime for our vacation in June, even though I would imagine it to be a different ball game, unless there's another variant, of course, that comes out, you know, back in June. Should I get it now? How do I weigh this? But then. Make this even more complicated, you even mentioned Stephen way back when that after a while, there is a chance by which you get these boosters and it starts having longer, longer longevity because everything's starting to equalize and you know, the virus starting to find its stability. The number of boosters is starting to really create a stability within your own immunology. And so now you just don't need those boosters as much, you know, so lot of all of this is this something that I should wait on. We're just getting now, do you think?

Stephen Kissler:

Yeah, I think that you know, my sense is that it's probably not going to matter too much either way. And so, and part of that is just because it's while we have a pretty good sense how the, the timing of the immune response on average, across large populations, When you try to understand that for any single person, it's really hard. People can be all over the shop and how quickly they develop a response, how durable that response is, how high that response is. And so, you know, we can, we can sort of adjust our strategy to give us the best chance to have the highest degree of immunity at a given time in the future. But as far from a guarantee that that your own immunity will necessarily be maximized at any point in the future. But I think the most important thing here to consider is that so first I expect the booster dose to have much longer lasting and unity than the first two doses that we got of the MRN. Simply because the really mostly because of the distance, that how much time has passed that oftentimes spacing out vaccine doses for whatever reason, the immunologists can tell you the reason, but I can't, but either way we know for sure that spacing out doses does help give you a longer lasting immunity in most cases. And so I expect that to be the case for these boosters as well. So translating what we know about second dose of know. To booster immunity in terms of the timing, probably just doesn't really pan out for me. The most important thing is that if you have the opportunity to get boosted to do so before you expect there to be high levels of transmission in your own community. And so, for places in many places across the U S you know, that means trying to get yourself boosted if you're eligible Really now, you know, as soon as you can, because we're, we're coming into the wintertime respiratory illness season. And so, you know, there's, there's a decent chance that, you know, by the time you go on your trip in the spring or, you know, early. Okay. Suppose we've got to be pretty low anyway. And so, you know, you'll, you'll have the high level of immunity, but actually you'll have potentially a lower risk traveling than you do, going to the grocery store here, you know, during, you know right now. And so, so I think that bearing those two things in mind is really important. So yeah, but that said, you know, if you wait a couple of weeks, Probably won't hurt that much either. You've already gotten two doses of the vaccine, getting your booster will definitely help. But I think that's sort of why I would say that. You know, don't, don't wait a super long time, but if it makes me feel a little bit better to wait a couple of weeks, I wouldn't fuck you. Good, great, great.

Matt Boettger:

I will. I'm excited to get it. Thanks Stephen. So I think the last thing we'll just touch on briefly is, I don't know if we mentioned this because it was two weeks ago. And if the kiddos were available for their vaccine officially, then it might've been right on the cusp. I forgot, but it's out. I don't know if you've heard anything about it lately. haven't seen a lot of Facebook photos of my friends and they're getting their kids vaccinated and it's been awesome. And I'm excited about this opportunity for my own, for my own boys. And any updates on how that's fairing or anything on your end of it's been going well and whether anything has been

Stephen Kissler:

side effects. Yeah. It seems like they're rolling out, which is great. I have not heard, you know, sort of consistent with the fact that kids tend to have fewer disease effects from COVID-19. It also seems that there, you know, dealing with the shot better than, than many of us old fogies. And so, I got flattened by my second dose for a good day. And so, yeah, so I think that it's, it seems to be pretty well tolerated. I haven't really heard any, any issues. You know, that's not to say that there haven't been, you know, like certainly there are allergies. You know, all of the things that have gone along with, along with vaccination, but those so far seem to be at very, very, very, very, very, very low rates. And so I'm really excited to see this, especially now, you know, we've, we're coming into the holiday season. And I think that having a lot of kids vaccinated can be really helpful towards keeping everyone safer from the spread of COVID-19.

Matt Boettger:

Yep. Absolutely. We're all for this and hope we can get the kiddos vaccinated. Obviously the risk for them is incredibly low, but like we said, we're all in this together to keep the variance down to hopefully zero. That'd be wonderful. And to keep those who are immune compromised, healthy, and safe. Thank you all for listening to this episode of the pandemic podcast. Again, if you leave a review, please do at apple podcasts, we greatly appreciate that. As well as. Give me an email, matt@livingthereal.com. If you have questions about your country, wherever that we're missing, we're ignorant of send us an email. We'll look into it. We'll bring it up in the next episode. And as well, if you can support us patrion.com/pandemic podcasts,$5 a month or so one-time donation, Venmo, PayPal, all in the show notes, have a wonderful week. We'll see you, I guess, after Thanksgiving break for the U S so have a wonderful Thanksgiving, Stephen, and we'll see you guys or. All really, really soon take care and.