#192 – COVID Part 2: Masks, long COVID, boosters, mandates, treatments, and more

This episode is a follow-up to our recent COVID-19 podcast with Drs. Marty Makary and Zubin Damania (aka ZDoggMD). Here, we address many of the listener questions we received about our original discussion. In addition to Marty and ZDoggMD, we are also joined by Dr. Monica Gandhi, an infectious disease specialist and Professor of Medicine at the University of California, San Francisco. In this episode, we talk about new data on Omicron, long COVID, masks, kids and schools, vaccine mandates, policy questions, and treatments. We also discuss some of the most prevalent misinformation and spend time talking about claims made by Robert Malone. We end with a conversation about our exit strategy.

*Please note: we recorded this episode on January 17, 2022, and in an effort to get it out as soon as possible, this won’t have full show notes or a video. Additionally, Monica was only able to join us for the first section of the podcast, so you’ll hear her drop off partway through.

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We discuss:

• Severity of infection from Omicron—reviewing the data [5:15];
• Factors contributing to the relative mildness of Omicron infections [8:30];
• Is SARS-CoV-2 evolving to cause less severe disease? [13:00];
• Potential of Covaxin—an inactivated virus-based COVID-19 vaccine [17:45];
• How B cells and T cells work together to defend against viruses [22:00];
• Comparing the COVID-19 vaccines, and the rationale for the time between doses  [25:30];
• Reviewing the purpose and effectiveness of boosters for reducing severity and transmission [32:30];
• Debating vaccine mandates, and putting COVID’s mortality risk in perspective [41:00];
• Why the topic of COVID has become so polarized [1:03:15];
• Reviewing the data on masks for protecting oneself and protecting others [1:06:30];
• The inconsistent logic used for mask mandates [1:16:00];
• Long COVID and the potential for vaccines to reduce risk [1:21:45];
• Risks for children and policies for schools [1:27:30]; 
• Reviewing the outcomes from Sweden, where the government didn’t impose lockdowns [1:31:00];
• Draconian measures implemented in Canada [1:38:15];
• Antiviral treatments for COVID and a common-sense approach [1:42:15];
• Importance of ending tribalism and having rational discussions with humility [1:47:30];
• Treating infection with monoclonal antibodies and convalescent sera [2:01:45];
• Reviewing claims made by the controversial Dr. Robert Malone [2:11:15];
• A potential exit strategy from the current situation [2:30:30];
• Change needed at the NIH [2:40:00];
• More.

Pre-show notes:

• A couple of weeks ago Peter, Dr. Marty Makary, and Dr. Zubin Damania (aka ZDoggMD) sat down and had a relatively informal discussion of the COVID-19
  • Podcast #189 – COVID-19: Current state of affairs, Omicron, and a search for the end game (January 3, 2022)
  • Different from our usual podcasts, this is a discussion among a group of us
  • We have tried to call out what is fact and what is opinion
    • We have a healthy mix of both
  • The format seemed to resonate a lot with people, and the follow- up was surprising
  • Peter thought it would be a one-and-done episode as they put to rest as many of the misconceptions as they could
  • It may be helpful to go back and listen to the earlier episode linked above if you didn’t hear it
• We are back with Marty and ZDoggMD, and this time Dr. Monica Gandhi joins us
• We will get into the newest data on Omicron
• We’ll talk about how viruses evolve over time
• Monica gives a great explanation of what B cells and T cells do, and how antibodies work
  • She explains the implications for different types of immunity: vaccine-induced and natural immunity
• We’ll talk about the ideal timing for vaccines and number of doses
  • We’ll talk about how natural immunity plays into this and if a booster is needed
• We’ll discuss some side effects of current vaccines
• We’ll get into the controversial topics of: vaccine mandates, masking, the lock-down in Canada, kids in school, Sweden’s approach to COVID, Joe Rogan’s podcast with Robert Malone
  • Podcast, December 2021 – #1757 – Dr. Robert Malone, MD 
  • ZDoggMD does a pretty good point-by-point analysis of where he thinks Malone is off the mark and where he is saying something valid
• We spend a lot of time discussing the fact versus fear approach to COVID
  • We’re still very much in a fear approach and it’s not clear why this is
• We end this conversation again talking about the future and what the exit strategy is 
  • We are in an endemic; this is no longer a pandemic
  • We should have strategies geared toward an endemic now

Severity of infection from Omicron—reviewing the data [5:15]

• Preprint in medRxiv Jan. 11, 2022 – Clinical outcomes among patients infected with Omicron (B.1.1.529) SARS-CoV-2 variant in southern California
• They found 52,000 cases of Omicron, none required mechanical ventilation
  • And remember, 52,000 documented means there are 4-5 cases out there in the community for every 1 that is picked-up with testing
  • Roughly half of infections are asymptomatic and a lot of people have a tough time getting access to testing
  • So we’re really looking at a population of, say, a quarter million people with Omicron and nobody required a ventilator
• There was 1 death in this group (not in the ICU or intubated)
• Infection with the Omicron variant was determined using PCR diagnosis where S gene dropout was observed
• There was a net total of 154 people who were hospitalized out of, say, a quarter million infected with Omicron
• Of those hospitalized, 83% were there in the hospital for less than 48 hours
  • Remember way back about 2 months ago, this is exactly what the South African doctors observed early on
  • They noticed people were in the hospital about two days instead of eight days, and they proclaimed to the world this is a mild infection 
• According to the most recent CDC numbers, 98.3% of new cases of COVID in the United States are Omicron 
  • On December 10th, it hit 73%
  • Now, we’re at 98.3%
  • So we’re dealing with a different virus
• People who are still in the hospital are those who came in with Delta
  • Unvaccinated people who got Delta
  • And remember, people stay in the hospital a long time especially right now and it’s very difficult to discharge a COVID positive patient to a skilled facility or rehab so that’s inflating the numbers a little bit
  • Hospitals are truly strained, but it’s really those who had Delta
• If we look at the future, Omicron promises to be a mild virus based on all of this data

Factors contributing to the relative mildness of Omicron infections [8:30]

Current numbers of people in the hospital with Omicron

• Marty just looked this up, NYU, for example, reported 53% are not there for COVID, but they are COVID positive
  • These are incidental COVID admissions
• In Jackson Memorial in Florida, 65% are incidental COVID positive cases
• Perhaps 50% to 60% of the COVID hospitalizations are incidental
• This depends on how highly vaccinated the region is
• The numbers are even higher out in California for people with COVID in their noses because so many people are tested
  • So LA County reported 67%
  • This was closest to what we saw in South Africa during the Omicron surge which was 63%. 
  • And it wasn’t that South Africa was a highly vaccinated region; it was about a 25% vaccinated region
    • Instead, a seroprevalence study in SARS-CoV-2 in South Africa that showed 79% of adults had SARS-CoV-2 antibody
    • So think of South Africa, between natural immunity and vaccines, as likely having the same degree of immunity as California
  • So the higher the vaccinated region, the higher the incidental rate is

Study in South Africa just released aims to dissect the contribution of immunity to outcomes with Omicron versus the contribution a milder variant 

• Adding to this, a couple Omicron studies came out yesterday verifying this
• One from South Africa was really well-documented
  • It tried to tease out the reason for better outcomes with Omicron, looking at the contribution of immunity versus the more milder aspect of Omicron 
  • This focused on the 4th wave in South Africa
  • Preprint published on medRxiv January 12, 2022, Outcomes of laboratory-confirmed SARS-CoV-2 infection in the Omicron-driven fourth wave compared with previous waves in the Western Cape Province, South Africa 
  • This compared outcomes in the 4th wave to the prior 3 waves
  • Essentially what this study showed was that absolutely immunity is contributing to why in December 2021, January 2022, we’re having a better outcome with the latest variant

“The contribution of immunity, both natural immunity and vaccine induced, estimated vaccination probably led to a 0.24 hazards ratio of a severe outcome” – Monica Gandhi

• A hazard ratio compares the risk in 2 groups
  • A hazard ratio of 1 means there is not difference between the 2 groups
  • A hazard ratio of more than 1 or less than 1 means outcomes were better in 1 of the groups
• Here this study is looking at the risk of severe outcomes from COVID infection in people who have some form of immunity (from vaccination or recovery from infection) compared to people without immunity
  • They conclude that immunity provided protection from severe COVID outcomes with a hazard ratio of 0.24
  • The hazard ratio here divides the occurrence of severe COVID outcomes in people with immunity by the occurrence of severe COVID outcomes in people without immunity 
• As doctors in South Africa kept saying the Omicron variant is more mild, the fundamental question became, “Okay, is Omicron more mild because we have so much immunity in the population at this point, January 2022 now, that our T cells and B cells are attacking that SARS-CoV-2 variant?”
• It takes a while for the B cells to make antibodies; one may not have antibodies right away
• Maybe if one just got boosted, they may have antibodies right away if they’re older
• But say someone has been vaccinated or has natural infection
  • They now have T cells; and their B cells produce antibodies
  • This attacks that virus; it brings down the viral load quickly
  • This will make it less infectious and it helps the person do well with the virus
• And so, immunity, of course, will help one do well
• This is what probably what happened in 1918 when the world was transitioning from pandemic to endemic
  • There was a lot of immunity to influenza in the world
• The next question is also, is Omicron less virulent inherently than the other strains that we’ve had so far, the other variants we’ve had so far? 
  • Yes, it seems to be not just based on the 6 laboratory studies, including 2 in ex vivo lung transplants
    • So this is human lung tissue
  • And then also animal studies that show it can’t infect lung cells very well
  • 6  studies now
• What the South Africa study showed us was very good analysis distinguishing between immunity making it more mild and also having fewer less virulent,

“They estimated it’s 25% less virulent than Delta above and beyond immunity” – Monica Gandhi

• So it’s not just our increasing immunity in the population that’s making Omicron more mild, but it’s something to do with the virus itself likely, that it can’t infect lung cells well

Is SARS-CoV-2 evolving to cause less severe disease? [13:00]

• Less severe outcomes observed in children under 5 infected with Omicron versus Delta
  • Preprint available on medRxiv and PMC January 2, 2022, Comparison of outcomes from COVID infection in pediatric and adult patients before and after the emergence of Omicron

Do viruses cause milder disease as they become endemic?

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