Latest / The SHEA Podcast / COVID Update: BA.4 & BA.5 Impacts and Beyond

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COVID Update: BA.4 & BA.5 Impacts and Beyond · The SHEA Podcast

0:08
SPEAKER_01: Welcome to the Rapid Response Podcast brought to you by the Society of Healthcare Epidemiology of America, Shay, promoting the prevention and healthcare associated infections and antibiotic resistance and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
0:26
SPEAKER_01: I'm Dr.
0:26
SPEAKER_01: Ragavendra Thirapati.
0:28
SPEAKER_01: I'm the medical director of infectious disease at Keystone Health and also serve as the Chair of Infection Prevention at Wellspan, Chambersburg, and Wainsboro Hospitals.
0:37
SPEAKER_01: And I will serve as today's podcast moderator.
0:40
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.
0:50
SPEAKER_01: She is excited to launch this episode of the podcast COVID-19 updates what we know now.
0:57
SPEAKER_01: Today's discussion will focus on BA4, BA5, and COVID at large impacts and beyond.
1:04
SPEAKER_01: Our speaker today is Dr.
1:05
SPEAKER_01: Robert Wachter, a professor and chair of the Department of Medicine at the University of California, San Francisco.
1:12
SPEAKER_01: Thank you, Dr.
1:12
SPEAKER_01: Walter, for joining us today.
1:14
SPEAKER_00: It's a great pleasure, Ragab, thanks for having me.
1:16
SPEAKER_00: And thank you to all of your listeners for the amazing work they've done for the past three years.
1:20
SPEAKER_01: So, Bob, can you provide our listeners with your background and research as it pertains to COVID-19?
1:27
SPEAKER_00: Yeah, I am a generalist.
1:29
SPEAKER_00: I'm a general internist by training.
1:31
SPEAKER_00: I did a fellowship at Stanford in mixture of health policy and epidemiology and medical ethics, something called a Robert Wood Johnson Clinical Scholars program.
1:40
SPEAKER_00: Joined the faculty at UCSF a long, long time ago as a general internist, then became associate chair of the department, started the field of hospital medicine.
1:48
SPEAKER_00: I coined the term hospitalist a long time ago.
1:51
SPEAKER_00: And so that's what I do clinically.
1:53
SPEAKER_00: I take care of only hospitalized patients and work very closely with our infectious disease professionals.
1:59
SPEAKER_00: In terms of my research, I've moved around over the years.
2:02
SPEAKER_00: I've done everything from the role of activism in healthcare to the organization of hospital care.
2:07
SPEAKER_00: I've done a ton of work on patient safety and work very closely with Shay on that.
2:11
SPEAKER_00: The last seven or eight years, I've gotten very interested in the digital transformation of medicine and why it's been so bumpy.
2:17
SPEAKER_00: And when COVID hit, I kind of decided that there might be a role for someone like me, that there would be world experts opining on virology and vaccinology and aerosol science and all of the different aspects of it.
2:31
SPEAKER_00: And my lane might be someone who's pretty good at seeing the big picture, pulling together a lot of different threads.
2:37
SPEAKER_00: And it's turned out to be gratifying and useful.
2:40
SPEAKER_00: And a lot of people seem to follow me.
2:42
SPEAKER_00: What I try to do is sort of take and synthesize all of the literature and try to explain to both professionals and lay people kind of where we are and where we're going and try to make some sense of a lot of information and a big fire hose.
2:54
SPEAKER_01: Thank you, Bob.
2:55
SPEAKER_01: For those of you who are not following Dr.
2:57
SPEAKER_01: Walkter on Twitter, I strongly encourage you to follow him because it's very insightful and granular of how he dissects various topics with respect to COVID and beyond.
3:07
SPEAKER_01: And I have always found it very enlightening.
3:10
SPEAKER_00: Thank you.
3:10
SPEAKER_00: And I realize I didn't mention what my day job is.
3:13
SPEAKER_00: People could listen to all that and wonder how I get paid.
3:16
SPEAKER_00: So my day job is I'm chair of the Department of Medicine now at UCSF.
3:20
SPEAKER_00: So I run a department with about a thousand faculty and about seven or eight hundred trainees.
3:25
SPEAKER_00: That gives me access to some of the world's amazing experts in pretty much all of the fields that are relevant to COVID.
3:32
SPEAKER_00: And I don't think I've embarrassed them yet.
3:34
SPEAKER_00: So uh but that's kind of my day, day-to-day work is running this very large academic internal medicine department.
3:39
SPEAKER_00: Thank you.
3:40
SPEAKER_01: So, what do you think about the current landscape of COVID and with respect to the Omicron variants, the BA4 and five?
3:47
SPEAKER_01: What commonalities and differences are there between the two?
3:50
SPEAKER_01: And what is the big picture of COVID from where you're seeing it?
3:54
SPEAKER_00: I don't see much difference.
3:55
SPEAKER_00: Maybe I'm missing something between four and five.
3:58
SPEAKER_00: And I think for practical purposes, conflating them into one thing is probably a reasonable simplifying assumption.
4:05
SPEAKER_00: In the US, BA5 is now about 80% of cases, BA4 is about 10%.
4:11
SPEAKER_00: So I think it's fair to say that this combination of variants is the dominant variant or variants in the United States, having quickly taken over, really in the past month.
4:21
SPEAKER_00: I think, you know, we've since Omicron hit in December, we've gotten used to this kind of weird roller coaster.
4:28
SPEAKER_00: Okay, there's a spike and then it comes down quickly, except, and that's what certainly happened with the original Omicron in December-January, except now, as it's about to come down, it gets propped up again by a new variant that's about 20% better than the last variant at infecting people.
4:45
SPEAKER_00: And so rather than the roller coaster that we're used to seeing, we've really seen this plateau that's lasted almost about six months, really since February.
4:55
SPEAKER_00: And the plateau looks like things are stable.
4:58
SPEAKER_00: They're actually not.
4:58
SPEAKER_00: What you're seeing is a rapid fall in the prevalence of the prior variant, but it rapidly then being taken over and supplanted by a new variant that's 20% better at its job of infecting people.
5:12
SPEAKER_00: What's different about BA5, one of the things that we've all done with COVID is we get pretty good at pattern recognition.
5:17
SPEAKER_00: It's like, okay, I've seen this before and now I understand it.
5:20
SPEAKER_00: So the pattern recognition for the last several variants has been a new variant comes in, about 20% more infectious, replaces the prior variant very quickly, and props up the number of cases.
5:31
SPEAKER_00: And so they're pretty stable.
5:32
SPEAKER_00: What's different about BA4 and 5 is not only does it do that in terms of being more infectious, but it is uniquely immune evasive, more so than the prior Omicron variants.
5:42
SPEAKER_00: And what that means specifically is that your prior vaccinations and boosters are worth less than they used to be.
5:49
SPEAKER_00: And probably most interestingly, your prior infection is worth less.
5:53
SPEAKER_00: So if you happen to have gotten infected with BA2 in April or May, you know, you're used to people saying to you, okay, you know, that stunk that you got infected, but at least you now have really good immunity that's going to last at least three or four months, so you don't even have to worry about getting infected again.
6:11
SPEAKER_00: We can't say that anymore.
6:13
SPEAKER_00: Your immunity that you got from your prior Omicron infections is really not worth that much.
6:17
SPEAKER_00: It's not worth nothing, but not worth nearly as much as it was.
6:20
SPEAKER_00: And we are seeing an increased number of reinfections, in fact, including within four to six weeks after the prior infection.
6:27
SPEAKER_00: And so that's where we stand.
6:29
SPEAKER_00: Where we go from here really depends on are we going to see this pattern playing out again?
6:34
SPEAKER_00: And it feels hard, it feels sort of wrong to guess that we're not, since we've now seen it with four variants of Omicron.
6:41
SPEAKER_00: And yet, at least today, there's no variant on the horizon that looks like it's going to replace BA5.
6:49
SPEAKER_00: The possibility is this thing called BA2.75, which has taken off big time in India, but does not yet seem to be taking off in the United States or in other regions where there's a lot of BA5.
6:59
SPEAKER_00: So we may get lucky, and we need a lucky break every now and then with COVID.
7:03
SPEAKER_00: We don't get many of them.
7:04
SPEAKER_00: The lucky break would be BA4.
7:07
SPEAKER_00: Is the last major variant that is good at infecting people?
7:10
SPEAKER_00: And it then, if nothing replaces it as being a better variant, then it should begin to die off as more and more people have immunity to it and as more and more people get another booster.
7:21
SPEAKER_00: So that's fingers crossed that this is the last major kind of replacement variant that we see.
7:26
SPEAKER_01: How do you interpret the current case rates, both in the United States and globally?
7:30
SPEAKER_01: When I say case rates, not only the positivity rate, but also hospitalization rate and mortality with respect to the newbirds.
7:38
SPEAKER_00: Yeah, it's a good question.
7:39
SPEAKER_00: Each one of them is more kind of nuanced and fraught than it was a few months ago for a variety of reasons.
7:46
SPEAKER_00: So the easiest one to understand is a case rate in December last year was uh pretty much all made up of cases that were diagnosed with a test that was then reported to the public health department of your city and county.
8:02
SPEAKER_00: And so you could rely on that rate as being a pretty accurate reflection of people with diagnosed COVID-19.
8:09
SPEAKER_00: Now, obviously, it was an underestimate of all cases because a fair number of people had COVID and never got tested.
8:14
SPEAKER_00: But if you want it got tested, that got chronicled in a case rate, got rolled up into the Johns Hopkins numbers or the New York Times numbers or the WH numbers.
8:23
SPEAKER_00: So you could look at that number and say, okay, you know, I'm comfortable eating indoors if the cases in my region are less than 10, let's say 10 cases per 100,000 per day.
8:34
SPEAKER_00: The problem, as everybody knows, is starting in about January or February when home testing became easily available, is the case rates now that are publicly reported are probably somewhere between one-fifth and one-tenth of the actual case rate.
8:49
SPEAKER_00: If you had a case today, chances are you would be diagnosed with a home test and your city would never know about you.
8:55
SPEAKER_00: So that situation has been pretty stable for four months.
8:58
SPEAKER_00: And so I think you can look at case rate trends and fairly reliably say cases are going up but they're going down.
9:06
SPEAKER_00: But you cannot look at case rate numbers and compare them to case rate numbers in the past.
9:12
SPEAKER_00: So, for example, if your threshold for indoor dining is I want to see less than 10 cases per 100,000 per day in my community.
9:20
SPEAKER_00: If today I saw 10 cases per 100,000 per day in San Francisco, I would say I'm still not ready for indoor dining because that really is 50 or maybe 100.
9:29
SPEAKER_00: That's the magnitude of the underestimate.
9:31
SPEAKER_00: So that number has become less reliable.
9:33
SPEAKER_00: People look at sewage as another way of getting a sense, but I think you can look at the trends in case rates and tell whether it's going up or down.
9:40
SPEAKER_00: You just can't trust the number.
9:42
SPEAKER_00: Hospitalization rates, I think, are more trustworthy, but have also changed a little bit because of the number of people with COVID so prevalent.
9:50
SPEAKER_00: More people are in the hospital with incidental COVID, sometimes referred to as they're there with COVID rather than for COVID.
9:57
SPEAKER_00: And so that number early in the six or eight months ago was probably 70-30 that people were in the hospital because they were sick with COVID.
10:04
SPEAKER_00: Today it's probably more like 30-70 or maybe 50-50 at most.
10:08
SPEAKER_00: So when you look at a hospitalization number, it's an overestimate of how many people are there sick with COVID.
10:14
SPEAKER_00: The death rates probably have some of the same attributes.
10:17
SPEAKER_00: If someone dies of sepsis or a heart attack and they test positive for COVID, it'll probably get chronicled as a COVID death.
10:25
SPEAKER_00: And some of them are you died of something and you also had COVID.
10:28
SPEAKER_00: So each number has some nuances associated with them that they didn't have in the past.
10:33
SPEAKER_00: And you need to sort of put together a whole picture to try to get an accurate sense.
10:38
SPEAKER_00: What I don't like is the CDC spends a lot of time looking at the hospitalization numbers as in their metrics of how much COVID is there in your community.
10:47
SPEAKER_00: I understand that because if your hospitals are full, that might drive public health leaders, for example, to institute a mask mandate or do something more drastic because that's bad.
10:57
SPEAKER_00: Hospitals are full, we've got to be careful.
10:59
SPEAKER_00: But the hospital being full or not full really doesn't say anything to me that's useful about whether I should wear a mask.
11:05
SPEAKER_00: For that, I want to know how much COVID there is in the air.
11:08
SPEAKER_00: I mean, that for that, I want to know what is the probability that the person standing next to me in the line at the supermarket has COVID and feels fine.
11:15
SPEAKER_00: The hospitalization number tells me nothing about that.
11:18
SPEAKER_00: The number I like for that is not publicly available.
11:20
SPEAKER_00: It's a number at my hospital.
11:22
SPEAKER_00: We test everybody who comes in for anything for COVID.
11:26
SPEAKER_00: So if you come in for a colonoscopy, we'll test you.
11:29
SPEAKER_00: You come in for open heart surgery, we'll test you.
11:31
SPEAKER_00: So that we call the asymptomatic test positivity rate.
11:35
SPEAKER_00: No symptoms of COVID, we test you and you're positive.
11:37
SPEAKER_00: That number today is 5%.
11:39
SPEAKER_00: So that says that one out of 20 people in San Francisco who feel fine would test positive for COVID.
11:46
SPEAKER_00: If that number is accurate, if you board an airplane with 100 people, there's more than a 99% chance that someone on that airplane has COVID.
11:54
SPEAKER_00: And it probably feels fine and doesn't know it.
11:56
SPEAKER_00: Now, are they sitting in the seat next to you?
11:58
SPEAKER_00: I don't know, but they're on that airplane.
12:00
SPEAKER_00: And I've always fantasized what would happen if, as you boarded the plane, the flight attendant had a sign that said, I can guarantee to you that someone on this plane has COVID and doesn't know it.
12:10
SPEAKER_00: I think the mask wearing rate would go up quite a bit.
12:12
SPEAKER_00: So there are a lot of numbers to follow.
12:14
SPEAKER_00: They're all a little bit confusing.
12:16
SPEAKER_00: And I think you have to look at a number of different of the metrics in order to come up with a full picture of what the state of COVID in the communities and what individuals and public health leaders should do.
12:25
SPEAKER_01: I think that's a good segue to the next question about masking.
12:29
SPEAKER_01: So given this significant outbreaks, should people be wearing masks today and in what situations?
12:35
SPEAKER_01: And again, tied to that would be what would be your thoughts about mask mandates?
12:40
SPEAKER_01: And also, what would be the overall risk to these people if they do acquire COVID and what would be the risk for long COVID?
12:47
SPEAKER_01: So two different questions.
12:49
SPEAKER_00: I counted five different questions, Raga, but I'll try to go for it.
12:52
SPEAKER_00: So I'll tell you what I'm currently doing.
12:54
SPEAKER_00: I still wear a mask, and if I'm going to wear a mask, I wear a good mask.
12:57
SPEAKER_00: I wear a KN95 usually, and I wear it in crowded indoor settings, and I don't do indoor restaurant dining.
13:05
SPEAKER_00: I wear it certainly on airplanes and buses and trains.
13:09
SPEAKER_00: And I think it's a prudent thing to do because I still don't want to get COVID.
13:15
SPEAKER_00: As far as I know, I have not gotten it.
13:17
SPEAKER_00: Now, am I worried about dying from COVID?
13:20
SPEAKER_00: Not really.
13:21
SPEAKER_00: I've had four vaccine shots, and the evidence would say, as a healthy 64-year-old who's had two vaccine shots and then two boosters, my chances of dying of COVID are extremely low, almost certainly lower than the flu today, particularly if I got COVID and ended up taking Paxlovid.
13:37
SPEAKER_00: So I'm not really worried about what I would have been worried about in March 2020, which is getting super sick and getting up in a respirator and dying.
13:44
SPEAKER_00: I still am worried about long COVID mostly.
13:46
SPEAKER_00: And the best evidence says that the risk of long COVID, meaning symptoms that last more than a month or two, is about one in 10, might be one in five.
13:56
SPEAKER_00: It's lower if you're fully vaccinated.
13:58
SPEAKER_00: It's lower with Omicron than the prior variants.
14:00
SPEAKER_00: It's lower if you're a man compared to a woman, a little bit.
14:03
SPEAKER_00: So I would say if I got COVID, my risk for long COVID is probably one in 20.
14:08
SPEAKER_00: Is that high enough to merit wearing a mask?
14:10
SPEAKER_00: To me, it is.
14:10
SPEAKER_00: I could see other people saying 19 out of 20 chance I'm not going to get long COVID.
14:14
SPEAKER_00: You just told me there's almost no chance I'm going to die since I'm healthy and I've I'm fully vaccinated and boosted.
14:19
SPEAKER_00: I don't want to anymore.
14:20
SPEAKER_00: I'm sick of it.
14:21
SPEAKER_00: I don't think that's an irrational choice.
14:23
SPEAKER_00: It's just not a choice that I would make for myself.
14:26
SPEAKER_00: The other reason is when I talk about long COVID, I'm really talking about two different buckets.
14:30
SPEAKER_00: There's long COVID, as in this is what my wife had, you know, two and a half months out.
14:35
SPEAKER_00: She's still at the end of, you know, three to four hours of thinking hard, she would need to take a nap for an hour and didn't feel like her brain was working as well.
14:43
SPEAKER_00: I don't particularly want that, but that's she's getting a little bit better now, three months out.
14:47
SPEAKER_00: But there's the other form of long COVID, which is a number of studies have showed that a year after your case of COVID, you have a higher risk of a heart attack, you have a higher risk of diabetes, you have a higher risk of a stroke.
14:58
SPEAKER_00: I don't think we fully understand why that is, but the level of risk is similar to that you being a smoker or you having untreated high blood pressure.
15:07
SPEAKER_00: And so you put all that together, and I feel like do I need to do indoor dining in a restaurant or am I comfortable eating outdoors if I'm taking a significant chance with the amount of COVID in the air now that I'm going to get COVID and still feel crummy two months from now and maybe elevate my risk of having a heart attack or a stroke.
15:26
SPEAKER_00: And so to me, when I put all that together, I wear a mask.
15:28
SPEAKER_00: I don't think people are being crazy if they don't.
15:31
SPEAKER_00: I think people are being crazy if they don't get vaccinated and if they don't get at least their first booster.
15:35
SPEAKER_00: I think that's just absolutely wrongheaded.
15:38
SPEAKER_00: The mask thing, I think at this point, reasonable people can come up with different conclusions about it.
15:44
SPEAKER_00: And because of that, I'm not a believer in mass mandates at this point.
15:47
SPEAKER_00: I think that we needed them in the beginning.
15:50
SPEAKER_00: I think the evidence that they work is a little bit uncertain.
15:53
SPEAKER_00: I'd rather say, all right, you know, because you can mask as an individual and keep yourself safe.
15:59
SPEAKER_00: You can then take a medicine if you get COVID, the hospitals are not overwhelmed.
16:04
SPEAKER_00: I think it's fair to leave people to their own choices and reserve mask mandates if hospitals are getting overwhelmed and getting filled, which in most parts of the country they're not right now.
16:14
SPEAKER_01: Aaron Powell So on the same note, what is your opinion on the CDC's isolation guidelines, especially knowing how contagious these subvariants are?
16:22
SPEAKER_01: Do you think there is a need for a change or they're good as they are right now?
16:27
SPEAKER_00: I don't like them.
16:28
SPEAKER_00: I understand why they have them.
16:30
SPEAKER_00: It's a very pragmatic decision to say to someone if five days you feel well, your symptoms are better, you don't have a fever, you're okay to go, but you should wear a mask.
16:42
SPEAKER_00: If they wore a good mask and wore it religiously, there's probably a relatively low risk.
16:48
SPEAKER_00: But the reason I don't like it is President Biden has COVID now.
16:52
SPEAKER_00: He's not following the CDC guidelines.
16:54
SPEAKER_00: He is going to stay in isolation until his rapid test turns negative.
16:58
SPEAKER_00: I think that's the right answer.
17:00
SPEAKER_00: The average person with Omicron, their rapid test turns negative on day eight.
17:05
SPEAKER_00: We know that they are still infectious.
17:07
SPEAKER_00: One of the nice parts about the rapid test is it's really correlates quite well with infectiousness.
17:13
SPEAKER_00: So if you're still rapid test positive on day seven, you're still infectious.
17:18
SPEAKER_00: And if the CDC says you're okay to go out after day five, my fear is that a fair number of people read that, don't read about the mask part, and go out on day six and are infecting people.
17:29
SPEAKER_00: Now, why didn't the CDC say that?
17:31
SPEAKER_00: I think they're worried that is everyone gonna have access to rapid tests?
17:35
SPEAKER_00: They're expensive, it's a little bit unwieldy.
17:38
SPEAKER_00: And so they've kind of made a simplifying assumption that if you do wear the mask, you're gonna be relatively safe.
17:44
SPEAKER_00: That's probably accurate.
17:46
SPEAKER_00: But I'm afraid people read that and just say, okay, day five, I'm no longer infectious.
17:50
SPEAKER_00: That's just wrong.
17:50
SPEAKER_00: I heard the CDC director being interviewed today, and she continued to say that, well, even though the president is going to stay in isolation until his test is negative, she sort of said something like, Well, but we're confident that you're not infectious after day five if you're asymptomatic.
18:06
SPEAKER_00: I think that's just scientifically wrong, and I think they lose some credibility when they say that.
18:10
SPEAKER_01: On the same note, what are your thoughts about rapid antigen testing as it comes to today?
18:16
SPEAKER_01: There are a lot of reports about false negative rapid antigen tests.
18:19
SPEAKER_01: Again, with the current wave, do you recommend using them?
18:22
SPEAKER_01: And in what scenarios?
18:24
SPEAKER_01: Only when people get symptomatic, or is it before or after gatherings, after exposures?
18:29
SPEAKER_00: Yeah, I continue to like them.
18:31
SPEAKER_00: I think they're a very practical, very useful tool in helping to manage some of the hard decisions we all have to make every day.
18:38
SPEAKER_00: I think the evidence that they're more likely to be false negative with the later variants isn't all that strong.
18:46
SPEAKER_00: I've heard those anecdotes as well.
18:48
SPEAKER_00: But I think when Omicron hit, we learned that you can be negative on your rapid test for your first day or two of symptoms.
18:57
SPEAKER_00: So you should not count on a negative rapid test as giving you a good housekeeping seal of approval.
19:02
SPEAKER_00: You're fine.
19:03
SPEAKER_00: Don't worry about it.
19:04
SPEAKER_00: But you can certainly count on a positive.
19:06
SPEAKER_00: There still are relatively few false positives.
19:08
SPEAKER_00: You have symptoms and a positive rapid test.
19:11
SPEAKER_00: I think you're done.
19:12
SPEAKER_00: We know what you have.
19:12
SPEAKER_00: You don't need a confirmatory PCR.
19:14
SPEAKER_00: And I think you now have this tool that you can use to test out of isolation, that you should stay in isolation until your rapid test turns negative.
19:23
SPEAKER_00: Average person, as I said, that happens on about day eight.
19:26
SPEAKER_00: What to do with the negative and when to use them?
19:28
SPEAKER_00: I mean, if I woke up tomorrow morning with a sore throat, I would take a rapid test.
19:33
SPEAKER_00: If it was negative, I would still isolate myself from my wife and family, and I would not go into work for one to two more days.
19:42
SPEAKER_00: I would then take another rapid test.
19:44
SPEAKER_00: If it's still negative, I would say I'm okay.
19:47
SPEAKER_00: Now, is it possible that both are false negatives that I really have COVID?
19:51
SPEAKER_00: It's possible, but the likelihood is really quite low.
19:54
SPEAKER_00: So I think you can count on the rapid test to test out of positivity, but you have to really do two of them and space them at least a day apart.
20:02
SPEAKER_00: I'd like using them to keep an environment safe.
20:05
SPEAKER_00: So I'm going to a board meeting in a couple of weeks of mostly older people.
20:09
SPEAKER_00: There'll be about 15 of us.
20:11
SPEAKER_00: Everybody has to be vaccinated, everybody has to be boosted, but we now know that that no longer is ironclad protection against anyone being infected.
20:19
SPEAKER_00: We're all going to wear masks inside, but in addition, to keep things as safe as we can, we'll all do a rapid test a couple of hours before the meeting.
20:27
SPEAKER_00: And if anybody tests positive, obviously they will sit out of the meeting.
20:30
SPEAKER_00: I think the using the rapid test as an entire group using it before a get-together, particularly if there's anybody vulnerable there, is a wise use of the rapid test.
20:40
SPEAKER_00: And again, it's not a perfect test.
20:42
SPEAKER_00: You know, someone could test negative and be infectious and have COVID, but you probably become 90% more sure that everybody's negative, everybody has a rapid test than if you didn't use that step.
20:53
SPEAKER_01: Let's talk a little bit about vaccines.
20:55
SPEAKER_01: What are your thoughts about getting the second booster?
20:58
SPEAKER_01: And there is now a thought process that people should wait until the reformulated booster comes in the fall, versus people who are at risk should not wait and get the vaccine right away for the second booster, I mean.
21:11
SPEAKER_01: So what are your thoughts on this?
21:13
SPEAKER_00: Yeah, I think the evidence supporting the second booster has gotten stronger over the last several months.
21:19
SPEAKER_00: I mean, the data say that even compared to people who've had three shots, that fourth shot lowers your mortality by about fourfold.
21:27
SPEAKER_00: And obviously that's a more meaningful difference if you're at high risk of mortality.
21:32
SPEAKER_00: So I think it's no question if you're over 60 and you've only had three shots, if your last shot was in November 2021, you're not very well protected.
21:43
SPEAKER_00: Now you have some protection against severe illness, but it's not as great as it was.
21:47
SPEAKER_00: You've lost some.
21:48
SPEAKER_00: And I think the benefits of the second booster far outweigh the downsides.
21:51
SPEAKER_00: And I can't even really think of downsides.
21:53
SPEAKER_00: I mean, the downsides might be that you have symptoms after the booster.
21:56
SPEAKER_00: Some vaccinologists make the point that there's a risk of over.
22:00
SPEAKER_00: Boosting that you get this phenomena called imprinting, where you your immune system becomes too narrowly targeted and therefore not flexible enough to deal with some of the variants.
22:08
SPEAKER_00: I think that at this point is theoretical.
22:10
SPEAKER_00: I think the non-theoretical benefit that you've clearly have lowered your probability of infection.
22:15
SPEAKER_00: Unfortunately, it doesn't last that long, but at least for a couple of months, and the prevalence of the virus is quite high now.
22:20
SPEAKER_00: So I like having people with more protection against infection for a few months, and you've substantially lowered your probability of hospitalization mortality.
22:27
SPEAKER_00: To me, that argues that certainly people at high risk should get the second shot now.
22:32
SPEAKER_00: I think the more debatable issue is how about people at lower risk under 50?
22:36
SPEAKER_00: The White House announced today that they're probably going to wait on authorizing the second booster for under 50 because they think the new reformulated booster may be out sooner than they thought in September.
22:48
SPEAKER_00: My 32-year-old son called me the other day and said, Should I get it?
22:52
SPEAKER_00: And I said yes.
22:53
SPEAKER_00: Because the prevalence of the virus is quite high now, it's incredibly infectious.
22:58
SPEAKER_00: Your prior booster from a year ago is not helping that much.
23:02
SPEAKER_00: And even if you get it now, you know, and even if they've managed to get this new booster out in late September, a 40-year-old is not going to be first in line.
23:11
SPEAKER_00: They're going to be, you know, way down in the line.
23:13
SPEAKER_00: They're not getting their shot till October, November.
23:16
SPEAKER_00: And if there's evidence that getting it too soon is a problem, then just, okay, you wait.
23:21
SPEAKER_00: You got your second booster in July.
23:24
SPEAKER_00: You don't get your re-jiggered vaccine until December or January.
23:29
SPEAKER_00: Now, the argument there might be, well, what if it's so much better at fighting Omicron than the booster you get now?
23:35
SPEAKER_00: I think the evidence for that isn't all that persuasive.
23:37
SPEAKER_00: I think the evidence is it's a little bit better.
23:39
SPEAKER_00: It produces better neutralizing antibodies.
23:41
SPEAKER_00: I think when it's out, you're probably going to want it.
23:43
SPEAKER_00: But I don't think the idea of having to delay it by a month or two, or maybe get it a month or two early, I don't think it's so much more beneficial than the current booster that I would want to wait four months of being unprotected or underprotected in order to hold out for that shot.
23:58
SPEAKER_00: Plus, this is a pragmatic argument.
24:00
SPEAKER_00: Apparently, they're going to be having to throw out a huge number of vaccine doses, which just sort of seems criminal to me.
24:06
SPEAKER_00: So I think when I put it all together, I'd rather they authorize a second booster.
24:09
SPEAKER_00: For people now who want it, they explain it's not mandatory.
24:12
SPEAKER_00: But if you do want extra protection now, it's available.
24:15
SPEAKER_00: And then when the new booster comes out in the fall, you can get that too.
24:18
SPEAKER_00: Maybe you have to wait till the end of the line before you're eligible for it.
24:21
SPEAKER_00: I think that would be a better move.
24:22
SPEAKER_01: Excellent points.
24:24
SPEAKER_01: Moving on to treatment, what are your thoughts about Pax Fluid Rebound as well as the newer data that has come out about PaxLoid on the standard risk epic trial?
24:34
SPEAKER_00: Yeah, I mean, I think I still haven't seen any data that tells me that Paxlovid doesn't work or isn't helpful.
24:41
SPEAKER_00: You know, obviously the initial trial was done in unvaccinated people, which was a very pragmatic decision to have a high-risk population at high risk of hospitalization, made it relatively easy to find an effect and a statistically significant effect.
24:56
SPEAKER_00: The effect was huge.
24:56
SPEAKER_00: It was a 90% decrease in hospitalization rates.
24:59
SPEAKER_00: The subsequent trials and pragmatic sort of real-world evidence shows that it seems to work well in lower risk people.
25:07
SPEAKER_00: But like all things like this, the number needed to treat is far higher because you have a lower risk population.
25:12
SPEAKER_00: And so if there were significant side effects to it, which there really aren't, that larger number needed to treat would say, you know, for a lower risk person, maybe we don't want to give it.
25:23
SPEAKER_00: But as far as I can tell, the main problems with it are the metallic taste in the mouth, the drug interactions, which usually you can figure out a way around.
25:32
SPEAKER_00: The main, I don't know if I'd call this a side effect or just an epiphenomena, but the main issue with Paxovit is this phenomenon of rebound.
25:40
SPEAKER_00: And I have to tell you, I can't understand the literature here because the literature continues to say, including a fairly recent study from the Mayo Clinic, that rebound, meaning you were symptomatic, you became asymptomatic, you were positive on a rapid test, you turned negative, and then you became symptomatic again, and your rapid test turned positive.
25:58
SPEAKER_00: Both the original clinical trial packs of it and the recent Mayo Clinic study showed that happens in 2% of people.
26:05
SPEAKER_00: I just cannot believe that.
26:06
SPEAKER_00: You know, I can tell you 10 people I know have had it.
26:09
SPEAKER_00: Fauci had it, my wife had it, Peter Hotez, the vaccinologist from Baylorat.
26:15
SPEAKER_00: I mean, just friends and family have had it all over the place.
26:17
SPEAKER_00: It just can't be 2%.
26:18
SPEAKER_00: I know that Ashisha thinks it's 10%.
26:21
SPEAKER_00: I'm guessing it's 10 to 20%.
26:22
SPEAKER_00: And I don't understand why the trials don't show that.
26:25
SPEAKER_00: So is rebound a terrible thing?
26:27
SPEAKER_00: Well, it's inconvenient.
26:28
SPEAKER_00: You're certainly infectious again.
26:29
SPEAKER_00: You've got to go back into isolation.
26:31
SPEAKER_00: Is it harmful to you?
26:33
SPEAKER_00: I think that's the great unknown question.
26:35
SPEAKER_00: I can tell you my wife was feeling better, developed rebound, felt crummy for four days, and then went on to have a version of long COVID.
26:43
SPEAKER_00: And that's an end of one anecdote.
26:45
SPEAKER_00: You should not believe it at all.
26:47
SPEAKER_00: But I can tell you in my own mind, it's like I wonder whether her rebound contributed to her long COVID.
26:52
SPEAKER_00: I was hoping we'd have by now is a trial of Paxlovid for a week or 10 days of treatment that just feels like five days is probably too short.
26:59
SPEAKER_00: Unfortunately, we don't know the answer to that.
27:01
SPEAKER_00: It will be very interesting to see whether they give President Biden a week or 10 days of treatment.
27:06
SPEAKER_00: I know they're talking about it.
27:08
SPEAKER_00: I'm not sure if they'll do it.
27:09
SPEAKER_00: And if they do it, I'm not sure they'll tell us.
27:11
SPEAKER_00: But I think if I was his doctor, I'd probably give him a longer course.
27:15
SPEAKER_01: Nice points there.
27:16
SPEAKER_01: I know you do not have a crystal ball and it's very difficult to be a prognosticator, but do you think that BA5 will be the final dominant variant that we will have to worry about?
27:26
SPEAKER_01: Or is there something more sinister coming down the line?
27:29
SPEAKER_00: Yeah, I mean, all of us who have made any predictions in the past two and a half years are have been wrong enough that we're all very careful and circumspect about this.
27:37
SPEAKER_00: I would say that the odds are that this is not the last one, because it, you know, we've seen it, we've seen this play before, and many people thought Delta was the last one, and then Omicron happened, and then people said, okay, Omicron's as bad as it can get.
27:51
SPEAKER_00: How could it possibly get any worse?
27:52
SPEAKER_00: And then we've had four variants since then that have all been worse.
27:56
SPEAKER_00: So it feels like if you were an odds maker, there would be a bad bet to say this is the last one when it continues to be replicating, you know, millions and millions of times a day, and each one gives it an opportunity to get better at its job.
28:08
SPEAKER_00: On the other hand, at some point it will be the last one.
28:10
SPEAKER_00: At least so far, by this time with the prior subvariants, a new subvariant had already emerged that I think it was already clear that it was going to take over.
28:21
SPEAKER_00: And at this point, I think we're left with BA 2.75 with some worries about whether it will take over, but no good evidence that it's spreading in the kind of pattern that would predict that it will ultimately take over for BA5.
28:33
SPEAKER_00: So we may have a reprieve for a few months where there's no new sub-variant that takes over for it.
28:39
SPEAKER_00: But betting that that's it and we don't have to worry about a new form of SARS-CoV-2 on the horizon, that feels like I'd want a lot of odds if you asked me to take that bet.
28:49
SPEAKER_01: Sure, that is very true.
28:51
SPEAKER_01: So, do you have any final thoughts for our listeners for coming months and COVID at large?
28:57
SPEAKER_00: It's very, very hard to be rational about all of this now when we're all just so exhausted.
29:03
SPEAKER_00: Those of us who work in the field are exhausted from that work.
29:05
SPEAKER_00: Those of us who are just people getting through our lives are exhausted by the toll of it, knowing friends and family who have gotten very sick, some of us know people who died, all of us want to get back to normal life.
29:17
SPEAKER_00: And I think the challenge here is to continue to make rational decisions that are in sync with your own values and your own risk tolerance, your own preference, that is not overly influenced by your exhaustion and by social pressure.
29:32
SPEAKER_00: If you think about it a year or two ago, if you walked into a crowded space and you weren't wearing a mask, everybody would be glaring at you.
29:40
SPEAKER_00: Now in many parts of the country, you walk into a crowded space and you are wearing a mask, people are looking at you funny.
29:45
SPEAKER_00: And so I think it's very hard to kind of say, yeah, I get all that.
29:49
SPEAKER_00: Everybody's exhausted, everybody wants to move on.
29:52
SPEAKER_00: And yet here are the facts on the ground.
29:54
SPEAKER_00: Here's how much virus there is, here's the risk of a bad case, here's the risk of long COVID, here's here's the risk I'm willing to accept or not accept by virtue of not wearing a mask or eating indoors.
30:05
SPEAKER_00: And I think not to be too cruel to each other about their decisions.
30:09
SPEAKER_00: We're all making hard decisions every day.
30:11
SPEAKER_00: I can tell you that I will not do an indoor restaurant.
30:15
SPEAKER_00: If I go to a crowded indoor space, I will wear a mask.
30:18
SPEAKER_00: And yet this weekend I was at a 65th birthday party of a bunch of very close friends, and there were about 10 or 12 of us that went inside to have some drinks, and I took my mask off.
30:29
SPEAKER_00: And I kind of fully said to myself, it's possible I'm going to get COVID from this.
30:34
SPEAKER_00: If I do, am I going to be really pissed at myself and beat myself up?
30:38
SPEAKER_00: Or am I going to say that was a reasonable risk to take because this was such an unusual get-together?
30:43
SPEAKER_00: I think that's the way we have to think about it.
30:45
SPEAKER_00: Sort of really be rational about the risks.
30:47
SPEAKER_00: Don't sugarcoat them just because we're exhausted.
30:50
SPEAKER_00: But also say, you know, this may be the kind of state that we're in almost this may be forever.
30:55
SPEAKER_00: So the idea that you never ever take any risks, that probably is not tenable over the long haul.
31:01
SPEAKER_00: So we've got to be a little bit charitable as we all come up with this new normal for ourselves and make good choices for each of us.
31:07
SPEAKER_01: That is so nicely put.
31:09
SPEAKER_01: Thank you for such a great conversation today, Bob.
31:12
SPEAKER_01: And we really thank you for joining us today.
31:15
SPEAKER_00: Thank you, Raghu.
31:15
SPEAKER_00: Red, great to be here.
31:16
SPEAKER_00: Really enjoyed it.
31:17
SPEAKER_01: Thank you again to our speaker for sharing their perspective and experience.
31:21
SPEAKER_01: This podcast can be accessed on Shay's online education center, Learning CE, under the Rapid Response Program, where you will also find resources such as the SHA COVID-19 town halls.
31:34
SPEAKER_01: Interested in becoming a SHA member, take$1.20 off.
31:38
SPEAKER_01: Any membership type using the coupon code learning CE to do a checkout.
31:43
SPEAKER_01: This concludes today's episode of the Rapid Response Podcast.
31:46
SPEAKER_01: Thank you very much for tuning in.