Pandemic: Coronavirus Edition

The Pareto Principle strikes again ... super-spreader style

October 05, 2020 Dr. Stephen Kissler, Dr. Mark Kissler and Matt Boettger Season 1 Episode 45
Pandemic: Coronavirus Edition
The Pareto Principle strikes again ... super-spreader style
Pandemic: Coronavirus Edition
The Pareto Principle strikes again ... super-spreader style
Oct 05, 2020 Season 1 Episode 45
Dr. Stephen Kissler, Dr. Mark Kissler and Matt Boettger

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Show Notes Transcript

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Please consider supporting us to pay off all the equipment and software we had to purchase to pull this podcast off quickly without sacrificing quality! We are looking for $225 of one time donations this month to pay off our remaining "equipment bill." Thank you! You can do that in two ways:

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[00:00:00] Matt Boettger: [00:00:00] You're listening to the pandemic podcast. We equip you to live the most real life possible in the face today's crisis. My name is Matt Bogard. I'm joined with my two, three, two good friends. I can't even count right now, dr. Steven Kissler, an epidemiologist at the Harvard school of public health and dr.

[00:00:15] Mark Kissler, who was back from the university of Colorado hospital. How's it going guys? Good to have you back. 

[00:00:21] Mark Kissler: [00:00:21] Good. Good to see that. How are you doing? It's great to be here. 

[00:00:24] Matt Boettger: [00:00:24] It is awesome to have all of you guys back. It's fun. It's like we're in our little, little, I said we're like a little nest. I feel safe when we're all here together.

[00:00:32] Mark Kissler: [00:00:32] I like the border. It's a soothing blue border. And then this new app for good.

[00:00:39] Matt Boettger: [00:00:39] So, so for those of you, you who are not able to tune in to two, why two mic on our live streaming, this we're talking about, you can't see it. You're just listening to us. So we have a new, cool border. We had this sweet intro.

[00:00:53] That was pretty fun. It was revving Steven up. I think he's already like dance and that kind of stuff. but all the reason why. [00:01:00] You can try to subscribe, help bed, help us. We're trying to raise 225 more dollars. You can do that at Venmo PayPal on the show notes. Or if you do as little as $5 a month, you can do that to podcast.

[00:01:13] So. I think that's all the good news. Please give us a review. You can do that. We've had a lot of great reviews. It helps us feel supported. We get emails. I just forwarded some to Steve and Mark. Sorry about the delay from Tina again from Cypress, from Bruce, from us Australia. We'll talk about that a little bit.

[00:01:28] We love the feedback. It's so good. Great to hear how people are doing and just to hear that you're still alive. That's just really nice. It was just to get those emails, get those touch points that, we love it so far ago. We haven't heard from you in awhile, mr. . So we'll hopefully hear back from him. but I think that's it.

[00:01:42] How are you guys doing so Steve Mark, it's been a couple of weeks. How's hospital life. What's going on. How's the whole, how's the whole transition of hospital. Going to school family. How's that going for you? 

[00:01:55] Mark Kissler: [00:01:55] Well, we're doing everything. So kids are back. they're doing five day a week school now. [00:02:00] we, I don't know if we talked about it in a previous episode, but they had a quarantine, procedure that we had to do for one of our kids.

[00:02:06] Cause somebody that was in casual contact. With her tested positive. So her whole class went home for two weeks. but that turned out okay. And nobody else got it. and then, you know, we've been doing fine. We had our, one of them, one of the kids got Cova tested, about a week and a half ago. cause she had her first runny nose since 

[00:02:24] Matt Boettger: [00:02:24] February.

[00:02:25] Oh man. It's so 

[00:02:28] Mark Kissler: [00:02:28] well done. So little stuff, but they're doing great and it's, it's good for, it's nice for them to see other people and to, you know, to be back in the, in the swing of things. So I really liked that for them. hospital life is, you know, status quo. we're kind of just. Trucking along.

[00:02:43] I haven't been on a COVID service for a few weeks now. It's been a, it's been a bit because unfortunately it right now in Denver, our census, so the number of hospitalized patients with COVID is still relatively low. It's been staying. Relatively steady, even since I would say beginning of August or [00:03:00] so.

[00:03:00]and so even though we've had some ups and downs on our case counts, especially most recently we've seen an increase the statewide cases. so far, at least in the hospital side, things are, are going steady. 

[00:03:12] Matt Boettger: [00:03:12] Great. Steven. How about you how's life as a scientist right now? 

[00:03:18] Stephen Kissler: [00:03:18] Oh man. It's I mean, whoever thought that working from home could be so exhausting, I'm wiped out, but, yeah, I mean, I, just, just kind of carry it on right now.

[00:03:27] We're we're. Just pushing another project forward at the moment. looking at the, basically just how the amount of virus in your body changes over time and how, how much variation there is between people. And I think we'll probably actually talk about that a little bit on the podcast too. Okay. but yeah, just doing that and then trying to get outside and see the leaves when I can.

[00:03:46] It's, it's beautiful up here in the Northeast and the fall. So, that was something I hadn't appreciated before I moved. So just trying to do my best to stay sane. 

[00:03:54] Matt Boettger: [00:03:54] Now we just realized let's do another campaign to raise thousands of dollars for cameras to just sit [00:04:00] outside your window so we can watch the leaves in Boston while we're actually, I think it's a worthy, worthy expenditure.

[00:04:07] Don't you call it bank.

[00:04:11] Stephen Kissler: [00:04:11] That's the Patrion list. 

[00:04:13] Matt Boettger: [00:04:13] Well, yes. Well, let's 

[00:04:15] Stephen Kissler: [00:04:15] get it. 

[00:04:16] Matt Boettger: [00:04:16] No, we're not yet. That was just a joke. So please, we're not betting that crazy. Well, let's get started. We had lots of tag. Well, we don't have that much to talk about, but we have some good stuff to talk about. A couple of few things, be a little bit shorter of an episode as you guys could probably imagine those of you who are listening that we're definitely.

[00:04:33] Kind of in the throes of COVID and news is a little bit sparingly here and there, but it's where there's some good stuff still going on. I wanna start with you Mark. At first we talked about off the recording about this Regeneron. I don't know if sane from saying the word correctly. but I first, I didn't know if it was new.

[00:04:49] You're telling me that necessarily isn't necessarily a new thing. If you want to talk about regenerate a little bit, especially you were talking about this as something that maybe president Trump is, is taking as an experimental drug, and then just lump that [00:05:00] in with everything else that we're talking about.

[00:05:01] How, I've been hearing from the media that, you know, he's on REM disappear, which I think that's normal. And then, some people say he's now on the steroid, which oftentimes doesn't happen till later. So now he's put on earlier. Does that mean anything? Have you experienced with this? So. Talk about all that context.

[00:05:19] Mark Kissler: [00:05:19] Yeah. Yeah. I mean, I think the big, the big news and the big new thing this week is the, this for, you know, this is the week that president Trump was diagnosed with COVID. So I don't think we've, you know, the last episode was prior to all of that, Shifting. And so, in, in the time, since we've, he has been hospitalized at Walter Reed medical center and there's been some reports, it sounds like in the reporting has been, it's been a little bit hard to, to exactly judge and without knowing, you know, exactly what's going on, but it sounds like he's doing pretty well.

[00:05:49]and may have been on some supplemental oxygen at some point, but we're not totally sure based in, it sounds like, you know, there's been a little bit of mixed, so doing, from. The doctors [00:06:00] there and then some of the white house, folks about what's going on. Exactly. but all accounts seem to show that right now he's in a relatively mild, phase of the illness.

[00:06:10] So, we were talking about the different. Types of treatment, and situating it in the context of what he's getting. So, you had asked about this Regeneron trial, so there's, there's a big trial going on, that is randomizing patients to several different studies, or sorry for several different treatments, versus the standard of care.

[00:06:29] And one of the things that patients are being randomized to as these, this cocktail of antibodies, and so w. What the antibodies do. So there's different ways, again, that we can address the effects of the Cove infection. one of those is giving antibodies. So we tend to think of our own immune system being responsible for producing the antibodies to fight an infection, but we can produce antibodies, human antibodies in a lab.

[00:06:54]and then give those to people as sort of bypassing that step of the immune. Response. [00:07:00] and so that's what this, this subset isn't it, it does look like, president Trump is getting one, getting some of these antibodies, despite the fact that they're still under investigation. so that's an interesting, feature of his treatment.

[00:07:13]he is also getting rammed as severe. So that blocks viral replication that is, pretty standard of care at this point for somebody who is hospitalized. and then the dexamethazone the steroid Matt, just as you were saying, often we use that in more severe cases. and it does seem to show a higher effect size as you kind of look back at both of the.

[00:07:32] The studies on REM death severe and on dexamethazone REM desk seems to have somewhat of a higher effect size on earlier cases. and whereas dexamethazone, I think of is more for more severe cases and that's because it affects that immune cascade and that inflammatory cascade that's often happens after, the viral load has gone way up.

[00:07:52]and so it's a kind of a later effect that it helps to blunt, You know, I think everybody's sort of trying to read and say, you [00:08:00] know, since there's been some of the mixed messaging, everybody wants to know, well, how sick is he? You know, what's going on and can we use these, the therapies that he's getting to kind of back calculate and see what's going on?

[00:08:10] And I think it's tough, you know, it's tough to not be if, if you're not, or I as a physician would, you know, reserve kind of commenting on that because I just don't know the data, you know, I don't know exactly what. The labs and the vital signs and things like that are. And so, you know, I think that that kind of speculation is tough and it's hard to know what sorts of, you know, clinical things went into that decision making.

[00:08:33]so I would reserve, you know, such a sense of judgment about what's going on or trying to speculate about the severity of the case. but it does seem like for the most part, with the exception of these antibodies, he's getting pretty standard of care treatment, things that we use in our hospital all the time.

[00:08:48]And, you know, I think it'll be interesting to see I'm hopeful that, that these monoclonal antibodies will provide some therapeutic benefit to, we just don't have that data finalized yet. Okay. 

[00:08:59] Matt Boettger: [00:08:59] I'm [00:09:00] curious on when you were talking about the steroid, is it common? Cause you mentioned usually it's given right.

[00:09:06] When it, when it's kind of a higher threshold, is it less advantageous medically to give it so early? Or is it 

[00:09:12] Mark Kissler: [00:09:12] no, I mean, I think, There's I would say that it's, there are side effects to steroids. There's a certain subgroup of patients who never need them at all. but in general, it's a relatively low risk medication, and it's pretty widely available.

[00:09:26] And so I don't think that, you know, I'll often use it in, in a patient who needs any supplemental oxygen in the hospital. particularly if they have other risk factors for severe disease, and different hospitals will have different, Sort of guidelines for use about, you know, clinical pathway is about when you might introduce dexamethazone and the treatment course.

[00:09:45]so I don't think that it's, you know, it seems, it makes sense that he might be getting it at this point. I also don't think that necessarily, you know, I don't think it necessarily tells us how sick he is, the fact that he's getting it. It's just hard to know. You know, I think it may be out of an abundance of, [00:10:00] of caution and with relatively low side effects, they said, Let's just go ahead and give it.

[00:10:05] Matt Boettger: [00:10:05] Yeah. Yup. Well, I mean, this is a, Hey, if you're the president United States, of course, you're going to have a lot of, a lot of speculation, a lot of, a lot of people chiming in on what's going on. 

[00:10:13] Mark Kissler: [00:10:13] Right. It seems like the, yeah, everybody's, everybody's kind of like transfixed over the reports of vital signs and you know, it's a, it's a whole, another level of, it's just a whole nother level.

[00:10:25] Matt Boettger: [00:10:25] Yeah. Is it totally random? But I saw that Twitter's like going up like crazy because. President Trump is in the hospital with COVID and I don't get it. I mean, he's just accessible either in the white house or at the hospital. I mean, looks like a nice presidential suite. So not like there don't have cameras there if they don't need to, but apparently people are just like waiting for the tweets more than anything from president Trump.

[00:10:48] So, yeah, it's, it's a fascinating, just a 

[00:10:50] Mark Kissler: [00:10:50] circle. Anything that gives a sense of certainty in this uncertain time is probably, you know, people want to. Hang onto that. 

[00:10:58]Matt Boettger: [00:10:58] Absolutely. [00:11:00] Well, let's move on to what we wanted to talk about. One of their big, deep dives. This is something that's been on our radar for, I think, three to four weeks.

[00:11:09] Now we've been talking about, this, this, super spreading event and just a couple of days ago, saw a couple of articles and I, I really want Steven to come in and bring clarity to this. I'm a little confused, but maybe. Not entirely. So this is the largest study that's come out. I think out of India, you can even correct all of my errors when I'm done talking, Steven, but I think out of India, largest study on super spreading.

[00:11:32] And this is what I love back in the day, guys, back in the March, I think we started off, Oh, wait, this is like seven month anniversary. I think of us it's around this time, March 3rd. And I was thinking about this, like the March 3rd episode, I think we're saying, man, you know, We could be getting close to a hundred cases, you know, at some point in time and I'm like, Whoa, a different world, totally different worlds.

[00:11:54] So I think there's like 16 and we were, we were really early on. 

[00:11:57] Mark Kissler: [00:11:57] Oh yeah. I remember that. I remember cause we were [00:12:00] counting them in the single digits. You know, the first couple of we were just seeing and trying to wrap our heads around what exponential growth might look like, you know, and here we are. 

[00:12:09] Matt Boettger: [00:12:09] I still have no clue, but exponential growth.

[00:12:11] And here we are. So some things I've learned, some things I haven't at least experientially. It's tough to go to. So back in the day, So talk about this super spreading. Oh yeah. The one thing I wanted to mention is the predo. Well, I talked about it a couple of times. I love this principle, a really guiding force that really 20% of your efforts, your work, you really, it is kind of the part of your 80% of your consequences of to reward.

[00:12:35] And that this is a group. We mentioned this in the context of so many layers or episodes, whether it was cleaning food or that kind of, or whatever things you can do, really double down that 20%. And now. We see it rise. It's it's whether ugly or pretty little head and maybe in an ugly way seen in this article that roughly 19%.

[00:12:54] Contribute all of these of infections of Kobe contribute to over 80% of the [00:13:00] transmission. So now we're seeing a little bit more of a nuanced perspective of COVID not necessarily like the flu, which is kind of our widespread, generic seen as concentrated reality of, I, you know, I think maybe Steven, you mentioned one point in time, but yeah.

[00:13:14] There's this one woman who's like this poster child of it who infected 6,000 or 5,000 individuals. I don't know if that's true with this folklore, Reddit. I read it. I read it online. It's true. Right. I read it online. So, so can you speak into this, this K factor is going on. People are saying that are not, is no longer that effective.

[00:13:32] That's the K factor. We need to look at that and even things about Sweden and how in that. They did have a stricter policy in some areas kind of regarding these kinds of super spreading realities. So bring us up to speed of what's going on and how this maybe nuances are active. 

[00:13:46] Stephen Kissler: [00:13:46] Yeah. So, it's the, first of all, it's super exciting then from, from just like, Mathematical epidemiologists nerd perspective that there's, these, these numbers and these sort of ways of measuring epidemic spread are becoming more of like the, the [00:14:00] cultural, more like the cultural attention.

[00:14:02] It's like, cool. I mean, I think about these things all the time. Yeah. so essentially what it's referring to is that, when the, the. The most fundamental number? yeah, we think about in terms of disease spread is, is the reproduction number, are not, or are, if you just want to drop the zero, And that's, as, as we've spoken about many times before, is the number of people that an infectious person is expected to.

[00:14:22] In fact, if they were just dropped down in a population that didn't have any disease in it, so that's important and remains to be important. So I, I would say, in response to one of the things you mentioned, you know, the, the reproduction number. Continues to be important because that is the number that, that affects whether the, whether infections are increasing or decreasing period.

[00:14:42] If, if is greater than one infections are increasing. And if it's less than one they're decreasing, we try to keep it below one. that's, that's, that's the goal. but the question then is how do we do that? So, Of course the not everybody's going to infect the same number of people. There's a distribution around that.

[00:14:59] So [00:15:00] even if the reproduction number four COVID is on the order of three, so a given infectious person is expected to infect maybe three others, under standard assumptions, assuming no interventions, whatever, Not everybody is going to infect through people. There are a lot of people who aren't going to infect anyone, and there might be a handful of people who infect 20 others.

[00:15:19] And so you can think about this. There's a whole range of distributions you can think about. And the simplest one is where everybody just infects three. And for that, the, the, the K number, this dispersion number, from thinking about it all correctly, but it's, it would be zero. So for those of you who are Matthew out there, basically the cane number is the variance.

[00:15:38]or I guess in this case, the standard deviation of that distribution of the secondary infections. So, what that tells us then is as that K increases, then you're going to have, sort of this bigger spread where maybe on average, a person is going to infect three other people. But then, then you're going to get into this realm of the 80 20 rule, where a lot of people are going to infect no one, but a few people [00:16:00] are going to infect a ton of others.

[00:16:01] And that changes the way that we need to. I think about disease spread, because again, the, the fundamental idea is to reduce our, to reduce the reproduction number. But if you go back to your statistics courses, you remember that the mean of a distribution, basically the mean of a set of numbers is really heavily effected by numbers that are out in the tail by really, really sort of rare events.

[00:16:21] So the mean of a distribution, It's going to get pulled a lot higher. If you have a couple of people who are infecting a lot of others. So, so these super spreaders are super spreading events are basically taking that reproduction number and increasing it a lot. And so if we think about how we can prevent infections, well, either we can sort of shut everything down and make sure that nobody can transmit disease, which is a blunt force object.

[00:16:44] For sure. That's the idea behind lockdowns, right? And it works. you know, it works, but th but they're very disruptive as well. But another strategy is that if you can just sort of chop it up is that tail meaning if you can prevent the people, and if you can prevent the events where lots of people get infected, then the average of that [00:17:00] distribution decrease a lot, and you might even be able to get it down below one by just sort of focusing in a targeted way on those, on those really high spreading events, the super spreading events.

[00:17:08] So that's the idea behind this, and that's, that's why it's so important because. Speaking now, biologically and epidemiologically, the severe Corona viruses that we know of. So SARS, MERS, and now SARS, Coby too. all of them seem to, display a lot of this sort of super spreading behavior, much more so than things like flu, for example.

[00:17:29]and we're not entirely sure why, it could just have to do with the. Behavior like interactions between behavior and demographics of people who normally get infected. And, when, in the course of infection, you're infectious, but there might also be something physiological where there might be a very wide range of, just how much virus a person produces when they're infected.

[00:17:49] And that could potentially lead to these really huge amounts of variation in how many other people a person goes on to in fact, and so, so that seems to be a, kind of a quintessential feature of, of these severe Corona [00:18:00] viruses. And it seems to be, all of the evidence seems to be pointing that direction for SAR scurvy too.

[00:18:04] As I mentioned as well. So that raises the possibility of different types of interventions that are, that are more targeted at preventing these, these super spreading events. And, I've been advocating for this, since April, really, when, when this idea sort of first came about, because knowing what we knew about SARS, I, we sort of anticipated that.

[00:18:22] That would probably be the case with Sarz Kovi too, as well. So that's one of the reasons why I've been trying to make sure that I don't interact with more than five unique. People in any span of 14 days, because that limits the number of people who I could possibly infect two to five. Right. So that, that makes it impossible for me to be a super spreader.

[00:18:42] And, and so if we could do that, then, then that, that goes a long way in controlling infection. So that's the idea behind this. and I think helps to explain maybe to some extent why we've seen so much variation between different places and the severity of infections. Because one other thing that this really wide range of variants and the number of people, a person [00:19:00] that affects does is it introduces a lot of randomness and, almost like chaos into the system where, if, if you have a couple of these super spreading events, you can really ignite a large epidemic, but most of the time, the epidemics will sort of Bumble along and then.

[00:19:12] Fail. so it, it creates this sort of, boom bust economy of, of epidemics as well. The population scale, which is really interesting. And I think maybe helps us come to terms with why, you know, certain places were really infected, had really big epidemics early on, and others that were really similar in a lot of demographic characteristics just seemed to be spared for a time and then didn't get their epidemics until later.

[00:19:34] I think all of this sort of is consistent with this idea that super spreading is really important. 

[00:19:39] Matt Boettger: [00:19:39] That's great. So, okay. I want to go into more about the super spreaders, because I've been reading a few articles about this and they'll talk about these super spreaders, but then they don't talk about the person they talk about.

[00:19:49] Well, so to help the super spreaders stay away from indoors, not a lot of people, which is kind of the thing we've been doing. We've kind of nailed down our, like, I think it's something that we we've nailed our public [00:20:00] health initiative. It's like wear a mask, stay outdoors, wash your hands. Don't be in large groups.

[00:20:06] And social distance, those five things, right. That's kind of our public health message. And then in the super spreaders, I don't hear much about the person by hear about the circumstances by which super spring events happen. Now I'm probably, it's probably the chicken or the egg thing. It's probably a combination of both, but as it is, is a super spreader, particularly tied to the spreader and there, or is it more tied to the environment?

[00:20:30] Is there, is there a particular relationship. Because I just don't see anybody talking about the actual spreader, but just the circumstances. Why is that? Yeah. 

[00:20:37] Stephen Kissler: [00:20:37] So there's, there's a couple of things in play here. I think the first thing to say is that we, we just don't know, this is sort of one of the big mysteries and things that I think is a really interesting area of, of research and epidemiology.

[00:20:49] We don't really know if, if there are certain aspects about individuals, about their behaviors, about their social roles that contribute to more or less spreading out. Now you can imagine that there are some things [00:21:00] that are obvious where if, if, if there's, I dunno, a bank teller, working a desk or something where they come into contact with 500 people a day.

[00:21:08] They're more likely to be a super spreader than me who doesn't see anybody. So there, there are certain constraints there. And again, maybe there are biological constraints and it may vary by disease as well. So, so, so there are a couple of things in place. So first I think it's, it's, it's helpful to think about a super spreading event or a scenario where super spreading can occur, because it really reinforces the fact that any of us can be a super spreader if we're sort of the wrong person at the wrong place at the wrong time.

[00:21:39]And, and I think that that part of that is part of that is just because that's true. part of it just comes from, you know, a long, a period of, you know, there's, this is sort of a separate issue, but in public health, there's, there's often this, Sort of the knee jerk tendency is to blame the person for the spread of the disease.

[00:21:57] There's a lot of there it's very easy to sort of work in an [00:22:00] economy of blame and guilt and shame and these kinds of things. And I think that one of the things we're trying to do with this also is to remove that sort of preempt that. So it's something that's also not, not entirely sort of mathematical or epidemiological, but actually sociological here that's going on as well.

[00:22:15] But nevertheless, I do think it's also consistent with the reality, Yeah. So I think that's important. And the last thing I want to mention too, though, is, so as a mathematical modelers, oftentimes what we're, what we do is we build these very idealized systems where, you have these, agents on your computer who are interacting with each other totally randomly, and you can simulate the spread of an infection.

[00:22:35] And actually if you do that under pretty standard, pretty simple, Yeah, constraints. You actually end up with a distribution of secondary infections that just sort of falls out of the problem. So some of it is just sort of inherent to the way that diseases spread, that some people will just by chance run into more people than others.

[00:22:54] And some people will do that when they happen to be more infectious. And so there doesn't have to be anything inherent about a person or [00:23:00] even a scenario to get this sort of distribution that you frequently see now behavior and biology can contribute to that for sure. But the, the distribution already exists, even in sort of the most simple scenario that you can imagine.

[00:23:13] So, so that's part of it. Well, 

[00:23:15] Matt Boettger: [00:23:15] that's great. And this goes back to last week with you and I about, I think the Boulder thing, I think this can seem to confirm this reality of the super spreading event and. The public health initiative is pretty locked down. It seems to be a really good one, really effective.

[00:23:30]and so going to the lockdown, do you think now in light of what we know the super spring event is a lockdown, our one of our greatest assets still, or are there other things that are better now in light of Wayne? W what the benefits and the collateral damages and how we choose as concoction of how we best address coven in a way that squelches it.

[00:23:52] And keeps us going. 

[00:23:55] Stephen Kissler: [00:23:55] Yeah, I think, well first I think it's worth just bearing with us, like bearing in mind that [00:24:00] lockdowns come in a lot of different flavors. so earlier this year we were, we were facing, a national and an almost global lockdown, which is pretty . That, that was a very big deal. and the reason why that was necessary was because we, we didn't know about the, the, he modes of transmission for SARS curvy, too.

[00:24:17] We didn't have the tests to know where it was or how bad it was really anywhere. And so we were sort of forced to do this really, really blunt force, response that that was this sort of widespread lockdown. Nope. I do still think that, no, no, it almost gets into the question of what exactly do you call a lockdown? Now, if you're beginning to see an outbreak spreading, I can see local. Lockdowns have a certain variety being valuable. But now the thing that we're benefiting from is that we have the testing to know where the cases are much, much better than we did before.

[00:24:48]and, and we have a better sense of what contributes to spread. So, I think the lockdowns can be lighter. They can be shorter, they can be more local. and sometimes they won't be necessary at all because we will be able to, again, [00:25:00] try to avoid these super spreading events, trying to avoid. Parties and large gatherings without masks and things like that.

[00:25:06]and, and that, that alone might be enough to curb transmission. if it's not, then, then I think lockdowns again, maybe on a local, maybe on a, on a temporary scale may still be necessary because again, the it's, it's almost like a, yeah. If anyone has like, studied like the physics of nuclear reactors, there's something kind of similar here too, where, where you can sort of reach this point of criticality in the population where you have enough of these super spreading events that it's, that transmission can sort of become sustained.

[00:25:33] That the probability of another super spreading event happening is just really high because there's so much transmission happening. And once you reach that point, then I think a lockdown makes a lot of sense because you just need to put out the fire and put it out quickly. But until we get to that point, then I think that there are a lot of other things that we can do that are a lot more, agile, I guess.

[00:25:51]Matt Boettger: [00:25:51] That's great. yeah, I. I think you said it. Well, I think now if like there's like this higher threshold, by which for more commerce of [00:26:00] lockdown actually occur, you think you'd said it perfectly in March. You said it's early, both and Mark in March and April. Yes. The reason why there was a lockdown back then was a to help not overwhelm the hospitals, but you guys said all along and B, we don't even have the infrastructure in place to be able to deal with this yet.

[00:26:16] It's so until we get a solution, till we get a plan, we've got to do something to keep it from being like wildfire. Now. Thank you. No, thankfully we have a better plan. We have some good, good five step process, and this can help curb us from having another session you're locked down and just want to touch on Sweden as well.

[00:26:34] We talked about Sweden last week as well. This article. Brought back to Sweden again and just said, look, you're right. It didn't do a lockdown. But if you compare it through the lens of a S super spreading events, they are actually a little stricter than mine, or most places when it comes to those kinds of localizations.

[00:26:50] No more than 50 people in a, in a, in a setting. I know they had like different sets of institutions where online, some could go to class, they were kind of like, you know, like you said, there's no. [00:27:00] On a lockdown. There's a huge scale. We look at Sweden as being open, did whatever they were, they wanted to, but they did have their strict policies that seem to kind of correlate to more of a super spreading, preventative measure, which could account for while they did.

[00:27:13] They do have the largest death rate, you know, in their area. On another scale, they show signs of a little bit of success as well. Yeah, Mark. Do you need to add to this? 

[00:27:22]Mark Kissler: [00:27:22] no, I think it's, I think it's interesting. I, I mean, just reflecting back a couple of things, I think that the idea of the K is really interesting in terms of figuring out how, how sharp of a peak we've got, essentially.

[00:27:33] So how much is there variability in the D in the degree to which. Yeah, we expect the transmission to happen. That's an interesting concept. That's new to me. And, and it makes a lot of sense. How, if there's a lot of variability than working on these really high value scenarios is going to give us a lot of, downstream value.

[00:27:51] You know, it's funny being, living in a, in a family of five, to think about limiting our contacts as a group. [00:28:00] you know, as severely as you have been able to see, even as is pretty unfathomable, you know, also with like I've clicked, you know, clinical facing jobs and, you know, so I'll see probably, you know, 50 people easily, per day at work, and different people and patients and.

[00:28:16] Walk through the ER and all of that's with, you know, with a mask on and, you know, observing strict hand hygiene and things like that. but it's a very different scenario, I think. you know, in terms of like figuring out what is, what does it mean for me or for a family, or for folks who are working in, you know, interfacing with the public, in a different way that, you know, I think it's, it's different to sort of think about how do you prevent being.

[00:28:40]in the super spreader scenarios when kind of daily life brings you into contact with that many people. so that's one thing I'm reflecting on. I don't know if you have any thoughts about that. 

[00:28:49]Stephen Kissler: [00:28:49] Yeah, no, I think that's, I mean, that's a really, really good point and there's, there are a lot of people for whom sort of changing their behavior in a way to prevent, being at a scenario where a super spreading [00:29:00] event can happen.

[00:29:00] Just, just isn't possible. with, So one of, one of the demographics actually that is, that has been most affected by COVID so far, as far as I know, no, or our public transportation workers and there's, there's been a huge race. You have infection among, especially bus drivers in big cities. Yeah. And, and I think that, that, that the, the idea is, is, is trying to find principals now.

[00:29:25] So on a, on like a, city planning scale, you know, how, how do we keep people who are in these. Scenarios safe. Is there any way to, protect them to build the sort of, you know, any barrier around where the driver sits, anything like that to, to just sort of reduce the probability of them coming into contact with large numbers of other people.

[00:29:44] And then for people like me who have the luxury and privilege of not having to interact with many people, I'm recognizing that because I have that capability that I also, to some extent. I, I, I sort of taken the responsibility on myself to, to make sure that I'm not, sort of using, using my leisure [00:30:00] time to continue spreading disease more than I need to, or more than I could.

[00:30:03] And, and I think that, again, a lot of these are like personal decisions and I, I'm definitely not necessarily advocating for any one particular thing. other than just being responsible in whatever way that responsible means to you. and I think that just the principles that we're talking about here about.

[00:30:17] The, the chance that that can be this really wide variation in the number of people who a single person can. In fact, it was just important to bear in mind. And then as we sort of integrate that into how we live our lives, I think that that's the most important thing we can teach. 

[00:30:30] Matt Boettger: [00:30:30] Hey, it goes back to the, of pencil principle, right?

[00:30:32] It's like, it's, it's our, it's our adversary with COVID it's our, it's our advocate where, I mean, what's that 20% that we can help a little bit in our own lives. Just shed a little bit. That's reduced the amount of exposure, right? For you. You have the luxury, but to do it. Mark, you do not have it. I'm I'm in between you two, like where my kids are all at home in homeschool.

[00:30:52] If you're hearing banging, they're literally banging on the window and my basement trying to get my attention and I'm not looking at them. I'm putting my hand, like, stop, please stop. [00:31:00] So they're out there in their backyard. And, I go to, I go to work, but it's it's well contained. And so we do our best 20%.

[00:31:06] It helps. It helps go a long way. One thing I wanted to bring into this as well. In this conversation, Bruce from Australia wrote us. I sent you that email, sorry. Like two hours ago came probably last week. So he talks about wanting to give a touch base with what Australia is doing, how it's going, and it relates to this conversation.

[00:31:23] And I would love your feedback. Both of you on this. I didn't know this. So Australia is doing quite well. I mean, 18,000 tests, I mean 0.06% of a, of a positive case rate 10 cases and about 5 million. I mean, that's like a dream for us and they're still on a lockdown. I had to follow up with him and go, are you serious?

[00:31:41] Like, are you on a complete lockdown? I'm not sure what you mean by that. And you know, he's really concerned about, he kind of gave this quote. I love this. He's like I saw an interesting quote yesterday. His life priceless. We're precious, right? Priceless. Meaning when the government is paying or is it precious?

[00:31:57] I know this can be a false dichotomy. Things be much bigger, this [00:32:00] complicated, but I'm just surprised now. Hey, good news. The flu is pretty much nonexistent there and then pass 30 years. But in that situation, I don't know if you guys know about Australia. I don't know about the details. Like at this point in time, I think I locked down.

[00:32:14] It'd be. Not even even worth doing or remind, like not seeing the connection here. 

[00:32:19] Mark Kissler: [00:32:19] Yeah. What do you think is, do you know much about what's going on there right now? 

[00:32:23] Stephen Kissler: [00:32:23] I haven't been following too closely, so I think the lockdowns there are, as far as I can tell are I could be wrong, but I think they've been on the order of cities, which is still really big.

[00:32:33]if they haven't, I don't think been national for awhile. But yeah, it's, they've, they have taken a very different approach than the U S has for sure. and they've imposed lockdowns on cities when, when there were comparatively handfuls of cases compared to what we were seeing here, you know, every day.

[00:32:51]and it's, yeah, it's a very different approach. it's hard to speak into it because I think that, You know, we've, there's, there's been such a diversity of [00:33:00] responses, that, and again, it's frequently, our, our response does not perfectly correlate to what ends up actually happening. So, but nevertheless, it's.

[00:33:09]Yeah, I think there's all of these things have trade offs that I, that I don't know how to, how to measure and how to weigh. which is I think the, ultimately the, the role that the, that the politicians ideally are serving. And so, so certainly, I mean, if, if our only goal is, Well, I was going to say if only goal as public health, but if our only goal is preventing the spread of COVID.

[00:33:29] Then widespread lockdowns do make sense when there are only 20 cases around, but I think that's the question is we need to be very clear about just like, what are our goals and what are we willing to, to, to invest in them. and that's, those are much bigger questions than I don't, I don't exactly know how to answer.

[00:33:44] Matt Boettger: [00:33:44] Yeah. Trying to spot. But yeah, I was, I was just really shocked when I heard that. Cause they're like, Oh, we got our, I feel like the whole five things that we've been talking about in the U S and I'm sure globally, it's probably all over the place of just this distancing and yeah. It seems to be a great working process by the way, guys, before we continue, I want to press this button.

[00:33:59] I wasn't to see this word. [00:34:00] Hey, look at that. Do you guys see it on the screen? Sorry. I don't know if they can 

[00:34:04] Stephen Kissler: [00:34:04] see. 

[00:34:05] Matt Boettger: [00:34:05] All right. I didn't know that. Yeah. I was going to test something page. Thanks for giving us a plot. Cause that was awesome. I can post, I can post comments or questions on here as well. Just want to test it out for those of you on the podcast.

[00:34:16] It means nothing to you, but this was my one chance to press a button and see what it did. That's what it did. Okay. That's awesome. Okay. well the last thing I want to chat about briefly, it's okay. It's on people's minds. and that is the vaccine we've been drilling this over and over and over again.

[00:34:30] I liked this article and I want to propose it to both of you because I'm having the same question. I would imagine a vaccine could be available relatively soon, which means I'm going to have to make a decision for me and my family, whether we're gonna do this round the next round. And how do we, how do we begin to process this?

[00:34:46] Because there are a lot of people in the mix talking about advocating the vaccine. There's a lot of people against the vaccine. I just want to know who do I trust? Where do I look? What do I look to to know that I'm getting the most objective, [00:35:00] relevant information and not an agenda. And I know that's hard, everything's ripe with story, but where can I start to look or glance towards, right.

[00:35:09] Any ideas. 

[00:35:10] Mark Kissler: [00:35:10] This is tough. I feel like this is this. We've seen this coming in some ways that, this is the singularity between, there's, you know, there's a lot of vaccine hesitancy prior to COVID. To begin with, and then there's sort of a COVID, you know, suspicion as well. and as we've talked about again, and again, there's so much nuance in interpreting just the raw scientific data, and the ways that scientific data can be strung together to produce what appears to be a compelling narrative that may not actually correspond to what's actually going on, versus kind of a really rigorous understanding of what.

[00:35:44] The data is and what the limitations of, of that data. and so all that to say, I think, I think this is going to be, it'll be tough. I'm interested to see what's going to happen, but I do. I do worry that once there's a vaccine, it'll be kind of sparked a whole new level of, [00:36:00] suspicion and concern, re you know, regarding to efficacy the safety, you know, the intentions of the people that were putting the vaccine forward and things like that.

[00:36:08]and so. I agree with you, that, you know, figuring out kind of where you're looking for some of this, a good rigorous and, balance information. That's going to be super, super important. A lot of the same things probably apply to the vaccine scenario as have applied to the rest of the pandemic. and, you know, in terms of looking for, individuals who are able to.

[00:36:30] Helped to parse some of that scientific data or looking at it yourself. and especially if you have some training in that and evaluating the evidence and getting a sense of things, getting multiple different opinions, I think can be helpful. and then also working with individuals in community, and in conversation to kind of take all that.

[00:36:49] Information and turn it into something that's more understandable and can guide our actions. I don't know, Steven, if you have any ideas or if you have any specific sources, I think it's, we're in a, [00:37:00] we're in a very difficult time where things, you know, bodies that I would traditionally recommend. you know, I still recommend, like, I think the CDC is a good place to look for information about this thing, these sorts of things, but there's been so much suspicion, about the CDC, for instance, or about the world health organization or about these other.

[00:37:17] Bodies that are supposed to be our guiding, you know, getting institutions, that, that while I think that they still maintain that integrity and they're a good place to take a look and get that information from there. A lot of people who, who would not, who, who have disagreed with that as we've encountered.

[00:37:33]and so trying to kind of bridge that gap, I think is something that's going to be important and would do as well to start thinking about now before a vaccine is here. 

[00:37:41]Matt Boettger: [00:37:41] Steven. 

[00:37:42] Stephen Kissler: [00:37:42] Yeah, I agree. I don't have much to add there. I was, I was going to, really go for a similar, There's similar approach that, I think the best thing we can do here is synthesize various bits of information.

[00:37:56] That's out there to the extent that we're able. And, and again, as Mark said, [00:38:00] having, having trust in the organizations that are there for precisely this purpose, and, and also recognize that, there's, we also have a responsibility to, Form our beliefs from a, you know, from a variety of sources.

[00:38:14] And I think really Mark, what you said was, was exactly it, ideally doing it in community and in conversation and dialogue, That is a charitable yeah. Open and, and presumes the Goodwill of the other because, yeah, it's, it's just a tumultuous time. There's a lot of uncertainty in know confusion.

[00:38:32]I similarly still have a great deal of trust in the organizations that will be, making the approvals of vaccines. but I think that, there's, it's yeah, it's worth, It's worth just sort of taking in the information and in its totality, to the extent that we're able and, Yeah. Doing our best to just understand it.

[00:38:51] Matt Boettger: [00:38:51] Yeah. Yeah. And I know Matt, do 

[00:38:53] Mark Kissler: [00:38:53] you have any, do you have any thoughts? Cause you know, I think both, both Steven and I can have engaged in this in some ways, in a different way, because we have [00:39:00] these professional contexts who are, you know, involved. How, how do you, how are you, you know, now where we're at, you know, seven, eight months in, what are you looking to and how do you, yeah, 

[00:39:10] Matt Boettger: [00:39:10] I don't know.

[00:39:10] I mean, I, I'm more on the side of like, Hey, I'll take it. that's just who I am personally. I'm an early adopter about everything. It might kill me someday, but like, whether it's a beta product and software or whatever, like I'll, I'll do it. I'll try it out, try it. It's fun. Right. I was gonna see how it works.

[00:39:22]so I would tend to do, but I have a family now. And so I have to kind of, there's more voices in the mix, to, to discuss this and to figure out what's her best choice. And so, I don't know. I mean, I think we're all on board too. We want to do it. And a, when do it safely, you know, when I hear these news things about how typically a vaccine takes so much longer.

[00:39:39] And so there's like a certain point by which they release the information on data and it's, that's how they do it. But now everything's so rushed that the data is not being quite released yet because we haven't caught up with the new procedures with actually expedite lightning speed processes. So there's a lot of people who were like quote, independent scientists, which, which I do have a follow up question.

[00:39:57] Like who are these people? You think you have [00:40:00] professionals who look to you, but don't even know what the names are like Intel. March. I didn't know. You went to an epidemiologist pronounce on our first episode of infectious disease to deal with this stuff. I had no clue. It was my first introduction to that.

[00:40:12] That's who you go to, right? Who do you go to? What's the title of a person  that has this as their expertise, but understanding. The ins and outs of a vaccine. It's, it's probably not a veterinarian. It's someone else. I don't know who it is. So I guess let's start there. Is there, is there a specialty in this area of scientists?

[00:40:31] Mark Kissler: [00:40:31] Yeah. I mean immunologists throughout the people who can comment, but I think also, you know, we've seen, unfortunately we've seen folks use credentials, And in ways that are sometimes misleading as well. And so you'll have, you know, especially I'm particularly sensitive to this because it's, you know, my, my Guild, right.

[00:40:50] But it's when somebody says, well, I'm a doctor and XYZ, you know? Well, that's, that's true, but there's, we, you know, there are other things that we have to [00:41:00] appeal to another others levels of rigor and levels of kind of, and so it's not enough to just look for the title. Either. so, but, but I would say a good place to start would be looking at for, you know, folks who are working in immunology, or vaccine research.

[00:41:13]I think epidemiologists are still really the people to look towards in this scenario because, they're helping us to way, in a way, some of these risks and benefits and look at the population level. Concerns. 

[00:41:26] Matt Boettger: [00:41:26] Yeah. Well, great. I mean, that helps I'm here. Absolutely. Right. I'm not going to look just to a title.

[00:41:30] I want to, I want to say that this is my low hanging fruit. I want to start, they want something to bite down on and then expand my horizons. Like the opposite of in the onion. I want to start in the brain this, and then we kind of peel my way back together. So however I do that community. It's totally part of that.

[00:41:47] But at the same time, a little alarm bells go on. When you say community, because how many of us have a motto this community? Is that just our confirmation bias, what we want to hear? And it just, it just, we just go off the direction, down a slippery slope and off a precipice and just [00:42:00] do something bad where, you know, it goes back to Abraham when he was back on months ago.

[00:42:04] And in early April where he talked about, you've got to have community. And it needs to be diverse. You got you really, we need to diversify just like your income. You gotta diversify your friendships, right. To have a polyphony of voices that can come into you, trust that can weigh in and then use this.

[00:42:22] And I'm afraid that we don't all have that. And if you guys have that, you're listening to it. You guys rock. Right. But I don't, I don't think I have that as much as I thought I did. And a lot of things have revealed to me. So that's just my little toot, I'm horny or horny and I'm tooting, whatever it is. I sit it completely 

[00:42:40] Mark Kissler: [00:42:40] backwards 

[00:42:41] Matt Boettger: [00:42:41] and I am not going to edit that out.

[00:42:43] That is staying 

[00:42:44] Stephen Kissler: [00:42:44] in.

[00:42:44] Mark Kissler: [00:42:46] That's good. Sounds good. Okay. That sounds good. 

[00:42:49] Matt Boettger: [00:42:49] Yeah. Sure. All right. Well, we'll end there. The great conversation, Mark. Stephen. It's always good to have you both on, I feel like I'm part of your family begin. I know we're not blood brothers, but for you too, which I kind of like [00:43:00] this, I was, I was gonna say this phrase.

[00:43:02] That is totally not right, politically correct. So thanks Lee. I'm not, I'm not a, not a blood brother, but someday we're going to have that ceremony, like I'd mentioned about a few months ago and where I'll be. I'll be a blood brother as well, back in the eighties. Joking guys. Okay. Thank you guys for listening.

[00:43:19]if you want to get ahold of Steven Ste, P H E N K I S S L E R. By the way, every time I do that, I keep seeing singing this, the Mickey mouse song. Every time I do that, I don't know why, because it's like someday it's. So sometimes I feel like I'm going to actually spell your last name mouse by accident, just cause it's like in my head.

[00:43:38] As T P T and M or USC 

[00:43:40] Stephen Kissler: [00:43:40] Steven mouse. 

[00:43:42] Matt Boettger: [00:43:42] Okay. So the STB  me [email protected] Check it out. Just get ready to do another episode. I'm going to have Mark. And again, soon it's gonna be fun. We're gonna do something to live in the real. so, and then if you can't 225 more dollars left. To pay for all the awesome equipment, that kind of [00:44:00] stuff.

[00:44:00] You can do that at podcast, or just a one time gift and the PayPal or Venmo all in the show notes. You got it. They're having a wonderful week. We will see you next Monday. Take care. Bye bye.