Pandemic: Coronavirus Edition

Is India an omen or an outlier for the rest of the world?

April 26, 2021 Dr. Stephen Kissler and Matt Boettger Season 1 Episode 72
Pandemic: Coronavirus Edition
Is India an omen or an outlier for the rest of the world?
Show Notes Transcript

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Matt Boettger:

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 good friend, Dr. Stephen Kissler who is an epidemiologist at the Harvard School of Public Health. And Dr. Mark is out he's I think he's on, is he on vacation? Oh, he's back in the hospital. He's been all over the place, but yeah, I think he is, I think he's back in the hospital this week okay. So he's out for a couple of weeks. He said, so he, he misses misses ass misses everybody. How you doing

Stephen Kissler:

Stephen? Hey, I'm doing all right. How are you?

Matt Boettger:

Good. Good. It's been a, Oh, guess what can you, I don't know if you can tell I'm wearing like short sleeve.

Stephen Kissler:

Hey, it's not snowing anymore.

Matt Boettger:

No, it's spring. Oh my gosh. Fire is wonderful. Yes. Yesterday was like 78 degrees went for a walk. We were out in the backyard making the backyard look nice. Rev up for mother's day because. If everything goes well, our first time being inside with our mother-in-law will be on mother's day. So we'll do it then. Yeah. So this is a really exciting cause then my wife will be two weeks and we'll be all getting fully, fully vaccinated by then. So it's a super exciting a little, a little nervousness just because it's, it's just the different reality. And we're always trying to be careful with, with our mother-in-law, but the boys are just. Like beyond excited. That's all they talk about. It's like the best day ever. It's like Christmas times, like a hundred, like what Nan is going to be inside so she can play with our trains. I'm like, yeah, she can. So we're really excited. We're getting ready for that. So it's a beautiful weekend. I love spring a lot of hope in the air. We have lots of stuff to cover. So a few things to get started with normal stuff. We love reviews had another review. Sorry. I was gonna read it, but I forgot to put it in to put it in my show notes. So I'll do it next week. It was so inspiring. So thank you. So we could always use more reviews. We love them just to keeps us going. You can do an Apple podcast. There's a couple other venues that offer those kinds of written ones as well. If you want to support us, we greatly appreciate that patrion.com/pandemic podcasts as little as$5 a month or a one-time payment, Venmo pay Venmo or PayPal all in the show notes. Oh, no one more thing. If you guys want to check it out, I dropped a new podcast episode and living the real where I brought on once again, my sister, Angie long, which some of you probably remember back in like episodes like four or five or six. It was a favorite. We talked about one of the biggest reasons or problems that causes marriages and romantic love to fail and what to do about it. It was really inspiring for me, helped me out a lot. And we got to a little freebie that we can send out that I've been using myself to help really cultivate deeper friendships and with the people that are closest to me. So if you want to check it out, it's in the show notes. So we have another one coming up really, really soon. Okay. So we have a lot to cover. Let's get going, but all this jazz, first thing is non COVID related. Let's start with this just because otherwise we fit in anywhere else. It's going to be just awkward. So it's just not COVID theme, but I read this Stephen game-changing malaria vaccine is 77% effective at stopping infection. Okay. So this is my utter ignorance. Clearly I live in a first world country where malaria is not a really big issue because I don't really think about it every day. So I didn't know that we didn't have a vaccine for this, but so tell me about this. Is this really a game changer? This is our first vaccine and I guess the big, the bare question for me is, is this related at all? To the advancements in technology of what we've been doing with COVID.

Stephen Kissler:

Yeah. So this is this is potentially huge. So malaria is really one of the big big, bad infectious diseases out there. It's one of the major killers especially in developing countries and it is it can be especially severe for young kids. So there's a ton of childhood mortality that's attributable to malaria. And so that, that's one of the things that contrasts it with COVID for example, where essentially the risk profile from malaria is quite different than that from COVID where covered really is tends to be much more severe for very old people. Malaria can be extremely severe for very young kids which, which is just, it's just different, that's just in my mind that that kind of, yeah. That makes it just one more reason to really, really pay attention to, and to really try to tackle it. And yeah, so there, there aren't currently vaccines against malaria. We do have treatments available, but often those are hard to come by. Their resistance kind of alter those treatments. And so a vaccine has been a really, really important goal for malaria control for a very long time. And one of the things that I really like is that because of how much we've been talking about COVID vaccines, we can put this into context and say what, where, where is this vaccine in it's stage? How, how promising is it? And so it's a, it's basically just completed phase two trials. So that's basically demonstrating safety and some degree of efficacy. Hasn't yet started the really huge trials. That'll be the real proof of its efficacy. So these are preliminary estimates of how effective it is. But these estimates are good. Like we were suggesting for the COVID vaccine, we would have been thrilled with 60 or 70% efficacy, thankfully we got some MRN vaccines that had upwards of 90% efficacy, which is just absolutely incredible. But even something with, with 70, 75% efficacy is going to be, if that holds through phase three trials, that'll be frankly, a game changer for malaria. It'll save tons and tons and tons of lives. And so it's great news. There's, this vaccine has been in development for a long time. It started development prior to the COVID pandemic. And so it's not necessarily building upon technologies that have been developed for the pandemic per se. But I don't think it'll be long before we start seeing vaccines coming out that are like that, that build upon the build upon the, the technology that really got spurred from the COVID pandemic as well. So I think it's great. I think that this is something that certainly my field was extremely excited about. And I think it's a good reminder too, that COVID, COVID clearly is a huge international disaster. But it's not the only thing. It's and there are a lot of people who have continued to be focusing on malaria, on TB, on HIV. And some of these things that have been, huge contributors to mortality in many different parts of the world for a very long time. And those, those deserve our sustained attention too. And so I really glad that this, that this has come out and yeah, I'm just hopeful for more good news with with some of these other infectious diseases as well. It's this is a really interesting time to be in, in the world of infectious disease epidemiology. And we have, even after the COVID pandemic begins to subside where we've still got a lot of, a lot of things to, to, to tackle them.

Matt Boettger:

This is not the only thing on your guys' radar, but it's probably dominated it for quite some time. That's great. I'm good. I'm really excited. This is back. We said March and April, it's we're bringing a, bringing up in the next generation, really surge to use that word in a different way of like new profession, not new professions, but new desires. Back, I'm a year and a half ago, epidemiology that, vaccinologist immunologists weren't even in my mind. And now it's at the forefront of everybody's mind and now seeing what needs to happen. I think we've been dragging our heels for quite some time about how to deal with next pandemic and ah, we're going to get there and we're maybe, dripping our way slowly by funding it and ways by to, but now I think we're just going to put all our money into this and to really expedite, to exponentially grow, to keep us from the next pandemic. So it's not so long. I know that we had record breaking record breaking movement with the, with the vaccine, but we might skip here just for a second. It's down to further in the show notes, but we can talk about it is a Atlantic came with article about taking the pandemic seriously and how we need to take it seriously now. And they did a great job by cause, cause that seems like a, such a cliche statement and what they mean by that. It's do we meet, do we double our masks? No, that's not what they mean by there's a really short term solutions. And what they're proposing is no, no, no, we need to take it seriously. Meaning. We need to, and this is not a joke they're saying like, we need to get vaccines out within a hundred days. That needs to be the gold that's taking the pandemic seriously. And they mentioned that this is not this is, this is not a random number. This is based on a lot of data information about how to be able to get there. And you're realizing that the MRI a at least modern, I think Moderna had their actually vaccine in, in 48 hours. Like they're the, from the research that th the, the thing was developed now, then the whole process took longer. I want to kinda throw it back to you and this idea that's what it means to be seriously talking among your colleagues. And is that, is that, is that like a, a goal that you guys look at too, or is that real a real possibility, because in light of is one phase two phase three, all this stuff that happens, I'm guessing there has to be an enormous shift of how we actually do safety. In vaccines, because I don't see any other way by doing a paradigm shift. What are you guys talking about this idea?

Stephen Kissler:

Yeah. It's, it's this huge trade-off, there's definitely rolling out vaccines quickly as is hugely important for both preventing illness and mortality and preventing the spread of variants, because again, the more the virus that's spreading the more likely it is for the virus to pick up mutations that can cause it to evade the immunity that we've built up. But we, we, we can't, we can't compromise the safety evaluations. We just can't, we, we can, we can cut away the red tape, but we can't cut away the essential observation periods where we just need to follow people for long enough to understand, if, if they're going to show Severe outcomes from the, from the vaccine or not. So it's this really tricky thing. But I think that from emergence of a pathogen to getting people vaccinated, being a hundred days, I think that that's still there. There's just no way to, to actually speed up the trials enough to do that. But from post phase three trials too. Getting people vaccinated. That becomes a lot more doable because we can start ramping up vaccine stockpiles, as the trials are happening. And and especially as, as we're thinking about M RNA vaccines, I think that our prior estimate of how safe these vaccines might be is going to be a lot more robust after this pandemic, where before, since we, we we'd used MRN vaccines in, in many different contexts, but not quite on the scale that we'd use to them for for COVID, but now we have, and they do seem to be extremely safe as far as we can tell. And so there's every reason to believe that that safety for the most part should translate to other vaccines as well, that are based on the same technology. So I think that there may be still some ways to speed that up a little bit more. And that's something we should be thinking about. But again never, never compromising the safety.

Matt Boettger:

Sure. And I love what they talked about in this article, because it almost took turned in my mind again, I'm the layman here. So my visuals of the future of vaccine rollouts are going to be what's in my kind of purview. And what's my purview, even though I never watched the news anymore, I never watched the weather, but I feel like almost like a biologist, whether men and women were like, just like there's daily weather forecast, there there's almost forecasts. We have such a robust system worldwide of examining. This is why I think the proposing is that one of the first things we have to do is have a robust, robust, worldwide system of constant monitoring of every possible. That said at least the dominant hundred, like different kinds of viruses, especially respiratory respiratory ones, because other ones seem to be the most crazy when it comes to transmission, that kind of stuff that we're really having a worldwide, like almost weather station of every possible examination so that we can almost see it ahead of schedule. We can't get everything, but we have a much more, we can be ahead of schedule. And then, one, I think in this Atlantic article one strong credit to the Trump administration of like then a similar warp speed kind of reality on a map on a major scale, on a bigger scale, that we can keep this in systemic. And that's the first couple of steps. So I was encouraged with that's what got me excited. Like these are the future of the little kids that are coming up. I'm like, they're going to be the part of this, this worldwide coalition of little virologists. And vaccinologist to help bring about this, this, this powerful reality to prevent us from a worldwide long pandemic. It goes to another, or another article I read, we said about a month ago about how we were just pleasantly surprised about a decrease in suicides on the, on the flip side of that, a recent article came out here, the drug overdose deaths surge during the coronavirus pandemic, that was probably to be expected. There was a number, a number of reasons. Obviously why fentinol was, was, was, was put on these drugs. I'm not sure the reason why, and that caused an overdose. But hearing that there's another reason why we want to expedite this because obviously the longer the pandemic, the longer we're isolated longer, we're not in touch with community. The longer we go to places that are dark and dangerous and cause a harm to individuals and to a community. So excited about the future there. Now, another question I want to throw to you, Stephen, I read this article. I don't care about the article itself, but this is a good question. Just to pick your brain for a second. It says, we know a lot about COVID 19, but experts still have many more questions. So besides the article in your own mind, as you've gone from March until now in this past April, and you probably know, you clearly know a lot more about COVID, but as an epidemiologist, what are the still couple of remaining questions you're thinking what's going on here? I'm not quite certain about how this is working. Do you have any of those? What are the main one or two that are in your mind right now?

Stephen Kissler:

Yeah. The, there are to really that come to the forefront of my mind. And I think, but before saying that, I think, like you said, we've, we've learned, we've learned so much, we've learned a lot about the mode of transmission we've learned very quickly about the, sort of the risk profiles who's most at risk of severe disease, how it spreads in whom it spreads and yeah, just like how how distancing, how masking, how these different interventions play with with the spread of the virus. So it's it's, it's pretty amazing how much information we've amassed about this totally new pathogen over the course of a year. That the two things that I'm really interested in going forward are first have to do with the evolution of the Corona virus. As, as before this pandemic, a lot of my research focused on the flu and a lot of the epidemiology of the flu is dictated by the way that the virus evolves. Flu is this really interesting critter it has this genome that is split into a bunch of different segments which is different than the coronavirus, which is generally like one, one single genome, as far as I know, a and B since the flu is separated into different segments that can shuffle those like a deck of cards and that allows it to evolve pretty quickly and in these really surprising ways. And that's part of what's behind the way that flu pandemics behave and and, and a little bit about around what behind what's behind the seasonal spread of flu as well. And so as we think about what's going to happen with the coronavirus in the future, we really need to know how evolution is happening. And that sort of a curious thing, because clearly we have, on the one hand, there's this one evolutionary timescale where it's just collecting mutations over time. But then we have these variants that seem to evolve much more quickly. They're like much more distantly related to their ancestors. And there are a couple of hypothesis as to why that might be the case, but, but we're not completely sure. Why there are sort of these variants that seem to seem to evolve more quickly than you would expect. And the question is, it was one of the hypothesis that circulating is, maybe these are evolving in immunocompromised patients because they're able to carry the virus for a long period of time. It can pick up mutations and then it's able to spread out word from there, which is possible. I had a discussion with some colleagues last week as to some of the evidence for, and some of the evidence against that. If that's the case, then, then. Then we need to understand, why that's happening, where that's happening, what we can do about it. If it's something else, what is it? And so I think that figuring out what those dynamics are, because that's going to be sort of the, the, the workhorse that's developing these variants in the future will be super important. The other thing I'm really curious about is the and I think we'll talk about this in some of the discussion later on in the podcast, as well as why is it that these outbreaks of COVID seem to be so variable in their intensity, in their timing, in their location, their geographic scope. Why is it that India, for example, was really able to avoid a lot of the most severe. Outcomes from COVID for a very long time. And then all of a sudden, they're, they're seeing frankly, the worst outbreak that we've had yet in the pandemic, like this is, this is the most severe manifestation of COVID. As far as I can tell that that, that we've seen yet. No, no, that's, those are strong words. And I think that, that that's, you can make arguments that other other times and other places have, have also seen equally or more severe outbreaks. But I think as a whole, the fact that of what's happening across the country as a whole and the severity of it is just absolutely unbelievable. So w why, w why now part of that story will have to do with the variants. And, and so that'll tie into the first question, but, but we saw these kinds of huge explosive outbreaks. For example, in Northern Italy, Prior to, the, the widespread emergence of these different variants as well. There seems to be something about the virus itself that causes it to just have these absolutely explosive epidemics in different places at different times. And we don't really understand what causes that timing, what causes that severity. And until we do, we won't have a good sense of how to prevent it. And so I think we're going to spend a lot of time thinking about that.

Matt Boettger:

Great note. A couple of follow-ups he has the two questions is about the evolution and then about how. The virus randomly attacks particular segments of a population or a country or a city. Now you mentioned about there's something in the virus itself. Teach me on this for a second, because of a couple of weeks ago. Now, again, I may have misunderstood it that, or maybe Mark said that we really don't know when it comes to variants. We really don't know anything about the virus itself when it comes to the variance, meaning like we can see the mutation, but how it's going to impact somebody else. There's nothing in the virus itself saying it's going to impact. It's going to be more dangerous. We just don't know what we just know that it's mutate until we see its impact on a particular community. Then we say, Oh, and you can correct me of all of this is incorrect. The, okay, by that impact, clearly this mutation is much more infectious. But you're mentioned that the virus itself might have something like when it comes to. So first of all, maybe clarify that, is there something in the virus itself that can make it. I've clearly more dangerous that you can see on an, on a scientific level or do you have to always wait until it's impact because that's why I'm thinking about it when it comes to evolutions and it's changing, how do you then determine that? How do you actually then find out how viruses evolve and then why sometimes they exponentially grow and otherwise, is it anything in the virus itself that you can, that we just try to look for? Or is it typically anecdotal evidence of just, Oh, okay. So now we reverse engineered that impacted Canada that way. So we have to reverse engineer everything to actually determine about the virus or there is there things in the virus itself that we can learn about why the evolve this way, why they particularly. Hit a demographic of people at a certain particular point in time. Does that make sense? Yeah.

Stephen Kissler:

Yeah, so there's in terms of actually understanding the, how, how the genome of the virus maps to the way that it infects people and the way that it plays out in populations. We can get a little bit of information about that before we see it spreading in populations. And thankfully this was some work that was, that that was actually done sort of last summer. And some of what helped us to determine and identify some of these variants of interest in variants of concern. And so one way to do that is in the lab. It's to look at that in particular, the spike protein of the virus and the genetic sequence, that codes for it, and in a lab, you can experiment the LEAs, switch out base pairs in the genome, which can lead to differences in the amino acids, basically the building blocks of the protein in the, in the space. And then in, in, in dishes, basically in, in Petri dishes, you can expose human epithelial cells. You can expose sort of the, the cells that the virus infects to these mutated proteins. Now these proteins are not attached to live virus, so there's no risk of it, like creating a mutant and spreading outside of the lab. They've really done their work to make sure that we're not going to cause a second pandemic from this. That's great. But you can just take that bit of the protein and expose it and see if there are differences in how well it binds and how long it binds and what sort of infection it causes. And so that can give us a sense of which mutations we ought to be looking out for, even if they haven't really played out in the world. And that's one of the ways that we've identified some of these key mutations that are in the variants because we identified them in the lab first and we knew that if these emerge in the real world that could be a cause for concern. And indeed that, that, that has been the case. The, those predictions largely have been very good. But on the other hand, the, the only other line of evidence that we have is to see something really emerge and then to ask, what, what caused it. And that's a much more difficult sort of thing to do because everything there is then confounded by, D did this particular variant just get lucky, is it just have something to do with human behavior and what's policies were in place at the time, what the weather was. And it takes a lot, a lot of effort to really tease that apart. The other thing is that, of course, it's usually when these viruses change The the way that they behave, isn't attributable to just one single mutation. Usually it's an entire set of mutations that then give it this particular type of behavior. And that's much more difficult to do in the lab as well because the number of mutations that you could possibly test are just astronomically huge, and you'd never be able to do that rigorously. Yeah. Does this get us off into a much longer tangent? There, there are actually people developing methods to figure out how to do that sort of thing as well. But that's there, there are some complications with that too. So there are ways to figure that out, but it's, but it's tricky. And so we have to see how things play out now that said so we're talking about the attributes of the virus itself and what makes it more or less infectious. But I do think that with that first question there, they're an attribute of. SARS cov two as such that sort of all of the variants share that, give it this behavior where it has these explosive outbreaks and that it's not necessarily that there's a different, very enter a different type of genetic sequence that's causing outbreaks in one place or another. I think that some of this behavior can emerge from what what essentially is what we call in mathematics is this inherently unstable assist system, or like a chaotic system where you're like riding on this. A Razor's edge of equilibrium where most of the time you're going to not cause an epidemic. And that's like where, where the system likes to sit. But once in a while, some random fluctuation is just going to cause this huge, huge shift. And you're just going to enter this entirely different space, which is a major epidemic. And those events might be very rare, but when they do happen, they can be catastrophic. And that can just emerge from the way that the virus itself plays with human behavior and different sorts of things. And I think that super spreading probably has a huge role to play in this as well. That probably the more likely a pathogen is to super spread. The more likely the overall epidemics are to be these very chaotic sort of explosive types of things. But that's something that we need to explore a lot more before, before we can know for sure.

Matt Boettger:

Okay. I'm just hearing you say all these things. It just makes me feel like how maybe how lucky we are that you remember back in March and April, you were saying how COVID. It's, it's harder for it to mutate or it takes longer for it to mutate. Now we've seen it. I'm like, will we ever, have we ever been getting ahead of the curve if this was something like a flu pandemic that, that can, that, that apparently can mutate much quicker and it hits the whole world. We're trying to build the vaccine over a year. And it's, if, if COVID-19 mutated this quickly and it's tough, help us. Am I right? The thing we lucked out on this one, maybe. Yeah. Yeah. I'm sure there's ones that you didn't even less, but compared to what we could have had, this is a nice warning sign to help get our, our, our, our stuff in order to be able to iterate

Stephen Kissler:

much quicker. Yeah. Yeah. So like the measles virus for example, is famously has a very stable genome. But it's extremely, extremely infectious. And so there's a trade off there. So if we had something like a, like a super measles that emerged or something and, and then that would be very, very bad news. And it'd be good that probably it wouldn't evolve as quickly, but, but then there's the trade off with infectiousness as well. So there's, there's, there's all these trade-offs for sure. But you're right. I think that that the landscape would look very different right now. If we had something that was evolving a lot more quickly than this. So

Matt Boettger:

now, before we move on, another question is, is the trade-off. Is that like a principle by how viruses typically run? So typically if it's, if it mutates much more rapidly, it has a tendency to be less severe or is there no relationship between those two? It just seemed Oh, I could see how one thing's fast. We don't think slower just seems how life works. One thing is efficient and that at the expense of one thing that slower it'd be nice if it's the more deadly things are a little bit slower to mutate or is that not a principle of science when it comes to?

Stephen Kissler:

Yeah, unfortunately I think that, that, that doesn't yeah, the, the, the correlation there is not probably isn't very good. So for example, the, on the other side of the spectrum, there's like HIV, for example, which mutates incredibly quickly, it's very severe. But it's just like an entirely different type of virus. And it's just the way that it behaves that, there's, there's a reason we don't have a vaccine for HIV yet. And part of that is because of its, its its speed of mutation. And so yeah, it's it's I'm not sure what the trade off there would necessarily be, but I don't think we can necessarily count on it being a totally straightforward.

Matt Boettger:

Oh man. If only things were that well-oiled I know so much easier. Let's move on to another question that's related. I saw this article. What is a, syndemic another new terminology that I had no idea, probably another frightening reality. Now I don't know if this is an exaggeration of, I think claiming that we're in a syndemic or if they're using it in the proper context, but I think here they're just mentioning the context of look we have COVID 19, but now we have so many different variants. It's it's now turning from pandemic to a syndemic. So what is a syndemic? Is that actually a scientific term? And are we in that realm right now with all the variants going on?

Stephen Kissler:

Yeah. I I'm recalling now that I think we may have mentioned to the term syndemic before, on the podcast with respect to the overlap of flu and the Corona virus did the two of them together. And that, that could have been a syndemic as well, so absolutely a scientific term. Other so we mentioned the COVID and flu syndemic that that didn't really pan out because we were really worried about those two things interacting with each other. Other syndemics for example, that, that I think people pay a lot of attention to is for example HIV and tuberculosis. That's a really interesting one because since, since HIV is a immunosuppressant virus, basically it it causes the presentation of tuberculosis to be very different. So tuberculosis looks different in a person who has active HIV infection than a person who doesn't. And so that's part of what makes it a syndemic because not only is it two pathogens circulating in the same population, but the fact that they're together makes the dynamics of both of them look different than they would if each of them was individually there. And so in my mind that that's really the hallmark of a syndemic, it's technically, it's just when two things are co circulating in the same population at the same time. But but I think really oftentimes when that name is used, it's when. Two things either work through similar pathways. So flu and coronavirus, part of the reason we would have called that a syndemic is because both of them would have caused a strain on the same sorts of medical resources, where you need ventilators, you need ICU rooms, you need oxygen, these kinds of things to, to deal with severe cases of each or things like HIV and TB, where, where there's an interaction somehow between the two that is different than you would expect. If it was just two totally unrelated pathogens circulating in the same place. So the question then is, can we call the coast circulation of different COVID variants? A syndemic. I think there's an argument in both directions. I think that that it's on the side of, of, no, the syndemic is an overblown term for this, it is, it is still just one virus, even though it has multiple variants in it. It is generally has similar behavior. You generally get immunity to some extent, to all of the variants, if you've been infected with one of them even though the level of immunity that you get differs. But there seems to be some level of protection, at least against the most severe disease to a large extent But I think it, I think that that one could be justified in calling it a syndemic at this point, too, because some of the variants really do have different risk profiles. They have different, different odds of sending you to the hospital. If you get it. They're able to evade immunity, which I think is really key as well, because if you can get reinfected by a different variant, then, then they really do start to take on distinct dynamics in the population. And in my mind, one of the other things is that if you have to start adjusting the way that you intervene, depending on what the variant is, and you have multiple of these variants circulating at the same time that then you could reasonably call it a syndemic as well. And so I think that we can, we could mince words and decide whether we are or aren't, but, but that's, that's the idea. And I think that Yeah, call it, call it what you wish. But we do, we do have a complex problem on our hands

Matt Boettger:

either way. Yeah. It seems like part of the complex problem has been obviously with vaccines we've been talking about, but also finally I think I'm right now, I even proved it past you. Before we got on at home coronavirus tests hit pharmacies, right? This is it. We're here. We're here. We're here. You're already here almost. Yes. So now you can actually go and go to your, whatever pharmacy. And I think it's actually over the counter. You can get one here's one caveat. It is expensive as heck man. It is$24 for a pack of two. So if you want to test yourself every day to be cautious, you might want to get a heat lock or something like that on your house, so you can pay for it. But this is at least a good, good, a huge movement forward, right?

Stephen Kissler:

Yeah, exactly. It's a big step in the direction that we needed to be going needed to be going long ago, I think. Yeah. And the fact that these things are available is a very good thing. But, gosh, we gotta get that price down because they're, they're as good as I'm not going to say they're useless, but Oh my gosh. The, the value of these things as being able to test yourself regularly and to use them, to, to not have to worry about ah, do I really want to drop 12 bucks just to, just to know, whether I'm infectious or not right now that's, that's a lot. And so admittedly, I was, I, so they are available over the counter. I I ordered one pack from CVS. Hasn't come in yet because I'm just curious, but I was, I was originally going to order two or three and then I realized it was going to run me almost a hundred bucks. There's no way, I, I, I'm an epidemiologist with sort of a vested interest in this kind of thing. And mostly, I just want to see, like what the packaging looks like, how hard is it to open the thing, like what are, I want to know what. Just like w w w w w what, what we're being faced with. And I, I almost thought it was my professional responsibility to order at least one of these things, but when was all I could afford know that's crazy. Because again, the, and this gets into some of the other things that like so much of this pandemic has been an issue with socioeconomic disparities, too. It's, it's hit populations that are poor that have little access to healthcare resources already. And if you have a test that costs 24 bucks a pop that's your, that that completely eliminates huge, huge segments of the population to be able to test themselves who need it most. Yeah. Great that it's available over the counter, huge step in the right direction. Super exciting. It's really nice to see it on the shelf. We got a lot more work to do. We gotta bring the price down and especially, as, as we're moving forward, we're going to talk a little bit more about, what's happening in India and, and is this, an omen for what could be happening, later in testing is going to remain a super important part of our response to this pandemic. For many months to come. And so we need to get this sorted out.

Matt Boettger:

Yeah, no, that's, that's helpful. Cause we're gonna get in that segue here in just a second, because I was going to almost, tongue in cheek, like I was gonna say, is this test at home too little too late? It was, it was good when a great eight months ago. For the U S I'm thinking in a very self-interested way in the U S the too old, too late. I think you just answered the question. No, it's not too little too late. It's way too expensive. The good news is in the article itself. It says they really are working very hard to get it down to one to$3 per test. I think ultimately you really need it to be$1 for sustainability. That's the only, to be able to get a 30 pack for 30 bucks is much more then you could test. That's, to me, that's 60 bucks, first 30 days. Now we're starting to get a little. I'm hoping just$1 this will be a game changer. So let's skip right to that because let's put this in the context of India, because this is the question I asked you before we got on I'm looking at India. I want to get your kind of perception of what's going on in India. It sounds from what I'm reading, just really the most tragic situation we've ever had of COVID and from what I'm reading, which scares the daylights out of me, not necessarily for the U S but for India that it's maybe far from over for India, that this is this, this could continue that they're not at their peak, potentially, not even maybe close. And so my question to you is looking at India, seen Brazil now, India. Now from what you can gather. I know I've been down this road with you so many times, Stephen it's complicated. So I'll, I'll do the, do all the nuances for you that you can't give a definitive response, but is this like an omen is Indian omen for the U S or for the rest of the world or as an outlier. Cause that's what I want to know because now I know there's no clear cut answer for that, but if it had to gravitate towards one of the other, what evidence shows that India is either a potential omen for the rest of the world, or is a potential outlier for the rest of the world. And maybe we can throw in these tests how these Adam tasks could be a game changer for India.

Stephen Kissler:

Yeah. I want to echo, just like the, the what's happening with the COVID epidemic in India is, is just really, really awful. And it is among the worst that I've seen. Over the course of the pandemic. And it's, it's pretty crazy now that over a year, end of this, when, a lot of the narrative here in the U S is okay, we can finally start to breathe a little bit easier, we're, we're emerging out of this and then this it's it's, it's pretty sober in that, we're seeing such a severe epidemic there right now. And yeah, if anybody's listening who is in India or who has family, I know I have a number of friends who have relatives who live there and it's just like incredibly frightening. And just like, just like really, really hard. I've been trying to stay caught up on the news. And I, again, I feel like it's like my. Responsibility to some extent to watch the interviews and just see as, as, as clearly as I can what's happening. And it's, it's just incredibly hard. Absolutely my heart goes out to everybody who's like severely affected by this it's, it's just, it's, it's, it's really, really, really difficult. It's, it's really hard to know how to place this in context for the rest of the world. It does make me pretty alarmed for For countries that currently don't have a lot of access to the vaccine. And that's generally here in the United States, we're incredibly fortunate to have a lot of our population vaccinated on the promise of having a lot more vaccinated. We were able to do that relatively quickly. But I think, I think really what this is an omen of potentially is, is shifting into a new phase of the pandemic where they're going to be now huge international disparities in which countries are getting severe outbreaks. We may well see severe outbreaks in in a lot of countries countries that are developing, know, and and just that currently have, don't have a lot of access to the vaccine. That's one of, one of the difficulties in India right now is that they have about 10% of their population who have been vaccinated. And it's just a massive, massive country right there. So many people to vaccinate there.

Matt Boettger:

1.4 billion, I

Stephen Kissler:

think it's crazy. Yeah. So I, I think I read the other day that they're, they're vaccinating on the order of 3 million people a day, which is similar to some of our best days in the United States, but also their countries four times as big. And so the relative rate is, is substantially slower right now. And so one of the things is, one of the things we're still trying to figure out is if part of this has to do with the new variant if there's a variant circulating that that is behind some of this spread although some of it likely has to do with the other, that question number two that I was talking about earlier is that, you never really know when it's your turn. And there's something about this virus that interacts with behavior that interacts with policies that interacts with just the. Random chance to some extent that just really allows it to, it's like this nuclear reactor meltdown that all of a sudden, just spills over and creates this massive catastrophe. And that, that may be in part what we're seeing in India right now as well. It's just because more, large numbers of infections, beget, large numbers of infections. And and once, once that train is rolling, it's really hard to turn around. It's difficult. So I think that the, the outlook, the outlook here in the United States and in many extremely wealthy countries has probably not changed much in light of this. I think that, as we're getting vaccine rates higher, again, we still remain at risk of outbreaks, some of the things that we've been saying in previous podcasts, remains true. But I think that the, the really sobering thing is that, this it shows that, just how much of the world is still at really high risk. It's pandemic is far from over, and it is just causing absolute devastation in in India right now. And I think that we need to do everything we can to prevent this sort of thing from happening in other places as well. Now, thankfully, some countries have come to provide some aid. I know the United States, for example, has been sending rapid tests. They've sent personnel from the CDC, for example, to S to help assess the situation. We've sent raw materials for vaccine production. India is largely producing their own their own vaccines. And I, I don't know. I think that we're S we currently have a stockpile of AstraZeneca vaccines, which still haven't been approved in the United States. India has approved essentially the equivalent of the AstraZeneca vaccine, but they've been producing it all within the country. And so I don't know if there are any issues with actually sending those vaccines over, but I know the U S has been sending the raw materials for producing the vaccines, which I think is at least a good thing in its own in its own. And Yeah. And I think the, the more the more we can do to, to do that sort of thing, the better maybe in the show notes, I can post some, I have some colleagues, epidemiologists who are in India or from India, have family in India have reputable places where you can send donations. If you're interested where, one of the big issues right now is that they're just low on oxygen. They need oxygen compressors, and hospitals are running out of oxygen for patients. And so that's really one of the most acute needs right now. And so their organization helping to to eliminate, to, to address that need. So we can include some of that in the show notes, once it's over.

Matt Boettger:

Great. So you heard that from Steve and I'll put in the show notes at the top, if you want to donate, contribute that way. I know a Google and a Amazon, I think Amazon, or is it? Yeah, I think at Amazon and Microsoft is as promised commitment as well. And it's going to take everybody to help with that situation. Our hearts and prayers go with them and it affects, it affects the entire world as he was saying so many ways. Of course the variants and what comes out of that, but just reading about 20% of the world's generic drugs come from India, 60% of the world's vaccines come from India. When you locked down India, which is what, what a, like a. A tragedy. To think of that 60% of the world's vaccines come from India and 10%, and that's a high number from what I've been reading is vaccinated. Much of what they do is for the sake of the greater world and not themselves. So it's a time for us to invert that a little bit and bring our resources available, which I'm glad to hear the white house providing the raw materials. I know another, another one was export controls and raw material we talked about. There was another one I'm trying to look at right now, the British Southern about releasing some kind of. Trade organization to temporary relax patent rights. So that as well too, so that, so that they don't have to be afraid, they can actually just do it themselves and get their own, get the, get the actual water formula and not being, being afraid of being sued at down the road. This is a time where I think these are the times where we just release those things for the sake of the common good. And then we deal with rewinding those things when everybody's safe and and everybody's healthy. Please check out the show notes to help support that. Let's come back to the us for a second here and look at some good news. I've just seen States with springtime covet, 19 surges appear to have turned a corner sets up your way. The Northeast I saw, you mentioned too, and Massachusetts been talked about as being the ones being hit, not as bad as Michigan. But it sounds like you guys are turning the corner up there. Things are slowly starting to shift directions to the better and just going back. And I, in, in comparing this to California, California, just now the lowest, I mean the only, the only other place lower is it's a low in the economy, the U S of, of, of COVID any kind of positive cases. It's just, Hawaii is the only one that actually is lower than that. Outside of all of the U S comparing those two, what do you think contributes to the upper Northeast and then California hitting it? I thought initially that is just a natural immunity, which could be a good sign that it works for the Veritas because I, Southern California just got drilled in the winter. And there's something about up to 50% are considered naturally immune, which is a pretty big jump to, but, so your feedback on the upper Northeast, how's it doing? And then its relationship to California of how, how it's

Stephen Kissler:

unaffected now. Yeah. Yeah. I I'm, I'm really thankful that cases are starting to turn the corner. Again, Michigan was one of those places that I was pretty concerned for. And they did see a really bad outbreak just now. And thankfully cases seem to be turning around. Yeah, I think that with with the question of natural and unity in a lot of places that have been hit really hard, we, we do have a fair amount of natural immunity. Northeast certain parts of New York city and certainly California, especially Southern California. There's just been a lot of spread. In the winter in Southern California there a lot of that spread was included the spread of some novel variants that are now spreading across the country as well. And so absolutely natural immunity, especially natural immunity to those particular variants is probably helping keep cases down in California right now. Meanwhile here in the Northeast, part of what's been behind our surgeons is those same variants coming in and making it a little bit difficult to control the spring. But I think, again, vaccination rates are helping turn the corner. The weather is getting better so people can spend more time outdoors. And it's helping a lot people keeping windows open, it's like these little things that, that I think. Probably go a very long way towards reducing reducing the spread of infection. Yeah, I think, I think again, we're, we're in this phase, we talked about weeks ago about how there would probably be, especially due to the variants, this long tail of cases. And, and we have largely seen that across the United States where there hasn't been another, huge surge across the country as a whole, some places have seen one, but we're in this long tail that is longer than it would be if the variants weren't around, but here we are. And hopefully cases are decreasing for good. No, and, but importantly, we're not out of the woods yet. W I was speaking with some journalists over the past. I failed a couple of calls from journalists every week, but one of the things that's really been on people's minds is, last year we saw a lot of springtime epidemics in the Northern us. And then it waited until summer for Florida and Texas and Arizona, for example, to really get hit hard which is their indoor season. Yeah. When it gets really hot in Florida, you spend time indoors in the summer. I didn't think about that. Yeah. And so I think that there's, there's something still worth paying attention to there too. Recognizing that, all of the evidence is pointing towards the COVID spreads indoors, way more easily than it spreads outdoors. And so we need to be thinking about indoor spaces, how to keep them safe and recognize that the timing of people congregating indoors changes from place to place. And so for the places where people are starting to spend more time indoors, now we need to be keeping a close watch.

Matt Boettger:

Yep. And that goes to this article, I'll put in the show notes. I loved it. Vaccines alone will not stop COVID spreading. So I'm not gonna, I'm not trying to make that being like, Hey, we're gonna be in this forever. I just love this idea of the Swiss cheese illustration that was brought up was like brilliant. So to put in there, it's great. I'm sure you're familiar with it. You have, she may maybe even talked about it. Who knows, but I loved it where, you have one slice with true Swiss cheese has some holes and apparently she has no, there's less holes in Swiss cheese now. W, yeah. They're they don't understand why, but there's, there's some theories of why this is like random guys, but there used to be way more holes, but there's less holes now. But anyway, side tangent, but there's some cool theories on why there's less holes, but then unless there's, there's holes in Swiss cheese, that's our next podcast, whole series on Swiss cheese. But then of course the more you layer, this was cheese, those holes overlap each don't overlap and they start sealing in all the holes, right? So of course, like the vaccine, very few holes in it, but it, but then masks and outdoors, these kind of things that the more we add in there, the more safety we put in preventing ourselves from being infected. So just keep that illustration in mind, as you begin to even do small things, if you're vaccinated, just the littlest things by just opening up a, a couple of windows, right? It's like a whole other layer of Swiss cheese and it was very easy and it's a nice day. So might as well, I love it. I'll put in the show notes. Is there. And we'll put that as well. Let's get the vaccines a couple of days before we, we, we closed up shop millions of millions of people are skipping their second dose of, of COVID vaccines. Now I think that's a little bit dramatic from when I, when I went into details, this, I want to throw this past you but it sounds really intense, but it looks like 95% of people are actually following through with their second dose compared to, I know I don't, I guess again, you can create all of this that there's not very many vaccines that are actually two dosages, like within back-to-back apparently a what's the other one. There's a, Oh, for older people. Oh, I wish I remember what it was. It is.

Stephen Kissler:

Forgot. Okay. I don't think I'm more familiar with

Matt Boettger:

PDI next. Yeah, I know. I see it always on way in grocery stores in the wintertime, but nonetheless, there's two dosages and typically that one on a normal year, it's 75%. This is much higher than normal. So we should be pretty confident in this. Now that 5% includes. Yep. Maybe some people who were become hesitant maybe because Johnson and Johnson, AstraZeneca, that kind of got them a little nervous. And so they didn't want to follow through with their but largely it happens to do with, it seems either Walgreens, there has been some mishaps with all Walgreens, meaning that they get their first vaccine, which is Pfizer. They come back three weeks later and all they have is Medina. And so they have to delay it. So the more like logistical delays, sometimes being sick during that time, traveling students moving from one city to the next and then having difficult to get in their second one in a different city when they go back home. So it's complicated, but my, my confidence level is high that I think obviously clearly 95% of people are getting their second vaccine. When it comes to the larger picture of the U S and in that kind of video, people skipping their dosages. What kind of impact do you see if any, when it comes to the U S and potentially variants? Cause I think one of the things is, I think we talked about this theory at one point in time that if somebody gets their first dose, this was, this is way back when we were talking about one dose and that's only, and make it more widely distributed or two doses have less vaccine, fully vaccinated. And one of the theories was be careful because what if, what if you only get the first dose and then you get infected, but somehow it mutates to be able to overcome that vaccinated response. And now we have this crazy mutation. Is that still a consideration or is there any kind of fear about that in light of millions of people skipping their second dose?

Stephen Kissler:

Yeah, I think that it's there, there is still some concern around that and, the virus can evolve and mutate and develop the ability to evade our immunity. Whether or not we've gotten one or two doses. I think that one dose might make it a little bit more likely. We can, we can compare to the strategy in the UK, which has largely been to vaccinate as many people as they could with the first dose and delay the second dose until there until the supplies were higher. And that makes a lot of sense because that brings down the total number of cases. And that also reduces the probability of any variant emerging which is a good thing. And some recent work suggests that that is actually probably a very good idea to just get as many people vaccinated as quickly as possible. Yeah. And that even from an evolutionary perspective, that's that's, that's a good idea. But that's of course, there, we're talking about delaying the second dose, but not necessarily skipping it altogether which is a very different thing as well. In my mind, the first dose from a lot of the trial evidence that we have available, the first dose does provide a decent amount of protection. By the time you get to about 10 days after your first dose, your risk of having symptomatic COVID goes down substantially. It's not the 95% that you get after the second dose, but it's probably on the order of 70, 80% or so. But the problem is that that usually a booster shot is the thing that gives you the long-term immunity. So one of the concerns is that if you just get the first dose, but then you don't get the second dose, then you'll have immunity for a period of time. But then that will decline a lot more quickly than it would if you got your second dose. And so that could put us in a much more precarious situation in six months, say than we would be otherwise if, if everyone was able to get their, their second dose. So I think it's really important, the, the trials were showed that it was the two doses that gave you the full protection. And so I think that whenever possible it's important to do that, but it's also no surprise that, any with any sort of vaccination medication, anything like that adherence is, is always a problem. It's hard to get people to come back in the doors or to keep taking pills or whatever. And so it's going to happen. And so I guess all we can say is, if you have gotten the first dose. I would highly recommend getting the second. And and I, I think that that will, that will really help both both of you individually and, and our, our, our community as a whole.

Matt Boettger:

Great. That's awesome. And I'll put a couple of show notes, links in the show notes to just about the efficacy, to continue helping people navigate this difficult train, to inspire them, to get the vaccine it's important. So this is a really global importance to be able to keep the variance down and to get this at Bay. And there's great evidence and just help people realize that they're not comparing, should I get the vaccine or not get the vaccine? That's not the right comparison because I've been helping a lot of people through this and they keep going down that path, which makes sense. Cause that's what you're thinking. Should I get it? I get it. But it's not that it's, always, always reminding them that it's actually getting the vaccine or being exposed potential of COVID and then they're both have risks and the risks are. Astronomically higher with COVID. So I'll put a couple of these articles that have incredibly, really good graphs to show the difference of the, the, the exponential difference in the risk between getting a vaccine, even something like AstraZeneca in Johnson, Johnson, right? It's one in a million chance of getting a blood clot and comparing it to the blood clots, like one in 20, right in, COVID not even a fair comparison. And that helps people see what they're actually really comparing and to navigate because I'm, I'm guessing I'm pretty certain that if your option was, get the vaccine or not to get the vaccine and the vaccine has nothing to do with reality, you wouldn't get the vaccine because you don't need it. But the, cause there's no point in putting this into your body that there's no need for it. So that's not actually the real issue, a couple of things. I'm always put in the show notes. I think that's what I'm just going to show notes for risks, skipper, that we're running short on time to the last question. I really want to get a year your answer from, cause you said you've also fielded this question from a couple of journalists the past week. Was this idea of vaccine, vaccine breakthroughs another concern among among many people of, okay, I'm going to get vaccinated, but what are the chances that it breaks through that, that vaccine? And I, and I still get it. Is there any evidence of what causes a breakthrough? Is it just an utter mystery or can we know what people might be a little bit more susceptible to a breakthrough?

Stephen Kissler:

Yeah, it's, it's really hard to know, who individually would be more susceptible to a breakthrough. A breakthrough is when a vaccinated person still develops COVID or becomes infected, again, there are different definitions to do you count it as a breakthrough if you've only gotten the first dose, do you count it as a breakthrough? If there's an infection, but no symptoms? Generally the most consistent definition that I've seen is in fully vaccinated people. If they have. And infection whether or not it's symptomatic. So we've seen a number of breakthrough infections, but many, many, many of those are not symptomatic. Some are though, and, and, and that is to be expected. There's some people won't Mount a perfect immune response to the vaccine. They do still seem to be relatively rare quite rare. And and generally the vaccines are very protective against, against severe disease, illness, and death. And so really, I think this is roughly in line with, with expectations. And I think really what it underscores is the importance of of getting cases down in the community as a whole, which, which vaccination is one of the best things that we can do for that, because Yeah, a breakthrough is a lot less likely if you're vaccinated, but it's a lot, lot less likely if there's no COVID in your community at all. Cause then you, then you can't get it in the first place. So I think that, it's, it's really just that now there's, there's been some questions too. There's this question from Twitter about the AstraZeneca vaccine and and the Johnson and Johnson vaccine that are based on the adenovirus which is it's, it's a chimpanzee virus actually that that they're using as the backbone. And so that the question is do you need a booster for these things because maybe your body will amount an immunity and immune response to the wrong thing. Maybe you're mounting it to the adeno virus instead of the COVID virus. The trials, the trials have been run and it's, it seems like a single dose of each of those vaccines is pretty effective. And so I think that, part of the reason for using the chimpanzee virus is as to because it's It makes it a little bit less likely that our human immune system will respond to it. And yeah, so I think that there's, there's, there can be some weirdness with the platform with the just the way that our immune system works and some of the randomness that's involved in the immune response as to what it actually attacks when it's exposed to something. And that will lead to variation in in, in how robust your immune response is. But unfortunately we don't really have any good sense of Who, how, how that plays out for any given individual. And it, it is probably largely up to just random chance, just what molecules your body happens to produce that day and and how it how it, how it responds to the, to the vaccine. Breakthrough infections will happen. They're rare. They're usually not too severe. They can be, but usually very rarely, and usually only in populations that are, have already been very severely hit in the elderly people with lots of criminal abilities. We're just still not a good thing. The most important thing we can do is keep cases down. Yep.

Matt Boettger:

That's great. Great. And then random question again related to this, but I don't know. Do you think there'll ever be a time by which we would be able to like. No. And the future of okay, here's your immunity. You hear me? Like immunity test, like almost like a diagnostic tool, like here in this, this, this vaccine will have roughly this kind of response. Do you think there's a future of that or is it just something like the immune system is just so complicated that I think, like you said, it can really boil down to maybe even the time of day. Of where your immune system's at, when you get the vaccine, it's not a permanent static reality, but you can get a scan and then you're permanently locked into that kind of response.

Stephen Kissler:

Yeah. I think, history is studded with scientists who infamously claim that something is too complex to ever figure out. And then a few decades later it's figured out. And so I don't want to get myself into that situation where I'll say that the immune system is far, far too complex. It is incredibly complex. I think it's never say never. I think that there are ways where we can we can get a better sense of how an individual's immune system works. It's possible. I think that it would be an incredibly big challenge though. I think what's more likely is after, after the fact There's there's a lot of research, actually, even at Harvard, that's being done on this by some of my colleagues where you can take a very small sample of blood and you can get a very good sense of what different pathogens a person is already immune to. And then you might be able to see, say this person's immunity to COVID-19 is a little bit lower than it should be. Maybe, maybe this person might need a booster to help give them fuller protection or something like that. I think that's, that's likely and that's, that's something that people are working on a lot right now. The predictive problem is a lot more challenging, but but I think even just being able to screen people for holes in their immunity could be really valuable.

Matt Boettger:

Yeah, no, I'm glad to ask the question cause that's really cool. What's Harvard's doing, I'd love to get that blood test someday. Thanks so much. I appreciate it. I know we're over an hour, longest one yet, but some great questions. Thanks for hanging in there for the full hour, Stephen, I've got a lot going on. Thank you all for listening again. If you can support us patrion.com/spend debit podcasts,$5 a month goes a long way. PayPal Venmo on the show notes. Please leave a review. If you want to get ahold of Stephen S T E P H E N K S S L E R on Twitter, matt@livingthereal.com, if you want to email us, let us know what's going on. If you have a question and check out my podcast, live in the real where I talked to Angie long about relationships and love have a wonderful week. We'll see you guys all next Monday. Take care and bye-bye.