COVID Delta Variant: Our Biggest Challenge Yet with Eric Topol, MD 16 minute MedCram on YouTube
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0:00:00.1 Kyle: I'm thrilled to be here with physician, scientist, author and professor, Dr. Topol, who has been voted the number one most influential physician leader in the US by Modern Healthcare. He's published over 1,200 peer-reviewed articles, three best-selling books, and he's now the founder and director of Scripps Research Translational Institute. And Dr. Topol, since the beginning of the COVID-19 pandemic, you've been a prolific communicator about the science as it comes in, and you have a large following. There're also a very loyal following among scientists because they know you're an optimist who's forward-thinking, but you're also willing to call anyone out at times, big pharma, the federal government, the FDA. So I wanna start with an article that you wrote in the Guardian a few days entitled, "America is flying blind when it comes to the Delta variant." Available here For people who haven't read this article, can you summarize the main ideas?
0:00:56.3 Dr. Eric Topol: Sure. Well, first, Kyle, thanks very much for your intro and really good to be with you. Unfortunately, we're confronting this, really the worst challenge of the pandemic, Delta. And we are not prepared, we're not checking the data. So in that piece, I talked about the people who are in the hospital. There's over 70,000 with COVID right now in America. We have no idea how many were vaccinated, when they got vaccinated, what vaccine, how old they are, their co-existing condition. We should have all that data on a daily basis as just the de minimis for understanding what's going on with the dynamics of this Delta wave, which in places like Florida and Louisiana and many other places are really, is having tremendous devastating effects.
0:01:49.7 Kyle: How does our surveillance and our testing compared to other countries? I know we're going through this Delta wave in a similar way to the UK and Israel, how does the US stack against those countries?
0:02:05.1 Topol: Yeah, well, we have a problem because we're not testing. We're less than a half of where we were in the monster third wave, and we were insufficient then. We're less than a fifth of countries like Israel and the UK that are going through the Delta wave before us. So our testing is grossly inadequate, so we don't really have a good hand on the denominator of cases out there, and so between the lack of testing and the lack of use of any rapid home testing, we don't have a handle on infectiousness and the kind of critical data elements that we need to be in control, to be able to have a real true assessment; are vaccines working, how extensive are they working, what can we do to achieve best practices to get control and containment of this virus again as quickly as possible?
0:03:03.2 Kyle: Well, you mentioned rapid testing there, and we've had Dr. Michael Mina from the Harvard School of Public Health on the show before, and he's of course a big advocate for rapid testing, as I know you are. Why haven't we adopted this yet in the United States? And also, could you speak to people that have heard or read in articles that rapid testing is just not as accurate as PCR, and so therefore we shouldn't use it. Can you address that question as well?
0:03:30.9 Topol: Really good point, Kyle. Michael and I have been united on this front. He's been the real champion. I think in recent times, he just gave up because it was hitting the wall, brick wall. The reason why it hasn't gone forward and where every household hasn't been distributed a big set, an ample set of free rapid, antigen test that are so simple and so quick and make the diagnosis of infectiousness. The issue about the lack of concordance with PCR is silly because PCR picks up any virus remnants, virus, copies. Whereas, what we're looking at with the rapid test is, do you have enough virus mass load to be infectious? It's a totally different principle, and that's the guiding one, so we could be so much more confident about schools if we did this every day with each child and teacher and staff and bus drivers. That's one way we could move forward. Many countries do this frequently for free, whether it's Germany, which by the way, they have as much Delta-97% prevalence as we do, and they haven't had any surge in Germany, Austria, Denmark. So many countries are relying, Netherland, on rapid testing. We don't have them. I think, to your question, it was because we had a vaccine-centric strategy that would have worked and we would have full containment now, but then came Delta.
0:05:02.4 Kyle: What do you think people... A lot of people don't understand about infectiousness of the Delta variant or SARS-CoV2 in general, with regard to this term breakthrough infections, what does that really mean? And how realistic is it for people to think that vaccines can create this sterilizing immunity where people don't have any virus in their nose and aren't able to spread it at all?
0:05:29.6 Topol: Your points are really important, Kyle. First of all, this term breakthrough is pretty crazy because we knew that when the vaccines were remarkable in terms of their efficacy from the large trials, largest trials ever in vaccine history, they were 95%. So what do you wanna call the 5%? They were breakthroughs? I mean, they're not perfect. And the problem with Delta is that imperfection has been accentuated, and the reason they're not perfect is they weren't expected to achieve sterilization, mucosal immunity. That would require intranasal vaccine, which we haven't put the foot on the accelerator to get those out there, and they're still in phase one early trials. So this was intended, these vaccines, to get prevention of severe illness and illness, that was what the end point was, the symptomatic infections, and they were quite good, better than expected, better than almost any vaccine in history for that end point. But as you aptly point out, they were not expected to fully prevent spread, but even though they did that pretty well, again until Delta came onto the scene and it's a much more potent higher-load virus with its infections. And that's what we are confronting now.
0:06:50.8 Kyle: I'm glad you mentioned intranasal vaccines, you wrote a great piece about that, I believe it's in the Scientific American. March 2021 Could you explain that, for people who are new to this concept, can you explain some of the advantages of an intranasal vaccine, especially with this virus?
0:07:07.5 Topol: Right. So with the shots we get in our bloodstream, we get IgG antibodies to various parts of the virus, particularly the spike protein. But we don't get long-lasting immunoglobulin A, the type of antibody that we need in our nose and upper airway. We get some of that, but that's not what it's directed, it's a blood-specific strategy. The nasal vaccine is for upper airway protection, which is how this virus gets into us, and there you are going after mucosal immunity and with this type of antibody of IgA. So they are very complementary approaches. And had we had effective intranasal vaccines and we're using them widely... By the way, I think they would be even more popular than shots, we would really hopefully be able to squash even Delta because that's where we're leaking, in our nose, in our upper airway. That's where the spread in these cases are happening among vaccinated, obviously most, the vast majority are the unvaccinated, but the ones that are occurring as breakthroughs are the people because they don't have mucosal immunity.
0:08:20.1 Topol: Now, by the way, so they don't have enough neutralizing antibodies in their blood either, many people. But what they do have is T-cells and memory B cells that help protect their lungs and their body from getting hospitalizations and death. So that whole principle is that your cellular immunity would kick in, even though your neutralizing antibodies would fade, that works for real severe disease, but it didn't really work well for preventing these infections post-vaccination.
0:08:53.1 Kyle: So in other words, an intranasal vaccine, if one could be developed and put out to market, could not only prevent potentially severe COVID hospitalizations and death, but also really help curtail the spread of the virus.
0:09:09.7 Topol: Right, exactly. We had a pretty good anti-transmission strategy until Delta, but if we ever needed another one, whether it's a universal SARS-Co virus vaccine or intranasal or both, this is the time. I wish we'd had them ready before, but you know, it's not too late. We don't know what's gonna be happening after Delta. I hope we won't ever see anything nearly this bad, but we should be ready.
0:09:37.9 Kyle: Speaking of being ready and what's next with regard to vaccines, where do you stand on this question about getting a third dose of, say the mRNA vaccines, like the Pfizer and Moderna vaccine, at this time in the United States? Do you think we're ready for that? Do you think it should be just for certain populations of people? Or do you think we should hold off on that and try to develop something that targets Delta variants and maybe some of the other variants that might come along?
0:10:06.7 Topol: That's another really good question. And we have this problem of global inequity, and are we gonna start giving boosters to everybody in our hundreds of millions of people? Or are those vaccines getting directed to places that are more desperate, that haven't even had the first shot? The problem is we really need both, and it does look each day increasingly likely we're gonna need boosters at the least, not just for immunocompromised. But if you look at people over age 60 in Israel who were the first to get vaccines back in January, they're having a considerably higher breakthrough infection rate. And now that over 600,000 people in Israel over age 60 have gotten boosters of the original vaccine, they're not Delta-specific, but they're getting restoration of that really high protection because it brings up their neutralizing antibodies. So I have to say, I was very resistant to boosters here, I thought, "Oh, no! We don't wanna go there. Our immunity is redundant, it'll kick in, and we don't wanna listen to Pfizer and Moderna tell us what we need." But the data, in real world data, at least from Israel, and now other countries are adopting that, it looks like that's where we're headed. The real question is, "Whom?" And also, "When?" 'Cause we have no plan yet in the United States.
0:11:31.1 Kyle: One of the graphs that really struck me that you recently posted was about the hospitalizations in the United States compared to Israel and the UK per capita, and you mentioned that this is one of the graphs that scares you the most about this current surge in cases. Can you explain that a little more?
0:11:49.8 Topol: Right, so as we discussed, Kyle, the testing is so low, it's not a good parameter. But the hospitalizations, that's the real deal, if people are winding up in the hospital, that's our best tracking. Fortunately, the deaths are still relatively low, so hospitalizations is our real marker now. It's like going in a car from zero to 60 in less than two second. Our rate of rise is scary fast. We've already exceeded 70,000 and that was 5X where we were five weeks ago. Now, this is the fastest rate of rise in our pandemic, and this is in the vaccination era, so that isn't good. The highest we've ever been is 125,000 and we're pretty substantially on that course. I never envisioned hospitalizations would get to this level and we're not done yet. Since the cases are continuing to accrue, obviously some of those people are gonna wind up in the hospital, it's just a lag. So without having containment of the virus or seeing any sign of a U-turn, like we've seen in other countries, hospitalizations are far greater than I would have envisioned with vaccines out there, even in states that were not. Like for example, Florida is on average of the United States. Does you see this happening in Florida; as you know, the worst hospitalizations of the entire pandemic, in Florida. That tells you something and what it tells you is we're just too darn vulnerable.
0:13:19.0 Kyle: Two-part question. First of all, how contagious is this Delta variant compared to other viruses? And two, how has your life changed since Delta variant with regard to things like mask wearing or physical distancing?
0:13:35.0 Topol: Yeah, well, it's so hyper-contagious, a super spreader strain, if there ever was one. And it's something that we are not fully appreciating that problem. And I think it's getting highlighted more and more each day when we watch these hospitalizations go up. And we know that some percent, whether that's 10% or 15%, whatever, is even among the vaccinated, fully vaccinated. So that just shows you how tough it is, no less looking at countries that are still dealing with Delta waves. In Israel, for example, much more vaccinated than we are as a population. So what I'm doing and what I'm suggesting is masks, high-quality, tight-fit. If you don't feel like you're breathing as easily, that's probably a good sign your mask is working well. And distancing and avoiding indoors. I don't now have a gathering indoors with vaccinated people 'cause I don't know whether they're pre-symptomatic, asymptomatic at this point. We're in the midst of this really tough wave, so I'm waiting to get on the other end of it before getting back to where we were before Delta got in here. So all these tools, the Swiss cheese model of air quality, filtration, ventilation, avoiding indoors and crowds, and all that stuff, we gotta do that, I think now, to protect ourselves.
0:15:00.5 Kyle: Do you think one thing that's been lost in those recommendations from the CDC and our government, washing hands, ventilation, mask-wearing, distancing, is just taking care of our own immune systems as well, getting adequate sleep? If you're at a high body mass index, now probably a good time to start thinking about losing weight, eating healthy foods. You think that, some of that's been lost in the messaging?
0:15:24.2 Topol: Sure. You can always suggest that. And that would be good whether we're in a pandemic or not in a pandemic. Unfortunately, I don't know that that's gonna wind up being so protective right now because we've got such a tough formidable foe, but no, I absolutely, that being exercising and being in as best shape as possible, sure, that's always good advice.
0:15:48.0 Kyle: Dr. Topol, thank you so much for your time, really appreciate it. And again, thank you for helping communicate to everyone on your social media platforms.
0:15:58.0 Topol: You bet, Kyle. Sorry we didn't have more time.