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

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”
  • Immune strength is inferred by measuring circulating antibodies
    • This is not the same a neutralizing antibodies
    • Both are part of B cell immunity
  • Then there is T cell immunity
    • See the podcast with Steve Rosenberg (on cancer) for an in-depth discussion of B cell versus T cell immunity
  • There is not a laboratory test for T cell immunity
  • There is not even a commonly available test to measure neutralizing antibodies
  • One can’t really measure what memory B cells are doing

{end of show notes preview}