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Things Discussed on Episode:
Can you Rate and Give us a Review in Apple Podcasts?
Please consider financially supporting us for the monthly upkeep and to help 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!
You can also follow Matt on his Living the Real podcast where he recently released an episode about what he has learned from the Pandemic so far. You can find his podcast here.
Things Discussed on Episode:
You're listening to the pandemic podcast. We equip you to live the most real life possible in the face of these crises. My name is Matt Boettger, and I'm joined with my two good friends, Dr. Stephen Kissler and epidemiologist, the Harvard School of Public Health and Dr. Mark Kissler doctor at the University of Colorado Hospital. Good morning. Happy Easter. Good to see you. It's been two weeks. Are you
Mark Kissler:guys doing well? How are you doing Matt hanging
Matt Boettger:in there? Oh, good. Hanging in there is it. I am feeling fatigued as if I almost feel as if. It's March, 2020. It's like, it's like, I'm having flashbacks. I'm just feeling fatigued. That's how it's done. How about you? I mean, I don't know. I think just Easter for us celebrating it is it's just exhausting for me. Cause I have to do an Easter vigil. It's at the church. I get home late. And then for those of you who have kids, the kids don't adjust to late nights. They, their calendar is they get up at six or six and then when it's Easter and the Easter Bunny's here. Right. That's that, that makes it even earlier. And so then the, just the recuperation from that, I just, I, it just hit me. And so I've been tired and. That's been the big thing and just all the stuff that's going on with the variants and the news. Like I said, I was just telling you guys before we start recording we can never go two weeks ever again, without recording, because my notes are like 14 pages. I was telling you guys already you know what? It's so overwhelming, how much to talk about and like my curiosity of what's really going on. I just want to say, forget it, everyone. We're doing a 45 minute guided meditation. I wouldn't buy market Stephen by me. Yeah. I am just going to, I'm going to take it in. You guys are leading this one, that kind of stuff. So, but we're not we have lots of cover. So here's a number of things that I want to chat about before we get going. Just the normal stuff. If you can support us, that would be awesome. You can do that at patrion.com/pandemic podcast. As huge as those figures a month goes a long way. As well as one-time guests, that's all it takes. It's PayPal, Venmo on the show notes that helps us keep it going. We can get more editing, faster stuff. We really appreciate that. If you can do that. We need that support as much as possible. And the reviews keeps them coming. We love them for better and for worse, even the critical feedback helps us to adjust and help us bring better content your direction. You can do that through Apple podcasts or whatever other factory allows for kind of that kind of reviews or. SARS, what are maybe I think that's all the good stuff. So let's get going. I'm going to go straight into in the news because we have a lot, like I said, when I did it this morning, going through this, it just never ended. And so I kept clipping things. The notes is about a month worth of stuff. So I want to start with gosh, I don't even know what let's start with some good news. Let's start with that. I saw here last week, Mark and Stephen that us suicides dropped in 2020. This is a huge shock, right? I mean, we, I think for me from March, April, may I had friends telling me this is ridiculous. Lockdowns are terrible. I'm not saying that lockdowns are a virtuous thing that actually ennoble people and make people inspired to do great things, but. That that, that suicides were on the rise and all these things. And I'm curious of, what's going to unfold in the next six months and we see. How 2020 fared for all these things that, I heard domestic violence increased. I would imagine that probably did. And that was just a really terrible thing. So other things are probably going to be real, but this is a small bit of good news, about 6% decrease in suicides in 2020. And I didn't know, Mark, Stephen, start with you, Stephen, is there anything that you would, could even imagine of the reason why that would have happened whatsoever? I'm just, this is great news. Yeah.
Stephen Kissler:I mean, I, it's really hard to say. I think, I think we would need to bring on a whole, a whole crew of people who are experts in psychology and all of these things to it to really understand. I don't, I mean, it's, it's, it's unexpected to me, me too. I mean, this has been an incredibly tough year, for so many reasons. So I think, I think, yeah, to my mind, it's really just, one, one small bit of, of good news in the midst of it all.
Matt Boettger:Yeah, Mark. Do you have thing to add to that, that you, any ideas speculations based with it or not
Mark Kissler:speculations? I think it's it's just great news. And I think that, in the, in the reckoning of this year, we're going to have to cut the data a lot of different ways and start to understand what's what's happened and attributing causation to those things is going to be difficult if not impossible for a lot of this stuff. I'll tell you that. That small piece, or that seems like a big piece of good news to me. And so I think I'll take that as it is. That's good. Yeah.
Matt Boettger:Great. Awesome. Well, one thing I want to throw right away before we get into the fourth wave, cause I have a lot of questions about that, but I saw this, I think this morning, Mark, about Regeneron. It says antibody cocktail, infection, injection prevents. COVID I know, I think this is something that's new on your horizon as well. Do you know what you think about this,
Mark Kissler:Whatsoever? Well, my understanding of this is that it prevents symptomatic. Infections, especially early once somebody has been, has a known exposure. And so at least the way that I'm interpreting the study design here is that this combination of there, this monoclonal antibody cocktail that they have it looks like it, it reduces the risk of progressing to symptomatic COVID. And so. What I suspect is that they're positioning this as something that people can use if they have a household contact who's infected. And so, you have somebody who works out in the community gets COVID. What do you do? For all of the folks who live at home? I think this may be something in the primary care community medicine setting where you could say, Oh, I can offer this to all of the close contexts and reduce the risk of, maybe. You have an aunt who's living at home or grandma who is living at home, getting severe symptomatic COVID from that exposure. And so I think that's pretty interesting and, and that's good. This is something that we've been using in mild to moderate COVID, in various settings and already and so I think this potentially may increase some of the applications for that. And. So there's that it is different, it's a little bit different from the vaccine on a couple of levels, right. Where one is that it doesn't seem to actually prevent infection. What I'm seeing is that it prevents symptomatic infection, so reduces the severity of the infection. And so of course, individuals could also still transmit even if they're asymptomatic or less symptomatic from the infection, but yeah, overall kind of an interesting. A new little piece of data on that particular therapy.
Matt Boettger:Yeah, I mean, good news. It's another, just another tool in our arsenal to help the spread. I'm not sure when it would actually be available. I'm assuming right now you couldn't do that right now. It's just Hey, I got it. I got, I got exposure to go to your doctor and get Regeneron or is that even possible?
Mark Kissler:Well it is, I mean, it is out, it is available, so people have been getting it. And so I think that it's more a question of if there's adequate supply and if the data is robust enough to really pivot the indications for use that way. That's what I think is. Pretty feasible.
Matt Boettger:Okay, great. So let's get straight in the fourth way, because this is a lot of conversations. Stephen went to talk to you. I mean, I have pages of information on this stuff. I mean, Dr. Osterholm other people just talking about this, this, this fourth wave, the intensity of it, the fear of it, the complexity of it. And I want to throw it to you because I wanna try and package this as much as I can. I'll let you run with it for just a, a handful of minutes. However you want to go, because I'm still confused about the fourth way, because we're seeing the upper Northeast, Michigan being pounded. And, and, and, and, or at least it seems like that at least from again, from the news, and there's a lot of this stuff about the ne ne ne. And so, first of all, why on earth is the Northeast Gideon's so obliterated. So I have my theories and maybe you can correct me and okay, maybe it's a compiler nation of, a factor a, there was no second or third real big intense wave. And so it's, it's having the ramification of that. Whereas something like California or New York city got obliterated. So, the immunity is already there. Also, it seems like they were picking up at the same time. Vaccines were starting to pick up so they didn't get the chance to be ahead of the curve with vaccines. So. So my mind I'm thinking, okay, a word heavy place where vaccines are pretty well-established and rolling out. So that's a safety measure. Be those communities that have already had tons of exposure, probably can rest a little bit safely with that. And then those people who haven't like other than where's your many, many other towns, rather than the country who haven't had the second and third wave, it is a possibility. But maybe mitigated by the, by the vaccine. So in light of all this stuff that I'm seeing, yeah. Fourth wave fourth wave is coming. There's, there's a fear. What is your assessment right now? Why the Northeast? And is it really feasible? Well, the Northeast could happen to Nebraska, Colorado, or at this point in time, are we maybe in a place where we could. Mm be feel safe.
Stephen Kissler:Yeah. I just want to take a step back that you're you're, you've really become quite the epidemiologist over there the past year. That was great.
Matt Boettger:Can I get, can I get an honorary certificate from Harvard school of public health? Absolutely.
Stephen Kissler:Just come on over. I don't know how much I have to add to that, yeah. No, I mean, I think, I think you're right. There's so much here that has to do with. With, with timing, with what specifically is circulating with, what's been circulating before. And as we've spoken so many times about just with block too and I, luck probably isn't the major driving factor, but, but there's an element of it that especially in the timing and the actual severity of things It matters a lot. If you happen to have a couple of really big, super spreading events that then spread it out into the community and really allow it to gather steam quickly that that can really change the course of a local outbreak profoundly So, yeah, I think I've, I've lost track of how many waves we've seen in so many different places. But I think just to sort of break down the state of things right now. So, Michigan I've been watching with with a fair amount of concern for sure, because they, they, they really are seeing a major surge right now where cases and hospitalizations are at the levels they were during the peak of their winter time. Outbreak. And that's, that's not something that I expected. I expected basically everywhere to see the maximum of transmission in January. And so, so that's really giving me as an epidemiologist pause because that doesn't really fit into my conceptual model of how this thing ought to behave. Now, again, there's There's a story of variants here. There's a story of timing and vaccine uptake. And previous transmission the, the Midwest was one of the last places to get hit with the first wave. Whereas, up here in the Northeast, we had a huge, huge surge in April of last year. And so, so all of these things are sort of combining to create the landscape that we're seeing now. I think that, the, the, the places where we're seeing a lot of spread if we zoom out a little bit past just these couple of weeks really are generally the population centers, the places where there's a lot of really high population density in places where there's a lot of connectivity like international connectivity. So even though California is doing much better now, they had one of the worst winter time surges that was partially driven by variants that we first detected in California that are now spreading across the rest of the U S a lot of the variants that we're seeing here now in the Northeast are the ones that were first detected in California. So in a sense, we're just sort of piggybacking off of their winter surge and that's prolonging our tail and causing some surges here too. Although so far the surges in the Northeast, generally aren't to my mind as as. Huge and magnitude as, as the one that we've seen in Michigan. So all of that is sort of playing together. I do think that again, we're, we're vaccinating people at a, at an incredible rate right now, and that's, that's hugely variable among different places in the country to which we can talk about at some point as well, but mean certainly in the Northeast The vaccine uptake is pretty quick. We still have a long way to go. And so my hope is that with that, and with the changing into the summer, we'll be able to keep a lot of these things at Bay, but the variants do make it a lot harder. I mean, they really are more infectious generally to, depending on which one we're talking about. And so it is, it is still a bit of a race.
Matt Boettger:Yeah. Okay, well, in light of this, you said a couple of things. So number one is the Northeast West had an uptake of vaccine, right. Like would sense of they're more probably prone to get the vaccine verse. We know that I, at least I just saw from the article this morning, the South is a little more hesitant in general. So there are some places in the South by which there's now a surplus of vaccine or getting to the point where you're probably searching for people to get the vaccine. I would imagine the Pacific Northwest, California, the Northeast, a little more likely to get that. So. I'm more concerned about the, again, the Northeast being hammered, at least Michigan. Now you're saying that this, this Michigan thing was a cause for you to pause. Is there, you may have already said it. I didn't quite see it. Is there anything that you can see with Michigan, particularly with okay. That, that makes sense. Or is it still kind of like, well, this might make sense. But this is a weird anomaly besides the tail of California, but the tail goes through Colorado and in Nebraska and all the way to the Northeast. So I'm like, how did it jump over? I know I get it. Then the variance here in Colorado as well, clearly. But do you, is there anything that makes sense of this particularly, or not really?
Stephen Kissler:It's really hard to, I, I, I mean, there are any number of things that we could say that, would say, well maybe. To, to explain why Michigan and why not other places. But I think, I think the difficulty is, is that we'll then have to revise those statements in six weeks when it's somewhere else, or if it's somewhere else as, as we've been doing throughout. Right. Like it was the first question was why Italy and then why New York and then why Florida, and then why. Different places. And part of it is just the way that the disease spreads. I think part of it is just that it, it, because it happened to be there and happened to have those events in it. And it certainly, the there are behavioral elements, there are elements with vaccine uptake, but I don't think that any of us could have said A priority that like Michigan is the place where this is going to happen. In hindsight, we can, we can explain some of that, but that doesn't help us explain why not other places that have similar landscapes as well. So while, while there are ways of sort of making sense of it, it's not quite like the, the. We've been talking a lot about causality today. I love it. It's it's not quite like the predictive type of causality where you can say a implies B in all cases, which is like the thing that we're often like looking for. Really, it's more of just sort of like giving an account of what happened, but something that's really far from watertight and oftentimes that's the best we can do in epidemiology, which is frustrating, but
Matt Boettger:yeah, sure. Mark. Do you want to add anything you're leading into the microphone?
Mark Kissler:I don't know. Maybe I just get excited. Anytime we start to talk about, some of these bigger picture, kind of these intersections between the scientific and the philosophical frameworks, because I think it's, it's something that doesn't get a huge amount of conversation, all the time, but it's, it's just something we've been living so much over the last. You're and just understanding the ways that all of this intersects with like our psychology and the decisions we make and like whether or not I get grocery pickup or go to the store or, XYZ. And I think it's just interesting to me to think about that sort of chain of, connection between these really foundational, scientific principles, and how I spend my Saturday, or things like that. And so I, that's all, I'm just I'm interested in, in thinking about ways that we might be able to tie into this, this idea of causation and stuff in, in other ways,
Matt Boettger:Sure. Yeah. I'm sure exactly. This, the idea that what you said, Stephen, that the complexity of causation, different kinds of causation, not a direct link, just feeds all the more of the hesitancy conspiracy theories, because it's not tight. It's not, it's not air tight. Oh, this why not here. And why here, there's no explanation. And that causes a lot of gaps. Right. And then we
Mark Kissler:fill the gaps with other wrestling Stephens, but I'm going to jump in just because I feel like. That's all that stupid of the last word. The other thing I was thinking is about how it seems the temperament to me, or, your baseline, where you're at with stuff really, really influences how you deal with something like what Stephen just said. And so if he says, epidemiology is really good at making some of these tuck things that can adjust our behavior in the future, but it's really tough to make an operatory. Say, this is the place where it's going to be bad. There is a certain cohort of people who are going to hear that and say, we need to be extra careful all the time. There's another cohort of people who are going to say it doesn't matter what we do it doesn't, it doesn't matter because we're never going to know we should just do it. And, and then anywhere along that spectrum and that is a really complex thing to deal with. And it's, it's funny because often I've had know through this pandemic have had the experience of. Talking to somebody else who I assumed was at the same point on the spectrum as me, and then realizing halfway through the conversation that they're at a very different point on the spectrum than I am. And just feeling that, that like conversational, here we are now in very different places that I thought we were consensus around how we deal with risk and causality and things like that. It's very hard to backpedal from that. Point, and, and I think having, I have a certain tolerance for some awkwardness and conversation anyway just a baseline it's I think maybe it's, but, but it's, that has been it's that feels to me to be the root of a lot of really hard. Disagreement and a lot of really hard and riffs in relationships, over the course of the pandemic is, are some of these things, where are you at in that spectrum of how you respond to uncertainty like that anyway?
Matt Boettger:Oh yeah, that's great. I mean, not to go on a tangent, but my wife and I'll put it back to you, Stephen. The chairman of the last minute here on this. But my wife went to a party outside the other day, just a small gathering and she was being safe and wearing a mask. And she was the only one, but she just wanted to be extra safe. And she was the very end and got into a conversation with a lady. And just, just politely asked, how have you been fairing with all this? And that opened a Pandora's box that my wife wished she never would have opened. And it was, it was, how, she takes a hydrogel. Cora Quinn every day. And you got to read the alternative websites and realize that there is no scientific evidence that the vaccines have any efficacy whatsoever and all this stuff on and on and on for like 45 minutes and made just Jan really. And then, and then constantly, and literally getting really close to her, like interface and then grabbing her phone and like, Oh, let me see the pictures. Oh, by the way, I've been exposed like tons of times this past month, but I'm not going and it don't worry, and so this, this, like, how, how do I back, how do I back out of this? And you, you, you don't know what you're going to get. Yeah. When you just asked a simple question, like how you've been doing through all this, and then you realize I should have never asked that question because that's, that's not what I wanted to be around. It's it's hard, right? Right.
Mark Kissler:And we didn't even go ahead and do yet that, in some ways that's that's what we need the most of it, because otherwise we're all getting our information from these super siloed, super isolated places. And self-reinforcing. You know that, and without some dialogue and friction, that feels pretty socially bad. Frankly, and, and it's not about winning people over to the side of truth, or whatever. Even as much as just let's have a little bit of conversational contact here, some reality, and and recognizing that I may be wrong, like where I'm sitting on the spectrum may also be skewed, as much as I feel like, I'm, I'm right. Going into these conversations. And just having a little bit of that flex, I think, but not, not fearing the contact and not fearing that, that friction or else, I don't know what, what would have, if, if we just don't engage, that seemed to be
Matt Boettger:worse. Yeah. Yeah. I've always been amazed of how everybody else has cognitive biases, except for me. Why, why, why am I the only
Stephen Kissler:one?
Mark Kissler:I just don't see it right. So, yeah, I know that's, that's the ultimate red flag, right. Is when you look in the mirror, you were the only person in the world who knows. Yeah,
Stephen Kissler:totally.
Matt Boettger:Oh my gosh. Stevie, I need to add to this, this, this,
Stephen Kissler:Oh gosh. Yeah. I mean, so one of the things that this was making me think of and Mark, this, brought to mind about that, like these. Questions of causality and temperament and sort of where we set our own personal responsibility. I have been reading this book that Mark recommended to me called the concept of mind by Gilbert Ryle and it's it, it basically just there, there's a whole section of it where he does this intense examination of the word, because what do we mean when we say, because and the, the. Metaphor that he keeps bringing up to illustrate. This idea is so there's an event in which the glass broke and there are two different ways of assigning causality to that. You can say that the glass broke because of the rock hit it. Or you can say that the glass broke because the glass was brittle. Both of those are valid causal statements. But one of them expresses a disposition of the glass and one of them expresses an event in which it getting struck by a rock was the immediate cause of that glass to break. But it wouldn't have happened if the glass hadn't been brittle, but it also wouldn't have happened. If the glass hadn't been. Struck. And so I think that there's a really interesting element here where our, our temperaments, our personalities, whatever, cause us to insert ourselves at different places in that. And sometimes at multiple places, but it's you ask yourself then what is my responsibility is my responsibility to strengthen the glass is my responsibility to remove the glass from the line of fire, or is my responsibility to intercept to the rock? Is it to, what are we. What are we doing here? And I think that depending on our profession, depending on our role in life, we can change as an epidemiologist. I spend most of my time trying to strengthen the glass or to, to do something like that to, to, to create dispositional changes in the dispositional landscape. But here, we're talking about Michigan, right? Where it had a disposition. To be infected. I had this, this disposition of brittleness, but that's someone else could say, well, that's not why we have this major outbreak there because you had to actually have the rocket. You had to have the variant come in, you had to have the super spreading event. You had it. There was this whole chain of sort of linear causal events that caused this epidemic. And so there's, that can cause this real disconnect, because we can argue so much about What, what, what is the reason for this? And we're actually speaking about on two entirely different planes, both of which are incredibly important. But I think that's that that might lie at the root of some of these, these disagreements and these uncertainties that we have about really what's happening right now.
Mark Kissler:Hmm. I feel like I've always coming into the room after I hear a crash, that's that's the role of that? The hospital is, it's well, here we are, looking through the broken window, and and I think that, that as just being conscious of the ways that, that both with this illness and with others, Over time creates a certain disposition in me. And that, that is that, that involvement, with frailty a disease, it's not. In consequential in the way that I start to look at the world, and just being aware of that, the change that's happened in me over the last, 10, 15 years as I've been engaged in, different sorts of kind of training and stuff like that. So, very interesting. I'd like to, yeah, we should, we should talk, let's get back to the news, but I think this, this sort of stuff is, I think really. Really important and it, and it has some ties, I think, Matt, to how you're feeling, this week too. And so it's not, I don't think it's it's not just an intellectual game, but I think it's pretty material to what's going on.
Matt Boettger:Sure. I agree. Yeah. I knew to get back to the news, but I'll just plant this seed of pride. Another loaded gun. I know we're probably going down another tape, but Mark use a doctor. What you in me, the causation for me is the final cause. Right. Sometimes it's getting to the point where like walking with someone and not being so set on the instrumental cause, which is a doctor. Right. But then when you talked about how medicine and how it can be so rigid and it's Pushing through looking for what's wrong, diagnose it, fix it, move on. Versus some people not, it's not your main profession, but like once some final cause like meaning purpose behind all this, that, that that's really important. I think what you're saying is about me is I'm probably a little struggle right now. I'm feeling tired and this idea of final causation. Purpose and meaning of like, where's this all going like that, that motivates me when I get a little bit tired and I don't see it, I get foggy and I get a little run down and I, I need a little, I need a little, a little amp and I'm like, man, I kept thinking the other day, I'm like, I can't wait to roll in person. We can do one together and I'll get amped up again and all that kind of stuff. So I know got to get going, keep going the news, but there's so many levels of this and. And, we talk about people go into extreme directions. That's some final causality of some, one world movement, and that's where it's going and that's the kind of stuff. And it's as we go back all the ways it's complicated. So speaking of complicated, these things with these, these variants are complicated. Stephen, do you have anything to speak on this double mutant? I'm curious of, of, of California. I've seen some articles about this. I don't know. I didn't mention to you before. Don't know if you're aware of this and I know it's still up for grabs. Is there any information about this double mutant and whether it might be something that we should be concerned about? So
Stephen Kissler:it's, it's so hard to know. I mean, we're starting to see these variants pop up all over the place. Yeah, I I keep thinking about this. This book I had when I was a kid where it was like full of these zoo animals, but the pages were like slit so that you could turn the top of it and the bottom of it. And then you would like to see this, like elephant mashed up with the rhinoceros, mashed up with a giraffe or something. And so I feel like these double mutants are in a sense, like at first we were just like, we have
Mark Kissler:that book now, just so you know, we got that. We pulled that out. And the kids love to shout out to kids
Matt Boettger:like totally groomed for epidemiology. Right. It's you're like, Oh, variants animal variants and okay.
Stephen Kissler:Yeah, go ahead. That's part of that part of what's happening here is that like the virus was just beginning to sort of mix and match these things. It's, it's mutating. There's, there's some evidence. I think this is relatively rare still, but the, that the coronavirus can also do what we call recombined, where if you're infected with like multiple variants or different things, then it can actually like share genetic information with each other. And so it can then sort of pick up. Mutations that are in other variants, which all sounds really terrifying. But ultimately what we have is this whole landscape where there's just a lot of variation in the genetic landscape of the virus. And we don't have a very good sense of what it does because again, the viruses behavior is so contingent on the population in which it spreads that that we keep getting back to this, but like it's, there there's, there's so little that we can attribute to the virus itself. Because the virus, the virus can't spread without us, it, everything about what we see is the interaction of the virus with us, with our immune system, with our behavior, with everything else. And so extracting sort of, is it, is it the mutation or is it the time at which the virus emerged or is it the mutation plus the level of immunity and the type of immunity that already exists in the population? It's really hard to tell. And, and that's why we. Keep coming up with this kind of frustrating conclusion that we don't really know if these variants, if some of these particular variants are things worth being concerned about or not. Because sometimes the variant we'll get lucky and we'll spread like wildfire in a given community, but that doesn't necessarily mean there's anything intrinsic to it that caused it to do that. Or even if it is, it doesn't guarantee that it will do the same thing when it's set loose in another community either. And so really the, the, the, the standard of evidence that we're looking for for identifying variants of concern is that they're causing major outbreaks in a given community. And then they do the same in multiple other communities that they're exposed to. But that, that, that requires quite a bit of time and a lot of observation to release. I see that happening. And so I think that it's, again, it's things that we are watching closely. Sometimes we have a mechanistic reason to believe that a virus might behave in a certain way where we know that specific mutations give it certain phenotypes or certain behaviors and an ability to bind to ourselves more effectively, or an ability to whatever caused some more severe illness. And so we can begin to sort of interpret it in those terms as well, but it's sort of this whole constellation of evidence that we're trying to piece together. And so just because something is a double mutant doesn't necessarily mean that it's scarier. Most mutations are actually harmful to the virus that it will most mutations cause the virus to become less effective. But. As the virus spreads, it's the successful mutations that we began to see in the population. So it's, it's this whole interplay between things. So that's a long way of saying that we're watching it very closely, but I don't think we yet have enough evidence to know for sure if it's something that poses a risk to the CR to the country, to the world. Because we just need to see it in more contexts before we can say that for sure.
Matt Boettger:Okay, well, first and foremost, the idea of saying the phrase double mutant should be in the title of a horror film. It just sounds absolutely terrifying, but, but that, so that one, and then also going back to the variants, I mentioned, you've mentioned a few times before Stephen, but just. Since Ontario is talking about increased infections and hospitalizations with young people, Dr. Auster home seen that children are being affected more readily. Again, is this something that's just proportionate to the increase of the surge or is this something that we see on any level it's unique to the variants that starting to tap in and infect younger people and causing more damage or harm to the younger generations?
Stephen Kissler:Yeah. So this is The the, the truest answer is that we don't yet know. I need
to,
Stephen Kissler:I should say that my, my intellectual disposition is to assign it to, to, to basically have a preference for behavioral and circumstantial explanations for things. Before I say that it's necessarily because of the virus has a new behavior just because of my experience, nine times out of 10, that that actually ends up being the right answer. And so reasons why we might be seeing what we are seeing In the data without the virus necessarily being preferentially, infecting young people or causing more severe illness in young people is that one thing we know for sure is that and some of the other variants are, are more severe. On the whole. And so they might multiply the risk of hospitalization by some factor. And we don't know if that factor varies depending on whether you're younger, old. But we can assume maybe that it's constant across all ages. If you combine that with the fact that largely it's the most at risk, the elderly who are vaccinated right now and that many communities are opening up. Young people have always. Throughout the course of the pandemic really been The, the ones who have been responsible for doing a lot of the spreading of the virus, who've really been where a lot of, a lot of the spread has really occurred. If you sort of start layering all of those things together, then what you end up seeing is that it looks like there that the increase in severity among kids is disproportionately higher than the increase in severity amongst the elderly. And that the average age of the person going into the hospital is really going down. But the question is whether that's because we're seeing fewer older people in the hospital, or because we're seeing more young people. I think the answer is both, but I don't think that it necessarily means that the virus has found a way to spread more easily in kids, as opposed to adults. It's just found a way to spread more easily. Period. And then there are all of these other elements going on, so I could be wrong about that. There may well be something as well that is causing it to be disproportionately more infectious, disproportionately, more severe in kids as well. That'll take a lot more evidence to know for sure. And from what I've seen I think, the. These other aspects can have such a profound impact on the data that we observe. A surprisingly large impact that when at first pass you would look at the data and say, well, this has to be an attribute of the virus because it's just so clear. But I've been fooled by that so many times that I've become very skeptical of that as well. So, so I think for me to be convinced that it's a specific attribute of the virus I'll need to see a lot more information.
Matt Boettger:Okay. Cause I know speaking of you were mentioning Stephen about how you can't just study a virus on its own. It's in relation to other things. Now, Mark, this might go to you as well. This article that I thought was pretty hopeful about T-cells by COVID-19 infection, respond to new, various new. Virus variants us study proposes. So this seems like really good news, so that we're talking to we're all of our folks on the vaccine rush the vaccine, but this could be to the 120 million people who have been roughly, we don't know exactly there have been have had COVID and then now immune, this is good news. Mark, do you wanna chime in first about this, the study of the relevance and how it might be helpful in the context of the current virus variants going on right now?
Mark Kissler:Yeah, I think the only thing that I would have to. To add to that is that there's, as we've seen throughout there's growing emphasis. Yeah. The role of T-cell immunity in helping to, to prevent future infection with COVID. And and T-cell activity in sort of getting rid of COVID, both of those things have been emphasized over the course of the pandemic. And so I think it's good news. It looks like the T-cell immunity that we're currently developing with any infection is also active against the particular variants. I, I think there could there be a scenario perhaps where we had a variant that escaped, human T cell immunity from this possibly. So these, these variants happen as a result of random. Mutations and some of those random mutations cause the virus to not work anymore, some of them cause it to gain additional function and, or, a superpower that we see increased spread or something like that, and others are totally inconsequential. And so the fact that the random mutations that have persisted yet are still susceptible to our T cell immunity, I think overall is is good news.
Matt Boettger:Yeah. Great. And to throw this in here quickly my confusion was I heard like months ago, or maybe two months ago that there were some articles saying that, Oh, natural immunity. Doesn't evade the new variants. And I don't know which one they're talking about. Me with the the South African one. I'm not sure, but this article seems to propose that the current variants, I think I just left it at that natural media seems to be good with, and then I've heard a month ago that it isn't. Is this new information or is there nuance here? Do you guys have anything? To chime in about this or no of Stephen or Mark.
Stephen Kissler:My sense is that the previous and previous infection and vaccination don't necessarily provide perfect immunity, meaning that they don't guarantee that you will not get infected either with the variant or, or with the wild type. So I was going through, there's always the chance of being infected despite having been infected before having the vaccine, the probability of that, I think. Increases with some of the variants in particular, the P one variant, which has some ability to evade the immune system. But also a previous infection and vaccinations seem to be extremely effective at preventing severe illness symptomatic illness and certainly hospitalization and death. And so I think that part of what we're seeing here is a different line at which people are drying too. Talk about immunity because immunity can be in so many different things. And so it's, it's like, does immunity mean total prevention from being infected and having any virus in your body or does immunity mean that you're not going to die and everything within that? And all of those are valid ways of speaking about immunity. But when it's compressed into a headline, it can get incredibly confusing.
Mark Kissler:Yeah. Could you just say that again? Cause I think it's worth emphasizing. I just had a conversation actually with somebody who, who told me flat out, they're like, well, the vaccines don't work on the new variants. And he said, no, actually that's not, that's not the case. And what Stephen, what you're saying, just if you don't mind. Say it again. What did, how, how did the vaccines interact with the new variants that we were currently seeing?
Stephen Kissler:Yeah, so it's, it's a matter of probabilities where as with everything with the immune system, our bodies have a whole distribution of variety. Our immune systems are as diverse as we are. And, and so, previous infection and vaccination, both. Very much reduce the probability that you will be infected with SARS cov, two of any type. You are a little bit more likely if you do get reinfected to be reinfected with a variant particularly the variants that are known to evade the immune system. So P one, for example is, is one of the ones that we're seeing infecting people more frequently. Then wild-type, if they've been previously exposed or vaccinated, but on the whole, that group of people is being infected at all at much, much lower rates. Furthermore the risk of hospitalization and death is very low with all of the variants. If you've been previously exposed or if you have been vaccinated. And so that's all very good news. And so that's that, that's the issue here is that there's immunity. Can mean, do I get infected or do I develop symptoms or do I, are we talking about likelihood or are we talking about a guarantee? And so I think that this is actually very similar to some of the Difficulty that we have, we've had talking about masks. It's a similar idea to saying that masks don't work well. What do we mean by work? I mean, w what we're trying to say is that there's, there's the spectrum of risk where a mask can make it less likely that you emit virus and then less likely that you inhale virus. And isn't going to guarantee that you will not become infected well, no, but it's. We're we're sort of doing the same thing with the word work. When we're talking about masks, what do we mean by that? As we're doing with the word infection here, where, where they're just different thresholds, where you can draw your line of what you mean by infection or protection. And, and I think being very clear about that is, is really helpful because the vaccines absolutely do give you substantial protection against the variants that we know of.
Matt Boettger:That's super helpful now to add one more variable to may or may not make it more complicated. What about herd immunity? So there's two words now there's herd and there's immunity by these two. Are we talking about a Buffalo herd, a human herd immunity serious. Now what do we mean by this? And Fowchee says 80, 85%. Vaccinations of this country before herd immunity, there are people now saying that, that they think that is not true, that we could achieve this with less percentage. Now we just talk about the T-cells, which to me that's really important that natural beauty at 120 million people, roughly who now have natural immunity for X amount of months with this many people already. Is it still at that threshold? And what do we mean? So I want to know what do we, what do we mean by herd immunity now? Is it, is it like stopping the virus or is it just, we just don't show it to anybody. We're we're all kind of Cognito holding it at Bay. Is there, is there a, is there a
Stephen Kissler:measure of this? It's I think you're, you're pointing to something really important, because again, we're talking about herd immunity, but the question is like, what, what do we really mean? Do, are we talking about like the end of the pandemic? Are we talking about eradicating SARS, cov two? Are we talking about it no longer about it? Sort of having a similar level of risk as the flu on a population scale on an individual scale, like across the world, in our particular community, what are we, what are we talking about here? And I think the answer is all of the above and all of it gets compressed into this idea of, of herd immunity. And so I think, I think to sort of break down my thoughts on this, that first of all, the, the threshold of herd immunity depends on how you get there. Because if you get there by natural infection the the disease naturally sort of people who are most likely to spread it because they have many contacts are also most likely to acquire it. So they'll get infected earlier in the course of the epidemic. And so it's almost you, the people end up getting infected are, are exactly the ones you would want to protect to prevent the illness from spreading. And so, and so you can actually reach. Herd immunity oftentimes at a lower level through natural infection than you can through vaccination. Now, I want to say very clearly that that is not an endorsement of herd immunity through natural infection because that still causes huge amounts of, deaths and hospitalizations. Right. So I think the best way to do it is through vaccination, but that's why there are these different thresholds that we've been quoting over time that maybe, you know, 60% of the populations through natural infection, but we probably need closer to 80, 85% with vaccination. Variants of course play into this as well, because without the variants, that threshold would probably have been closer to 70, 75, but the variants are more infectious that increases the number of people who need to be exposed or vaccinated in order to develop that amount of protection. And last, I think that And this is the thing that I've a lot of my conversations have centered around with. With other folks I've been speaking with is that herd immunity is not, it's not a permanent state either. It's a state that we can reach, but both the evolution of variants and the decline of our natural immunity. Can reduce that threshold that over time naturally will become sort of more susceptible to infection with SARS COVID two. Although I still think that previous infection and vaccination will still probably protect us on for a very long time against the most severe outcomes. And so what you end up with is actually the amount of immunity and this population is this sort of wiggly thing that will sort of go up and down over time. And then once we dip below the herd immunity threshold, we'll get outbreaks likely, and then that'll boost us back above it and we'll basically have a flu, like. Scenario, but hopefully our previous exposure, including vaccination will protect us from the most severe outcomes in most cases. And, and that's the idea we're reaching towards. So, so it's this, this tricky thing where we're herd immunity itself is sort of this dynamic state. It's this thing that that we'll constantly be attaining and then moving away from at least that's that's, that's my perception of it.
Matt Boettger:Okay, great. Helpful. No, that, that helps a lot. Let's get into a few more things here. We have so much to cover, but hopefully we'll get a few more in before the, the hour ends. One thing I want to talk about is the COVID-19 cloud lifts. As data shows a single case in one thousands cutout doors, this felt like pretty good news that like outdoors shows that it's extremely safe. This, put it in context that I saw that 5,000 people just attended a concert with no social distancing and effort to test in-person events. Have you heard about this? I think I've heard one other time where people were actually intentionally crowding people together in concerts with unknown mass. Just to see, Hey, I wonder what's going to happen here. Is this part of your work, Stephen?
Stephen Kissler:Yeah, this is not something I'm involved in. I've heard about it though. It's there's where they've I think there was early on, I guess it was probably last summer. I think there was a study in Germany that, that ran basically three concerts with different levels of distancing and masking is just to sort of see you what would happen, which I think is a really interesting idea. We can sort of break into the ethics of all of that too, but but I think it happens. Yeah. Yeah. And it does give it give some useful information, but I think that that's Yeah, that's, that's a whole, whole lot kind of thing, but I think you're right. The fact that, I don't know where exactly the estimate came from that, one in a thousand cases that can be acquired outside. And that's good that, that, that really suggests what we've. Yeah. Been pretty consistently aware of it's just that outdoor spaces are far lower risk than indoor spaces, generally speaking for SARS cov two transmission. And it's just nice to get it, to begin to sort of pin those down with
Matt Boettger:figures. And do you, does this mean, like I don't have to wear a mask outside or is this is this still like advantageous to wear a mask if you're less than six feet away? Or is it just so safe that, eh, yeah. It's okay. Or does this mean anything different for us for at least outside Hangouts?
Stephen Kissler:I think, not yet, but, but it's moving that direction. That that's part of the value of quantifying it is. And that's the reason why, why, why we do what we do, because then we can, we can start speaking really precisely about these risks and saying well, what is, what is the trade-off can, can we take off masks? There's does outdoors plus six feet of distance. Yeah, sufficient level of protection. That's something we're thinking about a lot. And I think that may well be, so I don't think that we're quite at a point where we would say absolutely. But yeah, but this is an important piece of evidence toward that end. Okay.
Matt Boettger:Great. Well now of course, he's really, really sick. It's obvious that you can see you stay away from them. Let's move to asymptomatic the vaccine. There's more research in the vaccine, Pfizer Madrona. It seems I've read an article that says that it prevents a somatic spread. Once you had the vaccine. Now it seemed very assuring in this article that this is like, I don't think it said a hundred percent, but it said pretty much. Do you guys know anything about this? Is this really like pretty much with once you had the vaccine and you're fully vaccinated, you're more than likely not going to spread it. Asymptomatically where's where's the spectrum on this? Any, any, any information on this Stephen Mark?
Stephen Kissler:I can start. I mean, so information again is still coming in on this. This was really the, one of the key, key, key questions at the beginning with with the vaccines, because the vaccines don't help you reach herd immunity if they don't prevent the spread of the disease. Yeah. And so, but, but the evidence is very good that The vaccines are, are pretty effective at preventing transmission. Probably like for the maternal and Pfizer vaccines, maybe not the astounding, like 95% efficacy that we saw against symptoms. And, but uh, and part of this is because it's so difficult. It's, it's easy to see if a person goes to the hospital. It's easy to measure. If a person, develops symptoms, it's much harder to measure if. Infection happens. And who infected whom. And does that exclude all of the other possibilities? How much virus were they producing? Was that virus viable? Were they in the same space for the right amount of all of that as much? And that's why we it's taken us a long time to get information on this, but. We've been getting it. And I mean, it seems I think last I checked, it was the estimates were like between 60 and 85% reduction in the risk of asymptomatic transmission. It's a huge range, but it's really good. And part of this is what was behind the recent CDC suggestions that did that a, you could begin to start mixing groups of people like one. Part of unvaccinated people with a bunch of other vaccinated people, because at that point, there's still a risk of spread, but it becomes much, much, much lower with when everyone has been vaccinated. And so, so we're still gathering information, but it's absolutely as as protective protective in the sense that it reduces probabilities. But not doesn't guarantee no transmission.
Matt Boettger:Okay, great. Now this is related asymptomatic. Asymmetric infection is a deep biological mystery. I saw this article and it's fascinating because Stephen Markey has taught me a lot of things. One of the things you've taught me about is that basically if you're infected with something typically evolutionary wise, the virus probably doesn't want to kill you off ideally. And no, it doesn't have a brain because it wants to survive. Right. And so I saw this article and I was really confused. I'm like ACE, genetic, infectious, Deaton, biological mystery. To me, it's like, it's common sense. Like we talked about silverware, if I'm a virus and I'm going to nigger and I don't have a brain, but I'm like, my goal is I'd go incognito. Nobody knows I'm here. I'm just chilling. I'm having a great time. I'm having a bunch of babies there. This is a great opportunity for me to have a party. And nobody knows that I can live happily ever after. Why on God's green earth. Would this even be considered a mystery? Is there, is there something I'm missing in this science? Granted, I got a high school degree and I didn't do very well in science class. So go ahead and tell me where I'm wrong.
Mark Kissler:I suspect the reason that they were talking about mystery in this particular article is because it's actually had some pretty understudied or asymptomatic infection in the grand scheme of infectious disease science, because it's only recently that we've been able to. Detect asymptomatic infection. And so that was, that was my understanding. And my gloss of the article is why it's a mystery. And I agree with you from this, evolutionary perspective of viral, excuse me, viral epidemiology. It makes a lot of sense for viruses to tend towards over time, less symptomatic. Or at least less highly what am I trying to say? Less deadly manifestations.
Matt Boettger:Yeah. Okay. All right. Steve, you have the dad on this one? No,
Stephen Kissler:I think that's exactly right. We have So Andy young, who's done this wonderful journalism over the course of the pandemic. Has a book called we contain multitudes. And it's I, I actually haven't read it, but I've read the jacket and I've spoken with many people who have read it. So it's on my list. Baby steps, baby steps. The idea is that it's that there's, we have a lot of microbes that live within us all the time. And, and most of those are either, they don't cause us symptoms. Some of them are actually essential for how we function. We need them. And so, and, and, and sort of the, the emphasis of the book is on that as well. So, just as sort of a counterpoint to this, that there is a lot of mystery, but there's, there's a lot of study of these microbes that that were in a sense infected with, but that sort of form an integral part of our sort of internal ecosystem.
Mark Kissler:Okay. Plus the Whitman. Do you know, does ed young have a have t-shirts like a band, like I would wear it an ed young t-shirt I,
Stephen Kissler:and we should, we should get on that. Yeah. Yeah. W somebody
Matt Boettger:tweet him or email him? Text him. I'll I'll wear tomorrow. That's awesome. All right. Okay. So wrapping up here. Here's my, here's my next question. This is about microbes and germs and this kind of stuff. I know this would be my soap box guys, but it hits me personally. CDC gives guidance and disinfectants. Now I'm not going to go down disinfectants route. And I'm like, how do you wipe your wind down that road? That was a year ago, but it came this nuance thing where like disinfectants versus soap and their guidance was. Basically. I mean, literally I think I'm really right on where I'm just paraphrasing this. I'm not trying to exaggerate, like if there is no known infection. Yes. Forget disinfectants, go with soap and water caveat. If there is a known infection, go with disinfectants, this is mind blowing to me and confused the heck out because basically what, what it sounds like to me is that this is not science, but psychology. This is Hey, if there's no known infection, Ornamental things like soap and water. That's cute. Do it feel good? Feel good, but if there's an infection, Holy crap. So if water doesn't work, you disinfect it, which makes no sense to me because I'm going to usually live in my house. During a pandemic as if there might be COVID in my house, not as if there's nothing in my house and I can just spit shine. My, my, my floors. It might, it might. It
Mark Kissler:might. Yeah. Yeah. I'll step in. I'm going to use Mike, some of my clinical language here for a second and say, I hear your frustration. And, and I've validated better now. I think that's valid, right? I think, I think it's valid because I suspect of what first soap and water do work. It's not purely ornamental. And I, what I, what I'm hearing I think is a deeper level of frustration with. Somebody who's very detail oriented, receiving lots and lots of highly detailed contradictory information for lots of differences over a year of extreme stress. Right. And so here we have. And so, so yes, like yes, yes. And yes, it is frustrating and it is, I think, particularly frustrating when it's conveyed in a way that feels very. Highly detailed, very precise. And you're trying, you're trying to do your best because part of the way that you're living out your responsibility is to be detail oriented. I think that's really admirable, and something like this can really throw. A wrench in the gears when you're like, have you tailspin wrong, over this time, I don't know what to do necessarily with that recommendation. I agree with you because it's like, sure. I don't know. Like we have to, from an epidemiologic standpoint where we don't, we're existing as if we potentially are exposed. Different times and things like that. Except for, to say that the, the basics still hold in this case, and I think all of those of us who are involved in scientific communication, be aware that your words can drive some people totally nuts. Got it.
Matt Boettger:Totally. It just leaves for gaps. Like I said, it just leaves for unnecessary conversations with other people sometimes. What does that mean? W w what do they mean by that? Like, why, why this, and not that I'm like, I have no idea. Well then, so it just, there there's another guideline for a CDC that you can reduce from six to three feet within schools. I'm like, what's that, some of this might be just negotiations with school districts, obviously making it easier and Hey, it's hard to teach from six feet away. I'd try three feet. Right. Let's see if that works for you, as
Mark Kissler:this is, I mean, it's just kids don't even know what day of the week they wake up in the morning and you're like, they have no idea what it's going to, what's going to happen that day. It's is it a school day? I don't know. Maybe it's, maybe it's a weekend. It's 63 feet has no meaning at all to the whatsoever under three foot crowd in our cohort, but
Matt Boettger:it was totally. Oh my gosh, I think. Okay. Well, I w I think we're in this here. There's still a few more things. I want to talk about outcomes raiser next week. We'll plant that seed or whenever Mark's back. Cause I want Mark in on that conversation. So we'll see, we're going to end there because it's, we're reaching about an hour and we've got to get this edited and pushed out. Thank you guys so much for all three of us being together. It's been awesome. For those of you who are listening. Thank you for listening again. If you can, in any way, support is patrion.com/pandemic podcast or one-time payment, then ma a Venmo PayPal on the show notes, you can reach out to Stephen S T E P H E N K S S L E R and Twitter. Check him out there. If you have questions for us, matt@livingthereal.com and I will send those emails directly to Mark and Stephen. I hope you guys have a wonderful and awesome week. We'll see you guys all next Monday. Take care and bye-bye.