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COVID-19 Variants: What We've Seen, Where We Are, and What's to Come · The SHEA Podcast

• 0:08
  SPEAKER_01: Welcome to the Rapid Response Podcast brought to you by the Society for Healthcare Epidemiology of America, Shay, promoting the prevention of healthcare-associated infections and antibiotic resistance and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:22
  SPEAKER_01: I'm Dr.
• 0:23
  SPEAKER_01: Jennifer Hanrahan, infectious disease specialist at the University of Toledo, and I will serve as your moderator.
• 0:29
  SPEAKER_01: Discussion on the podcast does not reflect Shay's perspective, but facilitates communication of multiple perspectives and experiences as we go through this challenging time together.
• 0:38
  SPEAKER_01: Shay is excited to launch this episode of the podcast, COVID-19 updates, what we know now.
• 0:43
  SPEAKER_01: Today's discussion will focus on COVID-19 variants, what we've seen, where we are, and what's to come.
• 0:49
  SPEAKER_01: Our speaker today is Dr.
• 0:51
  SPEAKER_01: Andrew Reid, Director of the Huck Institutes of the Life Sciences, Evan Pugh, Professor of Biology and Entomology, and Aberley, Professor of Biotechnology at Penn State University.
• 1:01
  SPEAKER_01: Thank you for joining us today.
• 1:03
  SPEAKER_01: Before we get started, I'd like to turn it over to Dr.
• 1:05
  SPEAKER_01: Ishra Kamal Ahmed for a brief news and guidance update for the week.
• 1:09
  SPEAKER_00: Hello, everyone.
• 1:10
  SPEAKER_00: For the global update, as of the 13th of September 2021, there have been 224 million confirmed cases of COVID-19, including 4.6 million deaths reported to the World Health Organization.
• 1:23
  SPEAKER_00: A total of 5.5 billion vaccine doses have been administered.
• 1:27
  SPEAKER_00: The big news last week was President Biden's COVID-19 vaccine mandate.
• 1:31
  SPEAKER_00: The measures will affect tens of millions of Americans and include mandatory coronavirus vaccination for all federal employees and contractors, vaccine mandates for workers and businesses with 100 or more employees with mandatory paytime off for workers to get shot and immunization requirements for the workforces of all health facilities that accept Medicare or Medicaid funding.
• 1:53
  SPEAKER_00: A trade group representing some 2000 consumer brand sent a letter to President Biden on Monday, September 13th, asking for clarification about his announcement last week that all companies with more than 100 employees also need to require vaccination or weekly testing.
• 2:09
  SPEAKER_00: The group included 19 questions regarding partial or full vaccination.
• 2:31
  SPEAKER_00: The White House has said that it'll provide more guidance on September 24 for the federal contractors affected by the executive order.
• 2:38
  SPEAKER_00: Jeffrey is then President Biden's coronavirus response coordinator has said that the rulemaking process for the OSHA component will take week.
• 2:47
  SPEAKER_00: In the last few weeks, most articles focused on the vaccine effectiveness against further hospitalization.
• 2:54
  SPEAKER_00: The first two studies in this podcast focused on the protection of COVID-19 vaccination against several infection and further medical care.
• 3:00
  SPEAKER_00: And the last two are on the topic of COVID-19 data.
• 3:03
  SPEAKER_00: In an article published in the Lancet Regional Health America on September 8th, 2021, to an observational cohort analysis, the researchers compared unvaccinated, partially vaccinated, and fully vaccinated adult patients with COVID-19 infection requiring emergency care or hospitalization within eight hospitals of Temperia.
• 3:22
  SPEAKER_00: They found that as vaccination has increased regionally, emergency care visits among fully vaccinated individuals have remained low and occur much less frequently than unvaccinated individuals.
• 3:33
  SPEAKER_00: However, if hospital-based treatment is required, elderly patients with significant comorbidities are at high risk for severe outcomes, regardless of vaccination data.
• 3:43
  SPEAKER_00: In a similar study published as an early related visitors in MWR on September 10, 2021, the orders here affirmed the high potential of COVID-19 vaccine against comorder and severe COVID-19, resulting in emergency department urgent care and hospital visits, and under, of course, the importance of fully COVID-19 vaccination and continued benefits of COVID-19 vaccination during Delta 3 and Pominance.
• 4:07
  SPEAKER_00: On the same day, September 10th, another early release article published in MMWR, the authors found that during February 1st to August 6th of 2021, vaccine effectiveness among US veterans hospitalized at 5 Veteran Affairs Medical Center was 87%.
• 4:23
  SPEAKER_00: Emirate COVID-19 vaccine agreements are highly effective, including during periods of widespread circulation of the Delta variant.
• 4:30
  SPEAKER_00: The public health implication is that to protect against COVID-19 related hospitalization, all eligible persons related to COVID-19 vaccination.
• 4:38
  SPEAKER_00: Now for the last two articles associated with that.
• 4:41
  SPEAKER_00: An article published on September 13 in the Journal of American Medical Association explore the association between healthcare factors and access death is not assigned to COVID-19 in the US.
• 4:51
  SPEAKER_00: The percentage of access death is not assigned to COVID-19 or higher in countries with more uninsured individuals with fewer primary care physicians per capita or with more debt at home than in the nursing homes.
• 5:03
  SPEAKER_00: Dying at home may also be associated with increased possibility of a coroner being involved who is united with less professional training than medical examiners.
• 5:11
  SPEAKER_00: The analysis suggests that marked variation in cost of death entertainment may also kill the populations most accredited for COVID-19, leading to inadequate positive responses.
• 5:21
  SPEAKER_00: And for the last article published in the Journal of American Medical Association on September 9th, 2021, the authors found that through a cross-sectional study of over 15,000 U.S.
• 5:31
  SPEAKER_00: nursing homes, that federal data underestimate the impact of COVID-19 on U.S.
• 5:36
  SPEAKER_00: nursing homes because federal reporting guidelines did not require facilities to report case and death data until the week ending May 24, 2020.
• 5:44
  SPEAKER_00: Approximately 44% of COVID cases and 40% of COVID-19 deaths occurred prior to the start of mandatory reporting.
• 5:52
  SPEAKER_00: This accounts for more than 68,000 unreported and 16,000 unreported deaths nationally.
• 5:58
  SPEAKER_00: Failure to account for this issue may lead to misleading conclusions about the role of different facility characteristics and state or federal policies in explaining COVID-19 outbreak.
• 6:07
  SPEAKER_00: That's for it today, and thank you for listening.
• 6:09
  SPEAKER_01: Thank you, Dr.
• 6:10
  SPEAKER_01: Kamal.
• 6:11
  SPEAKER_01: Ahmed, I will now move into the discussion with our speaker.
• 6:14
  SPEAKER_01: Dr.
• 6:14
  SPEAKER_01: Reed, thank you so much for joining us.
• 6:16
  SPEAKER_01: Can you start off by telling us about your background and any research you've done around COVID-19 and its variants?
• 6:23
  SPEAKER_02: Thanks very much, Jennifer.
• 6:24
  SPEAKER_02: My pleasure to be here.
• 6:25
  SPEAKER_02: I'm an evolutionary biologist.
• 6:26
  SPEAKER_02: I've been working for about 30 years on disease-causing organisms, how they evolve and particularly how they adapt to new things like different hosts and drugs and vaccines.
• 6:36
  SPEAKER_02: And I used to have to explain to people why pathogen evolution matters.
• 6:40
  SPEAKER_02: And obviously, I don't need to anymore.
• 6:42
  SPEAKER_02: Delta is showing us that these things really do matter.
• 6:44
  SPEAKER_02: I've mostly worked on malaria, but also some viruses of rabbits and chickens, where we can do experiments that aren't possible in humans.
• 6:50
  SPEAKER_02: My own COVID work is around community immunity and wastewater surveillance.
• 6:55
  SPEAKER_02: But last year I started really engaging in the evolutionary potential of this virus and obviously is now a very much an ongoing process of great concern globally.
• 7:03
  SPEAKER_01: Can you provide our listeners with a brief overview of what we've seen from COVID-19 variants and what we've learned from them and how this will influence the future?
• 7:12
  SPEAKER_02: Variants are the result of virus evolution.
• 7:15
  SPEAKER_02: Virus evolution always happens, especially when a virus jumps into new species, new host species.
• 7:21
  SPEAKER_02: The variants are lineages that have a trick that enables them to be more infectious, allows them to spread faster.
• 7:27
  SPEAKER_02: So more infections per infection per unit time.
• 7:29
  SPEAKER_02: And obviously anything that can, that has an evolved ability to spread faster will take over.
• 7:34
  SPEAKER_02: The tricks are things like better binding to human cells, more rapid replication, becoming infectious earlier in an infection, immune evasion, changes in spike, that sort of thing.
• 7:44
  SPEAKER_02: Well, I guess what we've learned is that our future will be dominated by what the virus does next.
• 7:49
  SPEAKER_02: Delta is something which is incredibly infectious and it would have spread anyway, but it also spreads in vaccinated people.
• 7:54
  SPEAKER_02: So if there's going to be more things like that to come, well, we'll get more of what we've seen with Delta.
• 7:59
  SPEAKER_02: So I think the future of research in this space is going to involve a lot more monitoring and surveillance and watching for new variants and new possible phenotypes that go with those variants.
• 8:08
  SPEAKER_01: So, what is the current state of the variants?
• 8:10
  SPEAKER_01: I mean, obviously, we're all very much aware of the delta variant, but we're now also hearing about the mu variant.
• 8:16
  SPEAKER_01: And what should we be concerned about in the future?
• 8:19
  SPEAKER_02: Yeah, mu is the next.
• 8:21
  SPEAKER_02: So it's popped up after Delta.
• 8:23
  SPEAKER_02: I think it's instructive in the sense that it shows delta is not the final word.
• 8:26
  SPEAKER_02: And actually, some of the earlier ones we've had alpha and beta and things, they're still around too.
• 8:30
  SPEAKER_02: I'm not at the moment too worried about mu.
• 8:32
  SPEAKER_02: From what I can see, it's not the same sort of highly transmissible variant that Delta is.
• 8:38
  SPEAKER_02: But I do think there's going to be more things around, and some of those probably will be more infectious than Delta.
• 8:43
  SPEAKER_02: As far as healthcare professionals concern, well, I think we should all expect more transmissible variants, perhaps vaccine adapted variants, maybe variants that are going to cause different types of clinical syndromes, maybe disease in different groups of people.
• 8:57
  SPEAKER_02: I, in terms of what you should tell your patients, well, I, you know, I say to people around me is don't get COVID.
• 9:02
  SPEAKER_02: And if you get COVID, don't transmit it.
• 9:04
  SPEAKER_02: So that means, you know, vaccinated, masking, distancing.
• 9:08
  SPEAKER_02: I think Delta is an example of a variant that's less forgiving of lapses in our behavior.
• 9:13
  SPEAKER_02: And future variants are likely to be more infectious and so even less forgiving of lapses.
• 9:18
  SPEAKER_02: So if we want to stop this thing, we need to, yeah, well, stop this thing.
• 9:21
  SPEAKER_01: So should we be concerned about the continued mutations and what our vaccine effectiveness is?
• 9:28
  SPEAKER_02: Absolutely.
• 9:29
  SPEAKER_02: I do think we should be concerned.
• 9:31
  SPEAKER_02: I wouldn't say terrified, I would say concerned.
• 9:33
  SPEAKER_02: We're in new territory here.
• 9:34
  SPEAKER_02: This is the first time ever we've had a new pathogen spill over into the human population, and then where we've hit it with a vaccine in very short order.
• 9:44
  SPEAKER_02: So we're on new territory, and it's a bit hard to sort of extrapolate from what's happened in other settings to this one because it is new.
• 9:49
  SPEAKER_02: But we can say that evolution in response to vaccination has been quite rare in the past.
• 9:55
  SPEAKER_02: So measles and smallpox, for example, haven't evolved in response to the vaccine.
• 9:59
  SPEAKER_02: Smallpox actually was eradicated because it failed to find a way around the vaccine.
• 10:04
  SPEAKER_02: So unlike antibiotic resistance, which is something that evolves very frequently, vaccine resistance is a lot rarer.
• 10:10
  SPEAKER_02: I've done some work on why it is a vaccine seem to be much more evolution-proof than drugs.
• 10:15
  SPEAKER_02: And we think we do know some of those features.
• 10:18
  SPEAKER_02: And interestingly, COVID vaccines don't have those features.
• 10:21
  SPEAKER_02: And in particular, many COVID vaccines are focused on rather few targets on the virus and they don't stop transmission.
• 10:29
  SPEAKER_02: So I think vaccine resistant variants will evolve.
• 10:32
  SPEAKER_02: We might already have some around, but there's likely to be more of them.
• 10:36
  SPEAKER_02: I think the way that's going to play out is that vaccine efficacy will drop in terms of infection and transmission.
• 10:42
  SPEAKER_02: But the history of vaccination is that even when that happens, the anti-disease vaccination effects, vaccinations stay very strong.
• 10:48
  SPEAKER_02: So you might be more likely to get infected in the future as a vaccinated person, but the ability of the vaccines to prevent you from seriously getting sick is likely to remain very strong.
• 10:57
  SPEAKER_02: Anti-disease protection seems to be better than antivirus protection.
• 11:02
  SPEAKER_01: So we should still be obviously strongly encouraging people to get vaccinated, regardless of whether or not there may be some ongoing infection.
• 11:09
  SPEAKER_02: Yeah, in my head, there's absolutely no evolutionary reason.
• 11:13
  SPEAKER_02: And then I think we know about evolution in other situations or nothing that we know about at the moment in this one, that would be an argument for not getting vaccinated.
• 11:20
  SPEAKER_02: And just out of personal safety, you're much less likely to get sick and die if you're vaccinated.
• 11:25
  SPEAKER_02: And that's likely to always remain true.
• 11:28
  SPEAKER_02: So I can't see a single reason why you'd want to not be vaccinated yourself, and certainly why you wouldn't want everybody around you to be vaccinated.
• 11:35
  SPEAKER_01: So are there any predictions for what may be down the road in terms of variants?
• 11:41
  SPEAKER_01: I mean, obviously we've mentioned the mu variant.
• 11:44
  SPEAKER_01: Is there anything else that we should be thinking about?
• 11:46
  SPEAKER_02: Yeah, you know, this is not physics or weather forecasting or even climate change forecasting.
• 11:51
  SPEAKER_02: Prediction is incredibly hard in evolution.
• 11:54
  SPEAKER_02: I like to think of evolutionary biology as advanced hindsight.
• 11:57
  SPEAKER_02: We really explain after the event what happened and why.
• 11:59
  SPEAKER_02: And we're pretty good at that.
• 12:00
  SPEAKER_02: Predicting forward is really tricky.
• 12:02
  SPEAKER_02: One of the reasons it's so tricky is we really can't know until something's appeared whether or not a particular phenotype is available genetically, right?
• 12:09
  SPEAKER_02: We need to have certain sorts of mutations to make the thing, for example, more transmissible.
• 12:14
  SPEAKER_02: And we can't know if it can be more transmissible until they appear.
• 12:18
  SPEAKER_02: So most of the prediction we can do is really find something when it's super rare and predict forward from that.
• 12:22
  SPEAKER_02: So we can't find something that doesn't yet exist and say it won't exist.
• 12:25
  SPEAKER_02: So I don't think there's actually data we can say on what's to come, but we'll only really know once it's here.
• 12:31
  SPEAKER_02: But from first principles, I do think we can say a few things about the evolutionary forces.
• 12:35
  SPEAKER_02: There's definitely going to be ongoing pressure for more contagiousness, more infectiousness.
• 12:39
  SPEAKER_02: Now we'd like to think that delta is the pinnacle, you know, it's as far as as high as or as effective as this thing can get at transmission, but there's no way to know that.
• 12:47
  SPEAKER_02: Only time is going to tell.
• 12:49
  SPEAKER_02: And I my bet is that there is, you know, more than delta, even more transmissible variants to come.
• 12:54
  SPEAKER_02: I think we'll see variants that are going to be better at both vaccinated and unvaccinated people.
• 12:57
  SPEAKER_02: Delta's one of those, and we'll probably see more of them.
• 13:00
  SPEAKER_02: It's quite possible we're going to see variants that start to specialize on vaccinated people.
• 13:04
  SPEAKER_02: Perhaps in those variants won't be so good at unvaccinated people, but they'll be better and better on vaccinated people.
• 13:10
  SPEAKER_02: And it might be that we'll start to see variants that are more lethal or less lethal.
• 13:14
  SPEAKER_02: I think that could go either way.
• 13:15
  SPEAKER_01: So, how do we know what's currently circulating?
• 13:18
  SPEAKER_01: Are microbiology labs doing surveillance for emerging variants?
• 13:22
  SPEAKER_01: And if so, how is that being done?
• 13:24
  SPEAKER_01: And should the sequencing be done primarily in public health or research labs, or should it be done more widely?
• 13:29
  SPEAKER_02: Yeah, Science Magazine has an article this week that says that in America there are 40,000 genome sequences being added to the database each week.
• 13:36
  SPEAKER_02: And that's just amazing.
• 13:37
  SPEAKER_02: 40,000, it took us 11 months to get the first 40,000.
• 13:40
  SPEAKER_02: And now we're getting that many a week.
• 13:42
  SPEAKER_02: It's terrific.
• 13:43
  SPEAKER_02: My view is that the sequencing should be done in any type of lab that where the appropriate quality control can be done.
• 13:48
  SPEAKER_02: It's pretty tempting to think that the hard part, which is tying the sequence to things we care about.
• 13:53
  SPEAKER_02: So it's pretty easy to get a sample and get a full genome sequence.
• 13:55
  SPEAKER_02: What you want to know did did that sample actually come from a vaccine breakthrough case or did it come from an unvaccinated person or a naturally immune person?
• 14:02
  SPEAKER_02: And then you want to know something about, you know, was that person particularly sick or not?
• 14:06
  SPEAKER_02: And how contagious.
• 14:07
  SPEAKER_02: Connecting that sort of data with the sequence is the hard part.
• 14:10
  SPEAKER_02: And that might be easier to do in some sorts of labs than in others.
• 14:13
  SPEAKER_02: But I think the fundamental thing is that we need a lot of surveillance going on.
• 14:16
  SPEAKER_02: And so the more sequencing, the better, so long as it's above a certain quality.
• 14:20
  SPEAKER_01: So, with all that we know about COVID and the variants, and given your expertise, do you have any thoughts on how we should be preparing for the future?
• 14:28
  SPEAKER_01: How can we prepare for what's next?
• 14:30
  SPEAKER_01: And when is the next wave or what is the next thing likely to be?
• 14:34
  SPEAKER_02: Yeah, I do think we'll see a lot more variance.
• 14:36
  SPEAKER_02: I think this is going to be a very dynamic situation.
• 14:38
  SPEAKER_02: And it's likely to be continue to be dynamic until we get to a situation, unless we get to a situation where transmission is very significantly reduced from vaccinated people, and if transmission is minimal from people who have naturally seen the infection.
• 14:51
  SPEAKER_02: In terms of what I think we should be looking out for, obviously we need to be keeping doing the genetic surveillance.
• 14:56
  SPEAKER_02: But for me, I'd be looking out for things like changes in disease severity, you know, are variants that might be more lethal or less lethal, or variants that might cause different types of disease syndromes.
• 15:07
  SPEAKER_02: So not necessarily the ones we've already seen, or that some people who haven't been getting sick in previous circumstances might start to get sick now, you know, young kids, healthy people without comorbidities and so forth.
• 15:19
  SPEAKER_02: So I think those are the sort of things that we should be watching out for, especially the healthcare professionals who are in a good position to notice unusual things, other sorts of things that might set in, like, for example, if you started to need other kinds of drugs to treat other sorts of symptoms, watch out for things like that that are changing.
• 15:34
  SPEAKER_02: And then in terms of the behavior for and how we might prepare, I think we've got to be rigorous in avoiding this transmission.
• 15:39
  SPEAKER_02: You know, the focus in clinical medicine is obviously, as it should be, on the patient health.
• 15:43
  SPEAKER_02: But from the public health point of view, we really need to be able to get this transmission under control.
• 15:48
  SPEAKER_02: And so that means we need very vigorous in the right circumstances, very visitors, you know, distancing, masking.
• 15:54
  SPEAKER_02: Healthcare workers need to be really rigorous with their PPE and so forth to try to get this transmission under control.
• 15:59
  SPEAKER_02: And maybe in the medium term to long term, we might get other ways of using our existing vaccines, which make them more potent in a way that stops transmission more successfully than they currently are.
• 16:09
  SPEAKER_02: Or we might get different types of vaccines, for example, mucosal vaccines that we sniff, which might generate an immune response in the upper respiratory tract more effectively.
• 16:17
  SPEAKER_02: And that would help with transmission and so forth.
• 16:19
  SPEAKER_01: All right.
• 16:19
  SPEAKER_01: Well, Dr.
• 16:19
  SPEAKER_01: Reed, this has been very informative.
• 16:21
  SPEAKER_01: Do you have any final thoughts for our listeners?
• 16:24
  SPEAKER_02: I just want to re-emphasize, Jennifer, your point before.
• 16:26
  SPEAKER_02: None of this is an argument against vaccination.
• 16:28
  SPEAKER_02: There isn't a single evolutionary scenario which would justify withholding life-saving medicines from people now.
• 16:34
  SPEAKER_02: So it's very, very important that we continue to press for higher and higher vaccine coverage.
• 16:39
  SPEAKER_02: I also want to end with a note reminding people that we're right now a lot better off than we were a year ago.
• 16:45
  SPEAKER_02: There are things to be concerned about, and we've definitely got to keep the surveillance going and keeping a very, very good eye on what's going on.
• 16:51
  SPEAKER_02: And we're not out of the woods yet, but we are a lot better off than we were a year ago.
• 16:54
  SPEAKER_02: And that's because of the vaccines.
• 16:56
  SPEAKER_02: And you know, the disconnection between infection and severe disease is happening, and it's happening more and more as more people get vaccinated.
• 17:03
  SPEAKER_02: And long while those vaccines keep working.
• 17:05
  SPEAKER_01: All right.
• 17:05
  SPEAKER_01: Well, thank you, Dr.
• 17:06
  SPEAKER_01: Reed.
• 17:07
  SPEAKER_01: Thank you very much to our speaker for sharing his perspective and experiences.
• 17:11
  SPEAKER_01: This podcast can be accessed on Shea's online education center, Learning CE, under the Rapid Response Program, where you will also find resources such as the Shea COVID-19 town halls.
• 17:22
  SPEAKER_01: This concludes today's episode of the Rapid Response Podcast.
• 17:26
  SPEAKER_01: Thank you for tuning in.