January 3, 2022

COVID-19

#189 – COVID Part 1: Current state of affairs, Omicron, and a search for the end game

Where's the humility? People are hungry for honesty right now.” —Marty Makary

Read Time 25 minutes

In this episode, Peter sits down with Drs. Marty Makary and Zubin Damania (aka ZDoggMD), both previous guests on The Drive. Marty is a Johns Hopkins professor and public health researcher and ZDoggMD is a UCSF Stanford trained internist and the founder of Turntable Health. This episode, recorded on December 27, 2021, was in part inspired by some of the shoddy science and even worse messaging coming from top officials regarding COVID-19. In this discussion, Marty and ZDoggMD discuss what is known about the omicron variant, the risks and benefits of vaccines for all age groups, and the taboo subject of natural immunity and the protection it offers against infection and severe disease. Furthermore, they discuss at length the poor messaging coming from our public officials, the justification (and lack thereof) for certain mandates and policies in light of the current evidence, and the problems caused by the highly politicized and polarized nature of the subject. Themes throughout the conversation include the difference between science and advocacy, the messaging which is sowing mistrust in science despite major progress, and a search for what a possible “end” to this situation might look like. 

NOTE: Since this episode was recorded over the holiday and published ASAP, this is an audio-only episode with limited show notes.

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We discuss:

  • Comparing omicron to delta and other mutations [4:15]; 
  • Measuring immunity and protection from severe disease—circulating antibodies, B cells, and T cells [13:15];
  • Policy questions: what is the end game and how does the world go back to 2019? [18:45];
  • A policy-minded framework for viewing COVID and the problem of groupthink [24:00];
  • The difference between science and advocacy [39:00];
  • Natural immunity from COVID after infection [46:00];
  • The unfortunate erosion of trust in science despite impressive progress [57:15];
  • Do the current mandates and policies make sense in light of existing data? [1:02:30];
  • Risks associated with vaccines, and the risk of being labeled an anti-vaxxer when questioning them [1:18:15];
  • Data on incidence of myocarditis after vaccination with the Pfizer and Moderna vaccines [1:26:15];
  • Outstanding questions about myocarditis as a side effect of mRNA vaccination and the benefit of boosters [1:35:00];
  • The risk-reward of boosters and recommendations being ignored by policy makers in the US [1:40:30];
  • Sowing distrust: Lack of honesty and humility from top officials and policy makers [1:43:30];
  • Thoughts on testing: does it make sense to be pushing widespread testing for COVID? [1:52:15];
  • What is the end point to all of this? [1:58:45];
  • Downstream consequences of lockdowns and draconian policy measures [2:05:30];
  • The polarized nature of COVID—tribalism, skeptics, and demonization of ideas [2:10:30];
  • Looking back at past pandemics for perspective and the potential for another pandemic in the future [2:20:00];
  • What parents can do if their kids are subject to unreasonable policies [2:25:00];
  • Voices of reason in this space [2:28:45];
  • Strong convictions, loosely held: the value in questioning your own beliefs [2:32:15];
  • More.

§

Comparing Omicron to Delta and other mutations [4:15]

  • It is important to differentiate between fact and opinion
  • Omicron is a new surge so a lot of the information is in flux
  • There is some laboratory data (3 labs) that show that Omicron does not infect lung cells as well as the Delta variant
    • This is why we’re not seeing the cough and as much severe disease
    • We see more upper respiratory/ bronchus symptoms
  • Omicron is more contagious
  • Epidemiological data from South Africa
    • Their numbers are down now, over 35% off their peak
    • There is a shorter length of hospital stay- 2.5 days versus 8 days
    • Hospitals there were not over run
  • Bedside data also suggest Omicron causes a more mild illness
  • The observation of a milder clinical syndrome is complicated by the high seroprevalence in South Africa (from previous infection)
    • There is some natural immunity and vaccine immunity in this population
    • This is a more immune population and this has to be taken into consideration with the observation that this virus is a little more replicable and maybe a little less pathogenic
  • Question- with the immunity present in our population, will Omicron cause less of a problem than Delta (in terms of outcomes that we care about)? 
    • The population had less immunity when Delta began to spread
    • Delta seems to cause more severe disease than Omicron
    • Omicron begins to spread as there is more immunity in the population
    • Omicron is very transmissible but seems to cause milder disease
  • When are there enough mutations [in SARS-CoV-2] to cause new variants to be considered a different coronavirus instead of a variant?
  • Is this going to be the 5th seasonal coronavirus
  • Put this in context, there are 4 coronaviruses the circulate year to year and account for about 25% of the cases of the common cold
    • So will this (Omicron) become the 5th seasonal coronavirus? 
  • The Russian flu of 1889-1891 
    • Many postulate that this horrible pandemic may have been caused by a coronavirus that turned into 1 of the 4 seasonal coronaviruses that we live with today
    • This preceded the Spanish flu (of 1918)
  • A seasonal cold can actually kill somebody who’s medically fragile with comorbidities
    • Hospitalists see this every winter
    • Standard viruses can cause a very nasty syndrome; these viruses include: influenza (the flu), coronavirus, adenovirus, and RSV
    • People with comorbidities fill up the hospital
    • Hospitals operate at capacity
  • The question is at what point does this coronavirus become different from seasonal viral disease?
  • Thinking of this through the lens of evolution, Omicron would be the best (in terms of the virus’s best interest) because it is highly communicative and not lethal
    • The worst viruses are harder to spread and kill their hosts
  • Is there an evolutionary argument or logic to suggest that as the virus becomes  more evolutionarily fit it will kill less and spread more? 
    • This seems to make evolutionary sense
    • Compare it to SARS-1
      • It had higher fatality rate
      • It could be detected symptomatically when it was contagious
      • When people were asymptomatic, they weren’t contagious
      • This virus could be stopped by behavior restrictions
      • What is now considered hygiene theater, pointing a temperature gun at somebody’s head would have worked (to identify who is infectious) with SARS-1
      • Evolutionarily, this wasn’t avery successful virus
    • SARS-CoV-2 spreads with it’s asymptomatic and causes severe disease in vulnerable people (typically) 
      • But there are so many vulnerable people that this ended up causing a pandemic level of drama
    • Now Omicron spreads so fast that everyone gets exposed at some point
      • It causes less severe disease (we think)
      • This is a very successful virus that gets rewarded by being part of the pantheon of our seasonal biome that affects humans every year
  • Maybe Omicron is nature’s vaccine
    • For 93% of the population living in poor countries in the world, they don’t have access to a vaccine right now 
    • It may be ideal to get the vaccine over getting the infection
    • But maybe that is the silver lining of this variant, providing immunity to those not vaccinated
      • Maybe this is how the pandemic ends

 

Measuring immunity and protection from severe disease—circulating antibodies, B cells, and T cells [13:15]

  • A Johns Hopkins study in pre-print shows the importance of T-cell immunity in protection from COVID
    • This is an under recognized part of the immune system and absent from  much COVID discussion
    • T cell immunity is solid against Omicron as it is for Delta
  • Peter brings up the expression, “what gets measured, gets managed

{end of show notes preview}

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Marty Makary M.D., M.P.H. & Zubin Damania, M.D.

Marty Makary M.D., M.P.H.

Dr. Marty Makary is a Johns Hopkins professor and public health researcher. He is a member of the National Academy of Medicine, serves as Editor-in-Chief of the 2nd largest trade publication in medicine, called Medpage Today, and he writes for The Washington Post, The New York Times, and The Wall Street Journal. He is the recipient of the Business Book of the Year Award for his New York Times bestselling book The Price We Pay. He is a graduate of the Harvard School of Public Health, has served on the faculty of the Johns Hopkins School of Public Health for the past 16 years, and served in leadership at the World Health Organization.

Zubin Damania, M.D.

Zubin Damania, aka Zdogg MD, is a UCSF/Stanford trained internal medicine physician and founder of Turntable Health, an innovative primary care clinic and model for Health 3.0 that was part of an ambitious urban revitalization movement in Las Vegas spearheaded by Zappos CEO Tony Hsieh. During a decade-long career as a hospitalist at Stanford, Zubin led a shadow life performing stand-up comedy for medical audiences worldwide as a way to address his own burnout. His videos and live shows have since gone epidemically viral with nearly a half a billion views on Facebook and YouTube, educating patients and providers while mercilessly satirizing our dysfunctional healthcare system. The goal of his movement is to rapidly catalyze transformation by leveraging the awesome power of passionate and engaged healthcare professionals. [zdoggmd.com]

Facebook: ZDoggMD

Twitter: @zdoggmd

Instagram: @zdoggmd

Disclaimer: This blog is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional health care services, including the giving of medical advice, and no doctor/patient relationship is formed. The use of information on this blog or materials linked from this blog is at the user's own risk. The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard, or delay in obtaining, medical advice for any medical condition they may have, and should seek the assistance of their health care professionals for any such conditions.

72 Comments

  1. Thanks for the informed debate, in particular, mentioning the role of memory T and B cells in immunology. It is amazing how mainstream debate on the covid-19 vaccine is so ignorant in this area.
    FYI, there is a commercial diagnostic test measuring memory T-cells, – the Quantiferon test for tuberculosis which measures gamma interferon release of activate T-cells after presentation of specific immunogenic peptide epitopes. In the last 2 decades it has largely replaced the Mantoux test. This platform assay is also used in research for other conditions, most notably on celiac disease. It has not been commercialised for celiac disease diagnosis, but has advantages over current methods in this area.
    TB and celiac disease potentially have similarities with covid-19 in that they affect parts of the body where the humoral immune response has less of a role because mucosal surfaces and calcified regions are involved.

  2. Schools were brought up several times and I get their point, but what about the teachers? There certainly are teachers that are 60+, obese and at risk.

  3. 1.) I enjoyed it. This reminded me somewhat of the VPZD show.
    2.) Suggested edit for the show notes: instead of “Marty replies, ‘There’s really just one person…'” say “Marty jokes, ‘There’s really just one person…'”. The joking is clear when listening to the podcast but not when reading the show notes.
    3.) If Peter puts on his math and investing hats on, he may see a convexity (/optionallity) argument for supplementing with vitamin D that he has missed. There’s probably a joke in here about a (bounded) hockey stick payoff profile and Peter’s interest in hockey but… I can’t make it land.

  4. Thumbs up to Diane Lester’s mention of TB – not to long ago the second leading cause of death (at least in Canada).

    On the topic of clarifications – I also want to correct a possible misconception among the audience regarding antibodies which are not “neutralizing”. Antibodies can still augment an adaptive response even when not specifically blocking viral docking to its receptor.

    At some time, a brief mention of opsonization may be in order.

    https://www.ncbi.nlm.nih.gov/books/NBK534215/

  5. An oasis in the desert of pandemic lunacy – thanks – now if only more people listened, perhaps they may not insist on getting tested? (I doubt it, but hey, could be worth it)

    I can imagine designing a PCR reaction such that one can see any virus (or perhaps any bacterium by targeting the rRNA) – Oh yes, you will be able to see MRSA on practically anyone – and perhaps even some “dangerous” bacterium that is known to lead to neurological disease – the idea that analytical sensitivity is not the same as clinical significance/sensitivity is difficult for many to grasp – and yes, we had NEVER EVER had such widespread testing for viruses.

    I am reminded of how analytical chemistry instrumentation has improved such that what used to be detected in parts per (pp) million can now be detected at pp(billion) or even pp(trillion) – and so increasing the alarm because “we can see it”

  6. Peter: As a long-time listener, I have held you in the highest regard and felt you could be trusted to provide the best science-based advice on health and longevity. Instead of mucking up your track record of excellent and informative podcast episodes, you should have just taken Marty and Zubin out for a beer so you could bitch among yourselves about how you’ve been put out with public health’s efforts to save lives. I am a fan and follower of all three of you, and even bought one of Marty’s books after you had him on your podcast. How disappointing to see you engage in what was basically just a long rant instead of actually providing any real update on the state of COVID and COVID treatments. As a scientist, you know that masks (especially N95s) reduce the transmission of airborne viruses, so why act like mask mandates, especially during times of peak transmission, are the most ridiculous idea ever? Is a child really going to suffer long-term consequences if they have to wear a mask for a few months when indoors during a raging pandemic? If so, we Americans have become soft to the point of pathetic, and we don’t know what true suffering is.

    The timing of the release of this episode could not have been worse. The hospital where I work has been overrun since November. Patients are boarding in the ED for 24-48 hours before a bed is freed up in the hospital. This past Monday we had 102 patients in our 32 bed ED, with 18 patients boarding. The boarding is not due to lack of staffing. Somedays staffing is tight, but the real issue is there are too many patients who currently need hospital care. Now that we have omicron spreading like wildfire, we are seeing a huge increase in COVID patients needing hospitalization. Within a two day period, our 16 bed ICU went from one intubated COVID patient to 8. Zubin stated how hospitals are always overrun with flu cases in the winter. He said it’s rough, but we always manage to get through it. This is true, but perhaps Zubin has been away from the bedside too long, because this situation is different. We have been running the gauntlet for two years, with only a few months of normalization between spikes. Many staff members have left to do travel gigs or to change careers entirely. Real estate, anyone? The remaining staff are either burned out veterans or newbies with just one year of experience. It is a very dangerous time to be a patient in the hospital. The mitigation measures of masking, distancing, and vaccination are to prevent hospital overrun, but your podcast essentially downplayed all of that. This is easy for you to do because you will not be impacted. You can enjoy your little bubble instead of being in the nightmare that is the hospital. As this situation worsens, and our souls are sucked of every ounce of caring and compassion as patients yell at us because it is taking too long for them to be seen, or we are not giving them what they want (Ivermectin), more healthcare workers will hang up their hats and move on because it is just not worth it. But somebody has to take care of the patients. We should all do what we can to preserve, protect and support healthcare workers. Sooner or later, each one of us will have our turn on the stretcher.

    • Thanks for writing this. I too was shocked at the level of callousness and disregard for the suffering in this episode.

  7. The joking about suffering and death in this podcast was appalling. If one of your parents died because of any of the opinions set forth in this episode, I am doubtful the tone would have been so dismissive. Subscription cancelled.

  8. Attia mentioned Joe Rogan and he just did an interview on December 31st with Dr Robert W Malone who is a proponent for ivermectin and hydroxychloroquine. I was shocked. Never heard anything like it but it seems like he knows what he’s talking about. I don’t know what to think.

    I wish Attia had explained his views on masks in a little more detail. And he kind of backed into a statement that people previously infected with covid didn’t need the vaccine, I think.

    Otherwise, very interesting.

  9. I was disappointed by how uninformative this discussion was.

    So much time was spent on general points about the policy and communication landscape — that the public health establishment is suffering from groupthink, that messaging aims to be persuasive rather than nuanced and accurate, that folks on social media are polarized, dogmatic, and unthoughtful.

    Yup. But this has been obvious from the beginning. It frustrates me too and it’s why I listen to this podcast, to find an *alternative* to this state of affairs, not to hear people pointing it out.

    I would have appreciated more forthright argument backed by clear information. Like, are we masking and testing too much, since we’re already in the “end game” (because the disease is endemic, or mild, or so many of us have underappreciated T-cell immunity)? If so, where should masking and testing stop? What’s the argument exactly? Is the vaccine a bad idea for young men, yes or no? If there’s a strong argument for that, then make the argument.

    The meta point that “we need to be able to discuss these things” is weak sauce. Just discuss them!

    For instance, what I am I supposed to make of the point that the official sources have downplayed the risk of myocarditis in young boys? I’m sure they have. But have they downplayed it so much *that it matters*? Are you saying the disease is more dangerous than the vaccine, for certain groups, yes or no? For whom? That’s the concrete question I care about because, in my case, I need to make a concrete decision about whether my kid gets a booster or not.

    In the end, I don’t know if the guests failed to make this kind of informed argument because they were more interested in pointing out that official sources weren’t making these arguments, or because they hadn’t really done the homework to substantiate them and the arguments don’t hold water. So I feel like I don’t know much more than when I started. I just know that some smart guys are irritated.

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COVID Part 1: Current state of affairs, Omicron, and a search for the end game' /></div></li><li id="field_1_3" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_3"><div class='ginput_container ginput_container_text'><input name='input_3' id='input_1_3' type='hidden' class='gform_hidden' aria-invalid="false" value='https://peterattiamd.com/covid-19-current-state-omicron/' /></div></li><li id="field_1_4" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_4"><div class='ginput_container ginput_container_text'><input name='input_4' id='input_1_4' type='hidden' class='gform_hidden' aria-invalid="false" value='' /></div></li><li id="field_1_5" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_5"><div class='ginput_container ginput_container_text'><input name='input_5' id='input_1_5' type='hidden' class='gform_hidden' aria-invalid="false" value='' /></div></li><li id="field_1_9" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_9"><div class='ginput_container ginput_container_text'><input name='input_9' id='input_1_9' type='hidden' class='gform_hidden' aria-invalid="false" value='' /></div></li><li id="field_1_8" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_8"><div class='ginput_container ginput_container_text'><input name='input_8' id='input_1_8' type='hidden' class='gform_hidden' aria-invalid="false" value='' /></div></li><li id="field_1_7" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_7"><div class='ginput_container ginput_container_text'><input name='input_7' id='input_1_7' type='hidden' class='gform_hidden' aria-invalid="false" value='' /></div></li><li id="field_1_6" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_6"><div class='ginput_container ginput_container_text'><input name='input_6' id='input_1_6' type='hidden' class='gform_hidden' aria-invalid="false" value='' /></div></li><li id="field_1_12" class="gfield gform_validation_container field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_12"><label class='gfield_label' for='input_1_12' >Email</label><div class='ginput_container'><input name='input_12' id='input_1_12' type='text' value='' autocomplete='new-password'/></div><div class='gfield_description' id='gfield_description_1_12'>This field is for validation purposes and should be left unchanged.</div></li></ul></div> <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button' value='Sign up' onclick='if(window["gf_submitting_1"]){return false;} if( !jQuery("#gform_1")[0].checkValidity || jQuery("#gform_1")[0].checkValidity()){window["gf_submitting_1"]=true;} ' onkeypress='if( event.keyCode == 13 ){ if(window["gf_submitting_1"]){return false;} if( !jQuery("#gform_1")[0].checkValidity || jQuery("#gform_1")[0].checkValidity()){window["gf_submitting_1"]=true;} jQuery("#gform_1").trigger("submit",[true]); }' /> <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' /> <input type='hidden' class='gform_hidden' name='gform_submit' value='1' /> <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' /> <input type='hidden' class='gform_hidden' name='state_1' value='WyJbXSIsIjU1MGM3MDVmNDUwOTYxNmQyYTU0NTkwMjUzZjU2NGI1Il0=' /> <input type='hidden' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='0' /> <input type='hidden' class='gform_hidden' name='gform_source_page_number_1' id='gform_source_page_number_1' value='1' /> <input type='hidden' name='gform_field_values' value='' /> </div> <p style="display: none !important;"><label>&#916;<textarea name="ak_hp_textarea" cols="45" rows="8" maxlength="100"></textarea></label><input type="hidden" id="ak_js_5" name="ak_js" value="158"/><script>document.getElementById( "ak_js_5" ).setAttribute( "value", ( new Date() ).getTime() );</script></p></form> </div>
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