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Will We All Get Omicron in 2022? (with David Agus)

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Description

As we begin 2022, Andy gets the latest on where we stand with Omicron with the help of Dr. David Agus, a professor of medicine at USC, medical contributor for CBS News, and one of the clearest communicators out there. They discuss whether nearly everyone will get COVID-19 because of Omicron, what the latest data show about its severity, and the possibility of variant-specific boosters in the future. Plus, they break down the CDC’s new isolation guidelines and David tells Andy what it’s like talking COVID with Stephen Colbert.

Keep up with Andy on Twitter @ASlavitt and Instagram @andyslavitt.

Follow Dr. Agus @DavidAgus on Twitter.

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Transcript

SPEAKERS

Andy Slavitt, David Agus

David Agus  01:01

Welcome to IN THE BUBBLE. This is your host, Andy Slavitt. It’s 2022. Can you believe it? We made it doesn’t feel that way does it? You just heard David Agus being introduced from […], David is our guest today, I thought it would be great to have David start off the year by giving us a sense of where we are in this very different spectrum of things that Omicron presents, you know, we just saw on Tuesday, our first day, with recorded number of cases of over 1 million in the US. Now, that is a lot of ketchup from the holidays. But it’s also still growing at kind of a vertical clip. So we can expect, we might be hitting those types of days. And if you want to translate the number of positive tests that get reported to the number of actual positive tests that are out there, we’re probably looking at three or 4 million positive cases a day, there are days, when we’ve had 1% of the US population, test positive for COVID. It’s pretty astounding to think about what a dramatic shift Omicron has had; we saw it coming. We talked about it prior to the year. But now we’re in it, and what its gonna look like, how long it’s gonna last, unknown, but it is clear, that is absolutely going to strain and is already straining or hospital systems, we’re getting lots of reports now in different parts of the country of people who are not able to get surgeries, not able to do kind of basic medical care.

David Agus  02:40

And then of course, it extends outside of healthcare. Because the number of people that are down, we see a lot of things closed, schools for like teachers, buses, restaurants, you know, it’s happening, I think it’s a kind of the gross example of what a fallacy was to say that we have to choose between our economy and our health. If we don’t have health, if we don’t have a healthy population, we have nobody to actually move with the economy and to make the economy go. And so, you know, we’re going to explore today, some of the questions that I think are very much on your mind, I think, including going right at this question, this growing question of is it just inevitable that we’re all gonna get COVID. And yet people are saying that, I want to dive into that and see what that means. And David is going to spend some time on that, you know, I’ll tell you I, speaking for myself, and Lana, we don’t want to get COVID, we still don’t want to get COVID. Now, would it be a tragedy? Do I expect I would die if I got COVID? No, I don’t think I would die. It would be a tragedy if I spread it to someone else. So, we want to be very, very careful about that. It’s a contagious disease. This one is highly contagious, because Omicron appears to favor your upper respiratory tract, which is bad news from spreading standpoint. But it actually doesn’t like your lungs very much, which is good news from the standpoint of not developing pneumonia, or other serious symptoms.

David Agus  04:18

If you’re in the hospital, even these hospitalized numbers, I think there’s fewer people, on ventilators, fewer people needing assisted oxygen? So that’s the nature of this variant. But that’s this variant. Will there be other ones to follow? Will there be other ones with different characteristics? And the answer is very likely, very likely. Now, I can’t imagine something being fast enough to outcompete Omicron but it could certainly happen. One of the key questions that we’ll explore this with David of course, is what kind of protection will people who got Omicron have from other conditions? This is sort of talking about one thing that sort of specifically been happening to me a lot lately, and that’s in a lot of my TV appearances and reporters and just anywhere I go, I’m asked frequently to defend the administration or to take some bait to attack the administration. And you know, it’s a very interesting position because I think it’s always been newsworthy if I’ve said something that people could turn into a criticism of the administration. It was even brought up at one of Jen Psaki’s, recent briefings.

Andy Slavitt

So as you can see, they’ll try to use it against the administration. So I’ll tell you how I really think about it. I will say here rather say that my show didn’t say it anywhere else. I won’t make excuses. It is a very difficult job. And the people who are on the hook, including me when I was there, know they’re accountable is not a popularity contest. They just try hard to do the right things. Do they get it right every time? No. Should they admit their mistakes when they make them? Yes. Do I think they should be communicating more to the public? You know, more communications always good. But I’ll tell you that in the main, I think, a lot of the criticism that I hear, is it just as much as an expression of people’s frustrations? Why didn’t we see this coming? Why didn’t we see Delta coming? Why didn’t we see Omicron coming? Why are we still in the situation after two years didn’t the President promised we wouldn’t be in this situation. And, you know, I think the best you can do when you’re inside the White House and in these agencies, is focused on what you can control, what you can change. And I think they’re doing that I think we are so fortunate to have tools at work. And they’re getting more and as many of those tools as possible. Now, when you have a testing shortfall, that’s something people are frustrated with. That’s something that the President frustrated with, it’s something that people should be frustrated with. And, you know, in hindsight, in retrospect, I can always look at places where we’ve fallen short, and say, How can we do better next time I get that, I also would tell you that at a million positives a day, there was no circumstance under which we would not have some shortfalls.

Andy Slavitt  08:09

And so what I’d be saying and to kind of push us back to Agus is, yes, we have to deliver news that’s not always pleasant. A mad rush of new cases, like this way, we are going to have shortfalls of everything. Nursing staff, restaurant workers, tests are no different. And so it’s just the kind of thing that we are not used to here, you know, we’re not used to kind of a run on something or excess demand, and not being able to get it. You know, we’re it’s part of what we’re living through here. It’s part of what driven inflation, we had a great show on that towards the end of last year. So I want to put those things out there. Not as a defense, not as an explanation, but without someone trying to play gotcha. Just to say, yeah, the administration is accountable for doing the best job, they can talk to them plenty, I think they’re doing a ton of work. I don’t think it’s always going get recognized. I’m not gonna go criticize people who are doing the best I can, for doing the best I can. As you may know, I remember last year, I didn’t criticize President Trump, for the times he made an effort. I criticized President Trump when he lied. And when he deceived the public, and when he was not making his best effort. So in any case, I’m sure that the criticism will come, it’ll make them better, it’ll help. You know, they do listen, they do respond. They do get better. And I’ll help where I can from this side of the line. Let me get to David Agus. Let us get to the show. Let me tell you that there’s no need to be either optimistic or pessimistic about the year ahead. I think just experience the year ahead. As we experienced it, I think it’s gonna start out obviously, color by Omicron, what comes next? If anyone tells you they know, it’s anyone’s guess, but there’s a lot of reasons that I think you’ll hear in the show to feel confident that we could manage through with the great tools we have. And I love talking to David, I think you’ll hear a great conversation. I started off pretty intense going at some of the pretty rigorous issues. And it ends up actually, on a more personal note, pretty loose, and we actually get some good information out of David at that point in time. You might know he is the guy on CBS this morning. He is at USC, he’s the founding director of the Ellison Institute for transformational medicine, one of the best cancer researchers, teachers, explainers of healthcare, very plugged in to all the studies going on, hope you enjoy the conversation.

Andy Slavitt  10:56

So we’re starting the year in absolute bonkers form, very different than I think most of us expected to be going into 2022. So I figured I had to pick the one guest, who would help us understand what was going on going into this year, given that so much has changed. And it feels like the, for the average person out there who’s been spending the last year and a half, trying to avoid getting COVID, trying to minimize the effects of COVID. The game has completely changed. And now there’s all this talk out there are people saying it’s inevitable. We’re gonna get COVID, Omicron has change things help us make sense, David, of the kind of world we find ourselves in, enter 2022.

David Agus

So, I mean, there’s so many ways to look at this. The way I look at it is, you know, I’m an optimist, as you know, is that two years ago, basically this all began and vaccines were developed against Coronavirus, and for a long-time people have tried vaccines against Coronavirus, and it didn’t really work because Coronavirus is notable for its ability to change for its RNA to change over time. And we see Omicron, for example, has crazy numbers of change. But the shocking thing is that vaccines have held up and they still work. And so you know, if I told you Hey, listen, you were in a car accident yesterday and you were wearing your seatbelt, you got a bruise shoulder, you wouldn’t say well, the seatbelt didn’t work, my shoulders bruised. You know what’s happening with these vaccines is there are is some breakthrough cases they are remarkably mild, the vaccines are working, your shoulder got bruised, and that’s about it. We’re not seeing serious illness in any of the vaccinated complete individuals. And that is vaccines and a booster and they’re tolerating this very well, I think we’re in a remarkable spot from that perspective. Then you’ve got, you know, 65% of the country that is not fully vaccinated, many of them no shots, some of them, you know, the two shots and not the booster. And in those individuals, it’s certainly more serious. And we’re seeing hospitals filling up across the country. But it is preventable. And that’s the that’s the frustrating part of it. Omicron is going to take over our country. And it is and over the next several weeks, we’re going to see, you know, numbers that really, you know, dwarfs even what we have now and then it’s going to come precipitously down. And together with the vaccines and immunity provided by Omicron, I think we’re gonna be in a much better space come the second month of the year.

Andy Slavitt

You know, there’s this other group of people, maybe 9 million people, people who’ve had transplants, people who are immunocompromised people to whom this continues to feel very dangerous, or at the very least, uncertain. And, you know, if we had not lived through the last two years, but something that hit us right now, that was really taking a toll on most vulnerable, we’d be concerned. How concerned are you about people for whom they either can’t get vaccinated, or the vaccinations aren’t working as well as they do on others?

David Agus

You know, the problem with vaccines is that you implied it is that you need a pretty good immune system because we’re relying on each of us in the country to make our own immune response to provide that protection. And the vaccines are just an impetus a spur to do that. So there’s a cohort of people that have leukemia, lymphoma, autoimmune disease on immune suppressive drugs with transplanted others that are not going to be able to make an adequate immune response to that vaccine. About a month and a half ago, the FDA gave emergency use authorization for a shot in the arm from AstraZeneca that provides an antibody that protects and gives immunity so you don’t have to make it yourself. It actually gives immunity to those individuals. The problem is, it’s in remarkably short supply across the country. I get emails and I’m sure you do too. For people across the country daily saying I need this. I want this, I’m praying for this. And for those individuals, I feel very sorry because again, there is an antidote. We just got to get it to them as soon as possible. And they’re living you know, on the edge, you know, scared to death until that becomes available.

Andy Slavitt 

So what do you watch now? What do you recommend we watch? Should we be watching the number of cases? Or because as you said, a great many of them are mild and don’t result in hospitalizations. Whether they result in longer term issues, we’ll come back to that question, or do you watch hospitalizations and hospital capacity? In other words, is it time to shift our focus as a country to only those cases that become serious? Or should we still be worried about cases?

David Agus

You know, it’s an important question. I mean, certainly, hospitalizations are the key one. In Los Angeles now, we don’t have elective procedures as of last week. So if you had cancer surgery, heart surgery, when your is gallbladder out, you can’t do it, until the numbers of cases go down, because unvaccinated are filling up all of the beds and not filling the ICUs. And the ventilators like they used to, but they are filling the hospital beds. So I do think looking at hospitalizations is a very good metric of what to do as an alarm in the country because it affects the entire country’s health. But I still think number of cases matter when we look at policies regarding schools, regarding masks regarding restaurants and other places, that will be more dependent on the caseload than it will on the hospitalization. So I think they each have their role. Certainly the hospitalizations being the most important though.

Andy Slavitt  16:21

So I think there’s a lot of people out there who are hearing that getting infected with COVID now is just inevitable that this thing is too contagious. And that, you know, thank goodness, if it’s less serious, but do you accept that, like, should the average person and I think this is the thing people probably want to know the most, is the average person sitting out there? Is it safe to say that they will not be able to protect themselves? And at some point, they’ll probably get a case of COVID-19? Is that just inevitable? Or is there some other way of looking at it?

David Agus

I think, you know, it depends who you are. So if you’re, you know, in a family where everybody’s been vaccinated and boosted, I think that you know, your behavior is such that you will get it, I think that if you have a grandma who lives with you whose immune suppressed, then you’re probably going to restrict what you do. And the hope is you won’t get it. You know, over the last couple of days, there are four to 500,000 new cases a day being diagnosed in the United States. And if you argue the estimates out at most one in five that are affected are actually being diagnosed with the test giving testing issues in the country. That means that that’s two and a half million people a day. So if you’re infectious for five to seven days, we’re talking 10 to 15 million people have it at the present time. 10 to 15 million people are interacting with other people, and it is spreading at a remarkably rapid rate. So yeah, a large percentage of our country will be exposed to Omicron. The ones who are afraid and are minding their P’s and Q’s and actually staying indoors and not going out, will be able to prevent themselves from getting it but a vast majority are going to be exposed.

Andy Slavitt

So it’s a really big attitudinal shift, right? For people who I think, have felt that they wanted to avoid COVID-19 at all costs. And now, there’s this sense that, you know, I don’t know if it’s what’s the point of trying to avoid it, or this sense that as you say, the numbers are just so great that if you do anything at all, if you go to the grocery store, if you go see anybody that you’re because the numbers are so great, because you’ve got millions of people a day, more getting the virus, that when it comes to your community, it’s inevitable.

David Agus  18:32

Well, but the important part is, I mean, thanks to you, and many others, we have a backstop, right? We have the vaccine and immune status of much of the country that is protected from serious illness. So when that protection from the serious illness is there, my shoulders go down, and so should everybody else in the country.

Andy Slavitt

So you’re saying we should rethink, we should step back and rethink what it means to get COVID if you’ve been vaccinated, and if you’ve been boosted, you shouldn’t be as afraid of it?

David Agus 

We shouldn’t be as afraid of it unless the caveat being you have one of those immune suppressed people or high-risk individuals who live in your family or you’re exposing yourself to on a regular basis. And those individuals slightly different rules are going to apply. Then there’s the group that is vaccinated and they still need to use extreme caution at the present time because they’re the ones who are vulnerable to serious infection.

Andy Slavitt

So when you look at the landscape, do you think we could be conclusive now in saying that Omicron is less serious, causing less lethal amounts of illness than the Delta, or is it a figment of our imagination or some other thing driving it?

David Agus  20:08

I think that the data we’re seeing has two components to it. One is there’s a lot more immunity now in the country, both from vaccines and from prior exposure that will limit live lethality of Omicron, as number one. Number two is, as a virus itself, the data that are coming out of Denmark, the UK and South Africa, looked at it is slightly less aggressive causes less clinical symptoms than Delta does. The problem is, is that the number of cases is order of magnitudes more than we’ve seen with the other variants or will be, and so the hospitalizations may equal out about an individual basis is less. And then if you are hospitalized, the chance of going to an ICU on a ventilator are significantly lower, because it doesn’t like the lungs. As much as the Delta did, Delta loved our lungs. And the side effect was fluid leaking in the lungs, that made you go on a ventilator.

Andy Slavitt

Of all the things I’ve read, one of the things that strikes me is the most positive, if it turns out to be true, then I would explore that with you, which is this notion that because of the way it’s mutated, it’s not spreading in the lungs, or outside of the upper respiratory system as much as Delta, we’ve seen a few studies on that. And you’ve seen way more studies than anybody I know. And you can sort of sort through which ones look real and which ones look a little bit suspicious, is that finding feeling pretty conclusive to you?

David Agus 

Conclusive is a strong word. I think that the data in the animal models are pretty conclusive that it does like the lungs less than the other variants of the virus, you know, think of it like an engineer, right? When you make something, there’s an optimization parameter, I want to make a car that’s the most comfortable that goes the furthest on a tank of gas. That’s the safest right? You have an optimization parameter. Well, this virus optimize on the ability to infect, and other things went by the wayside. And in this case, the ability to bind into infect the lung cells appears to have gone down. So if you look at the data right now of hospitalizations, predominantly in the UK, on equivalent number of hospitalizations, dramatically lower lung effects than we saw with the other variants. And so it’s pretty good data and nothing is really conclusive. But I think that we’re getting more and more data, they’re all saying the same thing. Is that lots of upper respiratory, much less lower respiratory.

Andy Slavitt  22:23

If that’s true, does that mean that we’ll end up with fewer cases of lung COVID and fewer cases of other types of symptoms? Would that follow necessarily?

David Agus

Not necessarily. I mean, unfortunately, a lot of the lung COVID we’re seeing are because of the we called the neuro trophic effects of the virus, it likes nerves. And it can also be resided there. And we don’t yet know the long COVID ramifications of the Omicron changes. We just don’t have enough time to see them. And so over the next couple of months, we’ll get that data. When COVID first came out, we didn’t know what long COVID was. Then six, eight months later, we said oh my gosh, there’s a syndrome where some people are having lasting effects, even though they got better from the virus, their clinical situation didn’t get as better as we thought it would. And that’s what we call long COVID. Can we see that with Omicron? We just don’t know yet.

Andy Slavitt

Okay, so that clear. Some people are actually taking what you said to the next level, as we often do here, where we see one thing and we speculate further, which is that because it’s milder, that this will spell, if you will, the end of COVID as a serious concern, and that we will create yet another one of the Coronavirus as another sort of quote unquote common cold, so to speak, the Delta will be wiped out by Omicron. And the implication to me when I hear people say this is that therefore it will provide cross protection against future variants and Delta. And therefore this is this is really kind of a good thing. Is that taking it too far?

David Agus

You know, these are also people who say put your entire net worth into Bitcoin and you’ll become a billionaire. It has, but unfortunately, you and I are two of those. You know, I mean, listen, everything in this world is what we call probabilistic, right, that there are going to be future changes to Coronavirus. Will it evade the immunity that Omicron gave individuals, we just don’t know. And you’re really flipping a coin here. And we don’t know. And will Omicron, even though it’s a milder infection, especially if people are vaccinated, will there be long COVID implications in those individuals. And again, we don’t know that so I would not electively get infected with Omicron. Because I think that’s what you were alluding to let’s have an Omicron party and I’ll get the mild strain the variants and it will be super protected for the future. I wouldn’t because of the potential for long COVID which we just don’t know and because this virus is going to zig and zag and it may zag away from the immunity that Omicron.

Andy Slavitt  24:58

Does a vaccine or booster help with long COVID? Does that help to prevent with essentially the spread of the virus that would potentially lead to long COVID?

David Agus

Yeah, so there are two parts to it, I think it’s important to both. One is that yes, having being vaccinated, especially with a booster will decrease pretty dramatically your chance of long COVID. I think that data are pretty clear from two European Studies. The second is, is that people who have long COVID, and then go on to get their first vaccines, or who go on to get a booster shot, there’s a percentage of them, and it varies anywhere from 20% to 40%. And studies that have some clinical improvement, with that increased immunity that a vaccine will be implying that there may be some residual virus that when you get that immunity and your T-cells gets super prime, they can go in there and clean some stuff up and get some improvement along COVID. That’s a hypothesis. But it’s been seen, not in randomized studies. But there’s some pretty good anecdotal data on that regard.

Andy Slavitt 

Yeah, I’ve just been thinking about this idea that like, you could get, you know, 10s, if not hundreds of millions of people in the US alone infected with Omicron. And that if what you say is right, that if you’re, you know, the chances of long COVID are, let’s say they were equal to what they were with, with prior illnesses, even if people had mild cases, just imagining the millions and millions and millions of people with some sort of long-term debilitating condition or some form or another. That’s pretty scary. And it’s something that, you know, if it happens, you know, we’ll see it over time. But it would be a dramatic number of people just given the number of people getting infected with Omicron.

David Agus  26:40

Oh, yeah. I mean, if there were myocarditis, if there were long COVID, many of these complications, you know, scarring issues, we just don’t know. And so we’re holding our breath, and that they’re not going to be there. We don’t want people debilitated the rest of their life or not living to their optimal potential, because of this virus. And thinking that it was just benign. Let me get it get some extra immunity. And this is what happened. Don’t take that risk.

Andy Slavitt 

Yeah, it seems easy to follow the advice that says get vaccinated, get boosted it feels relatively easy, although not foolproof to follow advice and say, wear masks and so forth. I think for a lot of people, if they’re frontline workers, or you know, or they just get certain kinds of exposure or their kids go to school. You know, just take someone whose kids went just went to high school this week, for the first time since Christmas break. How do they avoid getting Omicron? I mean, what are the circumstances for some folks that make it so difficult?

David Agus

There’s a four-letter word I mean, it’s called test. And so we have the ability of doing tests, you know, children in school, and then isolating cases before they start to spread, and go viral as the expression is. And I think we have to continue doing the testing we’re doing in the United States and step it up. You know, someone asked me this morning, should vaccines be mandatory for elementary adolescent kids? I said, testing should be mandatory, there’s no question about it. If we want to go to schools and keep schools open, we’re going to have to start to mandate testing here and really get it done in an efficient way. So we can, you know, nip it in the bud when it happens, which I think is going to be critical.

Andy Slavitt  28:12

So let me change the topic a little bit. And then I want to come back and play this little, if you were head of the CDC game with you, David, because you’re such a good communicator. And I want to, I want to get sort of get to that level of general advice. But I want to just continue to add a couple more threads that we opened up here, one of the threads that we’ve talked about in the past are these new therapies, people are reading about these new oral therapeutics that people equate to like a Tamiflu, things that they take, there’s a new one from Pfizer, there’s, another one, and there may be others in the future. Now, I feel like America has a bit of a deja vu scenario where we read this thing, which has their 90% effective. And I think we all remember reading a year ago, well, the vaccines are 90% effective. Now, notwithstanding the fact that we’re now talking about protection against serious illness, which is more important. Back then we were talking about 90% to 95%, effective against even getting symptoms from COVID. And that turned out as the virus evolved, it turned out that the vaccine was unable to keep up and prevent people from getting symptoms anywhere near that level. So when we start to hear about these new wonder drugs, I worry that people think well, here comes another silver bullet, life will be back to normal. Can you just walk us through a little bit of what are the promising things and some of the unproven or concerning things potentially about some of these new therapies?

David Agus

So viruses aren’t alive, right? They get into our cells, and then they use our own machinery to make copies in the cells and that’s how they live and that’s how they, you know, do what they’re supposed to do. And so in order to do that, they need an enzyme called protease. And what this drug from Pfizer does is it blocks that enzyme. So developed specific for the protease of COVID-19, and it blocks that enzyme, the scientific argument is that it’s much less likely for there to be a change in that protease because it needs to be able to bind to the human molecules, and therefore, if it changes, it may inactivate the virus. And so because of that, we think there’s much less chance of a resistance. That being said, when we look at HIV, which is the other place that protease inhibitors kind of became the mainstay of treatment. Over time, some mutations can happen, and we can change treatments. But certainly, there’s a lot more encouraging things targeting a protease that there was targeting the spike protein, which really could change and not change the function of the virus. The Pfizer drug is a good drug, it’s not a great drug, it’s a good drug, because it’s really hard to get a high enough concentration in the blood to really be as effective as it needs to be. And because of that, you have to take a second drug with it, that basically competes with an enzyme to enable you to get more in the blood. So it makes it a lot more complicated, harder to do a little bit in terms of making this treatment.

David Agus

But there are newer protease inhibitors that are better binders that are easily absorbed coming down the pike. So I do think that this is going to be a way that we can really keep people from the hospital. If and the big caveat is, if we test sufficiently diagnose people early, you give it too late, it does nothing. So you really need to get the first day two, three, a viral infection. And then you give this, you can block people from getting seriously ill and I think our shoulders come down, you give it too late, because testing is limited or we stopped testing or wherever you live, there’s too much of a line, you don’t get that testing. It doesn’t add enough. So I am worried about using it right. But it is something important to armamentarium. And then obviously there’s the big part that you’re probably much more attuned to that AI is that supply as an issue is that the United States did lie a supply of it, but it’s not going to be delivered by contract, really until the summer. So some of it is coming down more every month, but certainly not enough to meet the demands that exist for this compound.

Andy Slavitt  32:07

Yeah. So just a review that I think January will deliver 200,000. And I think the total order is for 10 million, which will come complete until September.

David Agus

And how many cases are we having diagnose a day now?

Andy Slavitt

What’s interesting, because I wonder the right way to look at it. Because as you said, you know, you’ve got hundreds of 1000 people diagnosed a day. But you’ve got 30 or 40,000 people dying a month. And so I guess one of my questions around these is if you targeted them, to people most likely to die. In other words, you didn’t say that this was generally available, but you made it available to people with immunosuppressed conditions. Or, is this going to be controversial, but to people who are unvaccinated? Because there is no there’s a moral hazard in that argument. But you know, you could say if you really, really could save people’s lives, you could target them to the right people. You know, you could at the very least make a dent in that. But we’re not going to have general availability of this drug for quite some time. And I will say one thing that Pfizer did something here that they didn’t do with the vaccines that we wanted them to do, they are distributing them much more equitably around the world, something I know you’ve pushed for, and others have pushed for. It’s a part of the reason why we don’t have as many is because Pfizer is actually doing a part of what we talked about, which was a much more equitable distribution strategy around the globe. But if you think about it, the right place for these antivirals is probably the places where we haven’t gotten the vaccines to yet, namely, places like Africa. So Americans don’t like being patient, when there’s something they want, it’s certainly something is valuable and lifesaving is a therapeutic like this. But at least part of the reason not all the reason, but part of the reason is because there’s a big world out there and Pfizer’s got to do a better job, at least in this case, taking care of it.

David Agus 

Let me push back on you, because it’s fun to do. You know, we have kids in college, if one of their classmates gets COVID-19, we could give this pill potentially to the whole class. And then we’re not going to have to shut down that university. Because there’s a spread of COVID-19. So instead of just using it, for people who are seriously ill it can be used in a what we call a post exposure prophylaxis, and it actually could be used to stop outbreaks and enable us to continue to do what we need to do kids in school, be able to travel and do business. Hospitals open. When one nurse has COVID-19 All the other nurses […] we don’t have to shut down the ward. It could be used much broader if it were available.

Andy Slavitt  34:41

We could and we eventually will but it’s like, did you watch the TV show Mash? You know when Hawkeye that there’d be a helicopter coming in with seven bodies. And you know, they’re only two surgeons and they had to operate on the two most serious cases called triage. And that’s what you we have to do in a shortage. And for a short period of time. You know, we have to acknowledge and I think we don’t acknowledge this, then we’re kidding ourselves, we have to acknowledge we’re living with a shortage. And in during that shortage, the question is, what’s the best use of this medication? Is it for college kids? So they can go to class? Or is it for people in Africa? Or other parts of the world? Or even the US who would die if they didn’t get the vaccine? Someone who’s gotten a lung transplant, for example? Should the dose be reserved for them? Versus for the college kid? And I think that’s what we have to grapple with.

David Agus

We’ll I’m not sure it’s that simple a question. I mean, we have the ability of making a lot of pills here in the country, and we’re still making gobs of other pills. And so we could turn a factory into a factory for this pill that’s being used for something else.

Andy Slavitt

And I have spent some time on this. Not a ton of time on this. But the chemical processes involved here are more complex than just, you know, turning over a factory and creating instant scale. And so, you know, I think a lot of what I understand is, you know, people who poke at this, don’t say that there’s a lot of short-term opportunities to produce more here in the US long term, absolutely. Long term, no question about it. But the short term, we’re going to be facing the same situation we’re facing. We faced throughout the pandemic, when we don’t, we didn’t have enough vaccines, and we didn’t have enough tests as we don’t now, when the demand outstrips the supply, you can try to dress it up any way you can. But the reality is, you end up with a short-term shortage. That’s where we’re going to be. But eventually, it’ll be optimized. And I think the question that I was asking was, by the time it’s optimized, is it still going to work?

David Agus  36:40

Yeah. I mean, we’ve all inclination, it should work for the foreseeable future, and provide some benefit to people in this country, no question about it. And there are other  generations of molecules similar that are coming through that look just as encouraging or even more exciting. But you know, I really think we need to harness the best and brightest in our country, every great chemists should be called Arm saying, How can we produce this more effectively? And they’re not now and that’s what frustrates me is that we’ve got dozens of chemistry Nobel laureates who are not being called saying, are there better production methods? Can we increase the yield? Are there different reactions we can do? You know, we’re at war, and we need to call in every asset, we have to fight this war. And I’m just pushing here to make sure that we’re using the assets that are here in this country.

Andy Slavitt 

We absolutely need to and we should both keep talking to Pfizer about that. Because  they’ve been pretty good at scaling so far, they’ve got every incentive to do it.

David Agus 

They blown away every expectation, whatever they said, they exceeded, I mean, kudos to them.

Andy Slavitt

Well, that’s the other thing is, I think they may be under promising a little bit. Because I think that you know, Albert’s gotten in that habit, and I think it served him well. I wouldn’t go out on a limb here. And say that people have not been enamored with the CDC over the last few weeks and months. Now, some of this, I think, is natural. And it happens in the case of public health crisis, where, you know, there’s just too much too fast, and the CDC can’t speak to everything. Some of it is, you know, the CDC likes to be sure, before they come out with something. And then occasionally, they’ll come out with something before they’re sure because they’re trying to be aggressive. And people will say, well, that’s too fast. So I mean, I’m gonna allow for the fact and I’ve had Rochelle Walensky, on the show a couple times that I’m gonna have her back shortly that it’s a hard job. And it’s a job with constraints and with shackles, but nevertheless, I think people feel like they’re missing kind of a constant, steady voice, that when the news is bad, that explains it to them. Well, it tells them what they should do. So you are someone who you do a lot of public health communication. And CBS not just in the morning show, but with Stephen Colbert as a clip we played at the beginning of this episode, which was very well done. He’s not as funny as you are.

David Agus

Scary events sitting on Colbert talking about COVID-19. But yes.

Andy Slavitt

I bet it was. I’d love to hear about it. We will go there in a second. But if you were in charge of public communication, public health communication for the country right now, there’s a series of questions that people have that feel unanswered. So for example, boosters, you know, I’ve gotten my third which should be my posture towards getting boosters should I be thinking about this as something that I should be doing every four months, every six months, once a year? Should I be waiting and seeing? Should I get boosters to prevent myself from getting infections? Or should I only be prescribed boosters, if it’s a case where it’s gonna prevent something more serious, like a hospitalization?

David Agus  40:12

You know, in order to get normative behavior change, you need leadership. And we’ve been sorely lacking leadership as you’re aware, in our space. And they’re really good people. I mean, you know, the Director of the CDC, the Surgeon General, you can’t say a bad word about them. But at the same time, they’re not viewed as leaders about what our behavior should be, what our attitude should be, what our reaction should be in the country. And I think there’s a problem there. Part of the problem, relies that when you tell people what to do, and you don’t really explain why and give them an understanding, their shoulders come up. And the reaction is, I’m not going to have this person tell me what to do. You know, I think we have to be better in our country, in our leaders about explaining what’s happening, why we’re making a decision, and many of these decisions are not black and white, they’re shades of gray. And when people understand the reasoning that goes into them, I think it’s critically important, you know, the role of boosters. This was not I mean, as some of the media are saying, This was always a three-shot thing. And we just said to, you know, because they realized, if we said three, nobody would take it, that’s not true. You know, we didn’t really know the true immune response to this till we had hundreds of 1000s of people and lots of time.

David Agus 

And what we realized is that when you waited a period, that waiting is critical, right? Waiting that four to six months after the second shot, and then giving another shot enables the body to make a 20, 30-fold, 40-fold increase in immunity. And that was required because the virus changed. Right? This was not your original COVID-19, this was a new form. And we needed a really high level because we lost a lot of the points that our immunity was binding to. So we had to make the remainder really, really high. And that’s what it did. And you’ve got countries like Israel that says very quickly, you know, and very straightforward. We’re going to test four shots, see what the upside and the downside is, look at immunity, look at side effects, and then make a quick decision. And they did that. Right? They announced today, healthcare workers and people over 60 are getting a four shot. We’re not doing that here. We’re kind of doing the secretive thing letting Pfizer do their dance on some studies. And then the CDC reviews them, there’s not real leadership, there’s just responsiveness to what are the data. And what we’re looking for is leadership.

Andy Slavitt  42:25

What do you think we should be saying about boosters?

David Agus 

I think we should be very transparent what’s happening with immunity on a month-to-month basis, the different cohorts in the United States. And then what is the immunity required for the current variants and potential future variants. I think now, it’s very clear that a third boost or a first booster or a third shot is critical for almost everyone in this country, we saw age 15 to 17. You know, today, you know, getting it and we’re going to see more and more younger individuals, adolescents, I mean, 12 to 15 of adolescents are going to get these boosters, are we going to need to force out probably, particularly people on the frontline health care workers that are repeatedly exposed, and we have to protect them. We’re seeing now hospitals shutting words, because many of their staff are being positive. And if we can increase immunity with really no costs, we should be doing that. And we certainly need to doing that there are people who are elderly have other medical issues, who are probably going to need another booster shot four to six months out of the last one. And I think we have to start to prepare, it’s not like overnight, hey, you need a four shot, I think we start have to normalize those ideas now. So when they come four, and we’re not doing that normalization at all, we’re just waiting to the event and then bang.

Andy Slavitt 

Right, which sounds very reactive, as you said. So the third shot, the booster. Your perspective is that will wane in the same way. I mean, can’t keep that high of an antibody count up in your bloodstream for so long. Right? So because we’ve seen the period for Delta and Omicron, so quick, that’s why you think we’ll need we’ll need to have continual boosters. Is that right?

David Agus  44:07

Yeah, I mean, is that you think of it this way, with the original virus, you had a spike protein, they were 10 points, your immune system targeted both T-cells and antibodies targeted. And with every successive variant, we lose some of those points. So if they’re only two points left, then you need a lot of immunity, those two points to make up for the fact that eight of those points are gone. And so our absolute level needs to be really high. And that’s what we’re seeing with these boosters. We’re shocked, how well they’re working. I mean, they really are kickstarting immune response. And I think, you know, we’re learning that if there’s a longer period between the shots, your immune systems is hey, oh my gosh, I got to really rev myself up and we saw that, we saw that in the UK with the AstraZeneca, when they increase the duration between the first one of the second shot, they got better immunity. We’re seeing that here, when we increase duration when he’s second and third shot. We’re getting some pretty robust immunity that really is protecting people.

Andy Slavitt 

Got it but it won’t last forever. That only lasted for four to six months.

David Agus 

No, it’s not gonna last forever. At some point, we are going to do variant specific boosters. I am sure. You know, right now, the Omicron is going to pass this by before we’re ever going to do that with Omicron. But at some point in the future, it’ll probably happen.

Andy Slavitt 

I’m hearing in the fall is when people are targeting, is that what you’re sensing?

David Agus 

Certainly potential, certainly potential.

Andy Slavitt 

What about isolation, and quarantine, this is an area where many people are unhappy or dissatisfied with the CDC, you came out and said, and it felt abrupt to people to your point about wrapping things in communications. And it felt said to people where the guidelines were changed from 10 days to five days. Now, there’s a there’s a lot of reasons behind that. But there’s a lot of people who push back and said that they don’t think that’s the right idea. What do you advise people to get COVID? How long should they be isolated for?

David Agus

So, some of the important nuances of the guidelines were that it was five days, if you had no longer symptoms that day five, that’s important. So if symptoms are residual, you still need to be in isolation past five days, number one. Number two is we have a problem in that you know, what the test do now a PCR test two is the Amplified, you know, 30 letters of the, you know, 30,000 letter code of the virus. So you can have viral fragments there, no real active virus but viral fragments, and you test positive, you go, oh, my gosh, I still have the virus, even though you don’t you just have fragments, we call them false positives, right. And so there is a significant false positive rate. At this when you talk to people, though, and look at the data. By day seven, 40% of people have no residual symptoms, it’s only 20% to 30% at day five. So if you follow, you know, the rule, the guidelines of the CDC, most people still would go past five days, because they have some residual symptoms. I think that’s important, too. Then there’s a whole cohort of people who are only being caught being positive, because they went for testing because of workplaces, they wanted to travel etc. And those individuals asymptomatic, they could spread the virus, no question about it. You know, they’re gonna have a much shorter course we know of being infective. But it certainly is important that they isolate. And, you know, what the CDC did was, it was very complexity worded, you know, release that it took me seven reads of it, to really understand what it was saying.

David Agus 

We have limited testing in our country, right, we don’t have enough antigen tests, sending out you know, you know, a couple 100 million antigen test doesn’t do anything. You know, basically, we’re sending out the government enough for every person, that country to have two tests. That’s one week, that’s not going to help move the needle at all. PCR testing, as you know, is limited and much places in the country. So testing is a major problem. And if we’re requiring people to be tested daily, you know, when they have it to see when they test negative, that’s going to be hard, given the limitations of testing given the limitations of false positivity, etc. So they should have been much more transparent with why they were doing things and how they were doing it, right? We have 1000s of flights canceled in the country, hospitals don’t have enough staff to take care of people, restaurants are closing because waitstaff is closing any with a 10-day isolation period, all of those things were really critical. And then the other part of what they said is you had to wear a mask the other days counting up to 10. So you may still be infectious. And so wearing a mask is going to limit dramatically, your ability to spread to others. And again, people aren’t always following that, I think we have to do that wouldn’t have been amazing if instead the CDC said, hey, listen, if you test positive, because it goes into the federal database, you’re going to be FedExed, you know, antigen test, we want you to take them on day 5, day 7, and day 10. And as soon as you antigen test negative, then you can go out without a mask, that would have been a cogent policy that our shoulders went down, right? We just didn’t do things like that.

Andy Slavitt  48:58

Right. So make sense. So I think what you’re telling people who sets the well, if you’re five days to take it, if you can get your hands on an antigen test, take one.

David Agus 

If you’re five days without symptoms.

Andy Slavitt 

Is it that five days without symptoms, or is that your fifth day, if you have no symptoms?

David Agus

I’m sorry, if on the fifth day, you have no symptoms.

Andy Slavitt

By the fifth day, you have no symptoms, take an antigen test. If it’s negative, then you advise people, they can go out quarantine.

David Agus 

They can go out of isolation, but they have to wear a mask for five more days, every time they leave their home.

Andy Slavitt

You would advise that, you would advise if they leave quarantine, they’ll wear a mask for five days.

David Agus 

If they test negative on the antigen test and they wear that mask for five days. Yes, the isolation of five days makes total sense. But those are a bunch of ifs.

Andy Slavitt 

Yeah. Now if you can’t get a test, if you’re at homein your fifth day and you’re struggling to get a test, which I know some people still are, although I think that’s the situations, regional vegans get a little bit better, but it’s still very much true that particularly during Omicron, lots of people aren’t gonna be able to get tests. What do you recommend they do if the fifth day, they no longer have symptoms? What’s your advice?

David Agus  50:08

The answer is Andy, it depends. I mean, if you’re in a mission critical position, where you can’t leave work, your job needs you, then at day five, you need to go back and be religious about wearing that mask for five days, it really matters. If you have the ability of working from home for another couple days or not going out, I would do that I would err on the caution of making it longer if you can, if it’s possible. For many people in the country, their job is mission critical. And if you wear a mask at day five, and you’re without symptoms, the risk of being infectious to others is very, very, very small and makes sense.

Andy Slavitt

Yep. So look, I think that makes sense for people to hear. And part of what I think people are also grappling with is they would love for there to be an absolute right answer. And even the way you expressed this, which is, it probably makes sense. This is the wisest step. If you can do this, you should, if not, you should be careful, all those things indicate that there isn’t one clear specific moment when everybody in the country no longer is infectious. And in fact, people actually diagnose the COVID at very different times. Some people it’s the first day, some people, it’s the fifth day. So for the people who to whom it’s the fifth day, day 5 is really day 10. And so there’s a lot that the CDC can’t account for when they make these rules they have to do is they have to display themselves. And I think, you know, if 90% of people who leave, quarantine are not infectious. And 10% are, you can look at that either way, right? You could look at that and say, wow, 10% of people are going out of the streets infectious. And that’s a bad thing. But you could also look at it the other way and say, Oh, my God, nine out of 10 people are being told to stay home, and they don’t need to. And there’s a loss there as well. In fact, for a lot of people being told they have to sit down for 10 days, because of the work they do just isn’t doable anyway. So it’s a very tricky equation. And I find a lot of people criticizing it for some elements, but not looking at the whole picture. That at the end of the day, it sounds like it’s actually from listening to you close to the right answer, not necessarily perfectly delivered, but close to the right answer just needs to be explained better.

David Agus  52:32

It needs to be delivered better, you need to explain to the American people why you’re doing it, and what are the goods and the bad of it. And you know, that nothing is finite, right? These decisions were made with exactly what you said with a lot of nuance. And that needs to be explained in a clear and simple fashion to the people of the United States. They deserve that.

Andy Slavitt 

So what was it like in Colbert? What was that all about?

David Agus

So, you know, I’m about to go out, scared to death, they whisper to me go here, go this and tell me what to do. And then I start walking out. And then I looked down and I see a rope and I was like holy, you know, I’m gonna trip over this rope. And I jump up and run out, it turns out it was a reflection from the ceiling. And so they put out this little gif of me jumping a rope and running it look how enthusiastic he is. I literally thought I was gonna fall on my face on national TV, because I saw this reflection of a rope, which is, you know, it was humorous in many regards. But listen, when you’re with somebody like you who is very smart, a conversation is easy. And Colbert, if anything is very smart. So it’s a privilege. Listen, it’s a privilege to talk to people and to educate them. You know, it’s my job, right? I’m a university professor. So my job is to educate people around science. And I think that’s really important. And many people in my position, doctors, scientists, they forget that part of our job is to educate, you know, it’s the NIH, It’s public money that pays for us to do what we do. And so we have to give back by educating, it’s critical.

Andy Slavitt 

It gets people where they are on those shows, was it now you’re on the CBS Morning Show? Everyone seen you on the CBS Morning Show? Was it different? Did it feel different than being on the morning show?

David Agus  54:08

We’ll you’ve got an audience. And you know, I don’t normally speak in front of an audience. So all of a sudden, you know, you say something, and they laugh for the show. And you’re like, What do I do? Do I stop, do I wait, do I go? Nobody prepared me what to do for people responding to what I did. It’s kind of wild. That’s great.

Andy Slavitt 

Well, it was a great clip. We played a little bit of an upfront, we’ll put a link to it so people can watch you. It was. Lana and I were super excited watching you.

David Agus

It was a difficult decision. I’m in the greenroom and they have a bar in the greenroom. So you know, there’s temptation. Listen, I’m going to relax and have a couple of drinks before I go on, which obviously, would not have been a smart move, but it’s like staring you in the face because they want you to drink so you’ll say stupid things.

Andy Slavitt 

I was on the Comedy Central show. That recorded at 10:30 in the morning, and the comic is this Australian guy, his who hosts the show. Is on this like fifth beer on stage. And I walk in, and he hands me a beer. And he’s smoking. So it’s 10:30. So I drink the beer with him. I’m on an empty stomach. I’m not sure what to do on the comedy show, because my inclination when I’m around funny people is exactly the wrong instinct. It’s to try to out funny them

Andy Slavitt

I had Tina Fey on the show, and I’ve had lots of famous comedians on this show, if you listen, I’m behaving incredibly stupidly. I’m trying to impress them with how funny I am. And so that was a bad situation for me, you knew enough, you knew enough to be humorous and outgoing, but let Colbert be the funny guy.

David Agus  56:07

He warns you in advance. He goes, David, I like you. I respect you. Let me tell the jokes. You’d be the serious guy, I got done.

Andy Slavitt 

Oh, that’s smart. That’s good. That’s very decent of him. So this is gonna wrap up this Omicron things gonna start to wind down different parts of the country over the course of January, you think?

David Agus

Yeah, I think over the next two, three weeks in the places where it really hit hard. New York, LA, some of the bigger cities, we’re going to see a precipitous decline starting the third or fourth week in January. And then the rest of the country will be staggered several weeks after that. And we’re kind of going on data of what happened in South Africa, followed by Denmark in the United Kingdom, big ramp up, big ramp down. And then it really remains to be seen what happens afterwards, are we going to get more Delta, the South African data looks like Omicron can provide some protection against Delta, pretty significant protection. And that was a big, we were cheering when that came out last week, that was a big piece of news.

Andy Slavitt 

That’s a big deal. If that’s the case, then that a boat for at least a better year, one would think.

David Agus 

I’m very superstitious. Never say something like that.

Andy Slavitt 

Well, you did on my last show.

David Agus

No, listen, I hope so. I really believe that, you know, starting you know, kind of mid-February, we’re gonna be a much better spot, we’re gonna be back to a quote, new normal. And then, you know, one of the projects that I’m putting a lot of energy now is what we call G-pass is the global surveillance system, where countries across the globe upload the genomic data of the viruses that they’re sequencing. So we can have a dashboard of what’s going on around the globe about how the virus is changing. And what that requires is to take the sequence in and then to look, does it change despite the change the shape of the spike protein, how the nucleocapsid row, and then we can kind of predict and know what to pay attention to so we can know early, like we did with Omicron. No early, you need the earlier potentially, so we can interact, and intervene and hopefully make a difference.

Andy Slavitt

Well, that’s great. Well, good luck with that work. Thanks for keeping us informed. Thanks for being our first live guest of the year. I think we answered a lot of people’s questions, and also left people with a lot of the questions we just don’t know the answer to it yet.

David Agus  58:14

And I think that’s important. I mean, the public is seeing for the first time the sausage being made in our space. And we’re literally all learning as we go. And our job is to be transparent and honest, to tell what the data show and also to give what are our personal I think X and I’m very clear to say that right? I think it’ll peak second, third or third week in January. I don’t know that. And I think that I hope to get them right. But it’s really important that we use the right qualifiers and explain things. It’s our obligation.

Andy Slavitt

Well, thank you, you made a big difference in that with the public all the time.

David Agus 

Well, thank you. Hopefully, we’ll see you soon. We’re only you know, miles apart now. It’s kind of cool. Your wife sent me a picture yesterday, texted me a picture of literally our first year in LA. You took us to our first ever Rose Bowl parade. When we just moved to LA and with our little babies at the time, and it was, you know, a remarkable introduction. So thank you. It’s kind of nice to see that picture.

Andy Slavitt 

That was fun. That was a long time ago. We were young man. That was fun.

David Agus

Thank you, Andy.

Andy Slavitt

Thank you, David. Appreciate all of the time.

Andy Slavitt

All right. Thank you, David. Let me say what’s coming up testing conversation on testing all your questions on testing. We put out a post to collect your questions, and we have hundreds of questions. I’m gonna ask all the most important ones to Michael Mina, who is one of the Guru’s on testing. I think you’ll enjoy it. Hopefully get your questions answered. And then we’re going to focus on kids in our next episode, kids in COVID by talking to Paul Offit, who is going to be talking about schools and what’s next for vaccines for the youngest kids, and what he’s seeing in terms of current surge as it relates to kids. Good for kids. Good for parents. Good information. Have a great rest of the week. Talk to you Monday.

CREDITS

Thanks for listening to IN THE BUBBLE. Hope you rate us highly. We’re a production of Lemonada Media. Kryssy Pease and Alex McOwen produced the show. Our mix is by Ivan Kuraev and Veronica Rodriguez. Jessica Cordova Kramer and Stephanie Wittels Wachs are the executive producers of the show, we love them dearly. Our theme was composed by Dan Molad and Oliver Hill, and additional music by Ivan Kuraev. You can find out more about our show on social media at @LemonadaMedia. And you can find me at @ASlavitt on Twitter or at @AndySlavitt on Instagram. If you like what you heard today, please tell your friends and please stay safe, share some joy and we will definitely get through this together.

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