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In the Bubble with Andy Slavitt: Our Shot
All Podcasts Safe or Not Safe: Holiday Gatherings

Safe or Not Safe: Holiday Gatherings

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Description

Andy and epidemiologists Farzad Mostashari and Jennifer Nuzzo get together for a special holiday edition of Safe or Not Safe. They’ve got answers to your questions about partially-vaccinated kids, rapid antigen tests, in-person office parties (remember those?), airplane safety, and much more. Whether you are hosting people or will be someone’s guest, this episode should calm your pre-holiday COVID-related nerves.

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

Follow Farzad @Farzad_MD and Jennifer @JenniferNuzzo on Twitter.

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Transcript

SPEAKERS

Andy Slavitt, Dr. Farzad Mostashari, Jennifer Nuzzo

Andy Slavitt  00:08

Welcome to IN THE BUBBLE. This is your host, Andy Slavitt. We have our holiday edition of the show to help you get prepared for Thanksgiving with your family and friends. And yes, I think this is probably for most of us going to be how we do get to see family and friends. And so we want to make sure we’re prepared. And so we have a toolkit episode, which is another safe or unsafe episode for the holidays. If you’ve listened to the toolkit episodes before, you know that they are also game shows. That’s right, we pit two epidemiologists against each other to see which one can give you a better answer to your questions. So we take a lot of very good questions. Probably most of the things that are on your mind came in through voicemail and email and we will ask them to our two esteemed epidemiologist. The first is Farzad Mostashari. He’s an epidemiologist who works in New York City Department of Health. Where he established the Bureau of epidemiology services. He later went on to serve in the Office of National Coordinator for Health IT what does that really mean? He was like the healthcare data guy for the US government.

Andy Slavitt 

And Jennifer Nuzzo is joining us as well. Jennifer is an epidemiologist at Johns Hopkins, she’s a senior fellow with Global Health at the Council on Foreign Relations. She’s terrific. If you’re used to hearing other someone else on the show, then you’re used to hearing Caitlin Rivers, who is also from Hopkins. Caitlin now has a big job in the CDC. She’s helping us to design basically the systems for how we figure out where the next pandemics are coming from how to do the kind of tracking it’s almost like a big weather system that she’s designing. So we didn’t even ask her if she has time for her silly games. But I think you’ll enjoy this. I can’t believe it’s coming up on the holidays. It’s like where did this a year ago? I mean, I know we always feel that way. But I hope that this year, was it at least not a year that we wasn’t marked entirely by the pandemic. I know that it was for many. And I know that it’s hard to avoid this. I mean, it was the year of Delta, no question about it. But compared to 2020, when we literally had no idea what was going on, and a lot of reason to worry. And people were out of school, out of work and restaurants are closed. I’m hoping people got a chance to get back to much of their life, even under these sorts of strange conditions. And I think we’re going to talk about today like, are these strange conditions, kind of normal, normal ish conditions? How to manage them? Are there tools, etc.

Andy Slavitt  02:41

And I have to say that it leans optimistic, it doesn’t necessarily optimistic in terms of having any knowledge of what’s going to happen with the pandemic. Because we don’t know, I don’t think anybody’s got a crystal ball. And of course, I wrote this piece in the post last week saying the pandemic is not over. But I also said, we’re entering an era where we have many, many tools that allow us to live a normal life. And I hope that you got some of that this year. We’ll probably talk more about that. As we go into next year I hope we’re looking forward optimistically to that should be lots of things that remind like our family, like graduations, weddings, and hanging out with people we like our jobs, our careers, school, colleges, all those life events, and then bigger issues, elections, global warming, inflation, lots of other things. So plenty of stuff to think about, but I hope that this pandemic stuff down more toward normal roar than a large roar. Okay, that was my little roar this morning. You can hear the resonance in my voice. Okay, let’s bring on our game show.

Andy Slavitt 

Welcome to the holiday edition of safe or unsafe. We have back with us returning champion contested Farzad Mostashari, epidemiologists extraordinaire. You’ve tried a few times. And we have a new contestant very exciting. Jennifer Nuzzo, Jennifer has been on the show before we had a great episode with Jennifer earlier this year. She’s taken over because our prior contestant has now gone to work at the CDC. Welcome, Jennifer.

Jennifer Nuzzo  04:28

Thanks for having me back.

Andy Slavitt

This is a contest like everything in life. We’re gonna pose questions to you. And I’m going to tell you up front that points will get knocked off for answers like, well, it depends or I don’t know or maybe or could go this way could go that way. So just know that you will be more rewarded for definitive answers.

Dr. Farzad Mostashari 

No epistemic humility.

Jennifer Nuzzo 

Do we lose points for saying it depends on your personal risk tolerance because it’s […]

Andy Slavitt

Well, I think if you say that then maybe you want to say, but here’s what I would do. All right. Actually you can answer any way you’d like. And the truth is, there really is no punishment for saying that. It just kind of, I just want that to be the rule.

Dr. Farzad Mostashari 

I might win this time. I might win this time.

Dr. Farzad Mostashari 

I think you might. I’m not feeling good at all.

Andy Slavitt 

Farzad is feeling decisive. Okay. Well, we have lots of questions. We’ve got the holidays coming up. I think we, you know, we’ve been saying last year that, hey, next year, we’ll be able to get together with our families for the holidays. I think people by and large are, but they have lots of questions. Lots of great questions. I’m going to start with one from Dolores […]. She asks, what are the best mitigation steps hosting families can take to ensure families coming together? Stay safe? Should everyone test first? Ventilation? Air filtration? Jennifer, why don’t we start with you.

Jennifer Nuzzo 

I want the buzzer. I want to I want to hit it. So I mean, all those things, but also crucially vaccine make sure everybody who can be is vaccinated. That is the top of my list the thickest layer of protection. But certainly using rapid tests the day of adds to it, as does making sure you don’t have you know, stuffy indoor environment. I always try to crack a window or, you know, we have some air cleaners in the house. That just makes everybody feel more comfortable.

Dr. Farzad Mostashari  06:27

Yeah, I completely agree. We actually Andy we, after two years of the pandemic, our company had grown from 300 to 600 people, and we were like, we need to get together and we got together 600 people eating, drinking, talking. And we did not have a single infection. And the way we did was outdoors. Everyone was vaccinated, and everyone was tested with the rapid home rapid antigen test, we use the binax because we thought it had a good false positive profile, which we should come back to, but they tested before they left. And then they tested the day of as well every day of the conference. So that is if you want to be ultra-safe. And I know the listeners to this podcast, many of them are in that category. Yes, vaccinated and boosted. Yes, ventilation. And I think I think the rapid engine, it is a little pricey. It’s like 2022 bucks for a pack of two. So 11 bucks a person. But I really do think that it provides great assurance that you’re not infectious today, you might be infected. But you’re not infectious today.

Andy Slavitt 

Great distinction. Great. Okay, now we have a voicemail from Carrie.

Carrie 

Hi, my name is Carrie, and I’m holding Thanksgiving dinner at my house. It’s a big open, great room that opens into another room we have the ability to open crack a lot of windows doors, ceiling fan air purifiers, good HVAC system, there’s going to be between 10 and 12 people planning to have them not sit at a table but kind of sit in TV trays and separate in little pods of their families and couples. Everybody’s maxed, some people are boosted. My question is, even with good ventilation, and good separation and everybody being vaccinated. Lots of open space and all of that. I still want people to take a home COVID test. Is that overkill? Am I being the weird disaster person? You know, I’m the one that gives out the flashlights. So […] my kids at Christmas. So that’s my question is home COVID test overkill if you practice all the other stuff.

Dr. Farzad Mostashari  08:45

What did I say? Listeners of this show?

Andy Slavitt 

The best, aren’t they? What do you think, Farzad?

Dr. Farzad Mostashari 

I don’t think you’re crazy. I think you can reduce the risk with something that’s relatively easy to do, we may be able to actually ease up on some of the other stuff, right? So I’d rather have the test and then have grandpa be able to give, you know, give a hug. Right? So I think doing the test allows you to maybe be a little less kooky on some of the other stuff.

Jennifer Nuzzo 

Yeah, I completely agree. I mean, I do not judge people for their level of risk tolerance. That level of risk tolerance is different than mine. I personally think if you were doing all those, if you were testing and you had everybody vaccinated and you had good ventilation, I don’t think any TV trains I think you can sit around the table and enjoy a meal together. But you know, the point of getting together is to relax and connect and you know, if there are measures that are like non-starters for you that is required for making everybody have a good time then those are the right measures.

Andy Slavitt 

The calculated risk of either the hug or avoiding the TV tray I think you both but leading into this one, I think I’m hearing a little bit of if you did just one thing you can’t necessarily count on that one thing to work but if you starting to do multiple things, then you got an ability to interact safely. So Peter asks a different question. He says my office is having a holiday party, with probably about 40 or so employees and their significant others. Everybody’s vaccinated. But we will be indoors mixing and mingling, and I doubt many of us will be wearing masks. Attendance is pretty much mandatory. What precautions if any should I take before, during and after the party? Jennifer?

Jennifer Nuzzo  10:26

Yeah, I mean, that’s a bit of a tougher one, because the previous question was about Thanksgiving with your relatives, you kind of know what they do day to day, you know, their vaccine. I personally would feel comfortable in those circumstances as a vaccinated person around other vaccinated people. It’s not a zero-risk situation by any means. But I am comfortable absorbing some level of risk for the activities that I think are important. And a work function, you know, where my attendance is important is fine, unless you can push to do other things like, you know, perhaps rapid test. If it were me, I would be comfortable, but I realized a number of other people might just feel like you know what, I’m going to save my exposures for my family and going to a work meal is not really where I want to draw down my exposure budget.

Dr. Farzad Mostashari 

Alright, we’re finally we have one where we’re on the opposite sides of this. I don’t like this workplace. I don’t like it. I don’t like the fact that there, man, it made kind of mandatory, and they’re saying you’re going to be crammed in an indoor space and mingling and people are going to be drinking and they’re not going to be wearing masks. And hey, you’re seeing that everyone’s vaccinated. But what about the spouses? They’re not requiring spouses documentation from the spouses. I don’t know who these people are. I don’t like it. I’ll say that Andy, unfortunately, for our friend, there ain’t a lot you can do. Other than, like, my kids, I’m so in awe of them sometimes, like one of them was at a football game where literally 99% of people are not wearing masks, and he said, you know what, I’m gonna wear a mask. And it was just like his personal choice and he had this fortitude to wear a mask in that setting. And so I would say, literally the only thing you can, there’s nothing you can do beforehand. You’re not going to take monoclonal antibodies afterwards. The only thing you can do is wear a good tight-fitting mask during that and, you know, take a lot of cigarette breaks.

Andy Slavitt  12:20

So wear an N95, you won’t be the only one. You will not be the only one wearing an N95. Okay, good advice. Nancy […] asks, what’s the best way to be COVID-19 protected on longer plane flights? For those of us desperate enough for a vacation to take that risk? It seems, now she uses the word orifices. Or a facade? I don’t know. Farzad is immature as I am. Or the most vulnerable. So obviously wearing the best mask with the correct filter is the starting point. What’s the best mask? Isn’t N95, next best like in N95. We’re gonna cloth masks be made highly protective by using a better filter layer. What about other orifices? Covering eyes and ears? Are glasses protective at all, goggles, better face shields, ear plugs and whatever covers other orifices. Okay, Farzad you gotta go with us.

Dr. Farzad Mostashari 

Right. I will not worry about your orifices other than the obvious ones. I think the most important thing is the mask, no cloth mask is gonna is going to be as good as the tight fitting N95, KN95, that is definitely what I would do on a flight. Other little things I do on flights I try to, you know, strategically find the seat where it’s unlikely to be a middle seat occupied next to me. I try not to go to the bathroom. I don’t know. Like I think the aerosolization of stuff in bathrooms and there’s a couple of airplane studies. So I tried to stay out of the bathroom. Go beforehand. And I don’t take off my mask to have the pretzels it’s not worth it to me. And I turn on the fan the little air thing up above to get a little more air circulation going. So those are kind of my go to you know, plane tricks.

Andy Slavitt  14:16

Lana was flying yesterday and sat in front of the sneezer with the mesh mask. Yes, that’s right. Okay, Jennifer, anything you say differently?

Jennifer Nuzzo 

Yeah, I mean, I’ve been traveling you know, a number of times and I worry less about the plane and more about the congregation in the airports and I worry less about the plane because you know, at least well you know, the HVAC system is running there’s a certain degree of filtration that’s occurring. So I try to sit on the window seat just because I’m not near the aisle where people are walking and exposing, you know, obviously wear a mask. But I have found the dicier parts of travel to be the like overcrowded airports, the security check ins where they’re doing staff or the you know airline check in booths where they don’t have enough staff and just like everybody is cramped so try to get there early so you could you know, avoid the crowds etc, I think we probably give too much worry to the airplane and not probably as much worry to the airport.

Andy Slavitt 

There kind of HEPA filter generally speaking, right? The airplane?

Dr. Farzad Mostashari

If you do want to be in the Farzad crazy camp, you could take a portable […] monitor with you, you were actually, Andy, the first one who told me about this. And I at first I was like, what are […] monitor? Are you crazy? But it is actually cool to see the amount of sorry, new air circulation coming in to the airplane.

Jennifer Nuzzo 

I’m not sure I want to know that.

Dr. Farzad Mostashari 

It was like a 1500. So you want kind of want to be less than 1000. And I think that is something if you really want to use that also to measure the indoor air stuff.

Jennifer Nuzzo  16:00

But what do you do, though? I mean, I agree that would give you more information. But what do you do if you’re, if your device goes off and you’re on the plane? Do you like be like, I’m sorry, I have to exit.

Andy Slavitt 

I pictured Peter’s earlier question about his office party. I pictured walking around with an indoor airflow to having a beep and people tell them they’re breathing too heavily.

Andy Slavitt 

Susan’s asking a question and I think she just wants our permission. This is what I think, she’s got a slightly larger gathering of 12. It’s her family of four. Her husband’s parents, grandma and her brother, all over 70. Are all vaccinated but rarely wear masks and in low vax area. They have not had boosters. Okay, now, this is where we can see where this is going. But she’s got brother and sister-in-law and teenage niece who are anti-vax, anti-mask and […] where no one masks and they live in some low vaccinated areas. Only the nephew, who’s 19 is vaccinated. They’re badgering us to have an indoor Christmas thingy at their house. We are trying to do one outdoors by the gas fire lol or do we just wear masks indoors? What is the risk level? And I have no problem telling you my in-laws, hell no. What should we be telling your in-laws, Jennifer?

Jennifer Nuzzo

I would go personally and but this is where you could use a test with your relatives, particularly unvaccinated ones on the day of you know, I would feel comfortable enough with a negative test to say, okay, we’re gonna have a nice time. Now, you know, I think I mentioned we’d be talking about risk tolerance. You know, some people may be looking for excuses not to see their relatives. And, you know, it’s clearly an easier calculation to make if everybody that you’re going to see was vaccinated. But again, it’s about what you prioritize. And I think the past few years have given us or robbed from us so many moments to get together with family and to mark these holidays and occasions so that I would be willing to assume some risk, and you can make it safer with the rapid test. I personally wouldn’t probably wear masks indoors with my family once we had a negative test. But you could do that if you were really worried.

Andy Slavitt  18:42

If they didn’t take a negative test. So in here, here’s the question if you got unvaccinated people, and I’m assuming they’re unlikely to take a test, they’re not wearing masks, what makes you comfortable?

Jennifer Nuzzo 

Well, no, if they refuse to take a negative test, I mean, I think that changes the circumstances a bit. But I will say I do still feel protected from infection, or getting sick, I should say from my vaccines, you know, so I’m more worried about them being unvaccinated than I’m worried about myself. I think we have to make that clear, because I think sometimes we equalize those two things. But you know, I wouldn’t assume necessarily that they’re opposed to negative tests, we see a number of people opting out of vaccination for testing. So you know, it may be a possibility, particularly if you buy it for them and, they use it right there. It’s really easy.

Jennifer Nuzzo 

So Jennifer thinks you must go, you must go. What do you think, Farzad?

Jennifer Nuzzo 

So is this time where I can try out math, Andy? Can I try that math for you? Okay. All right. I know that sometimes you have […] demeanor about like, well, I can’t handle complicated things.

Andy Slavitt 

If it’s more than the fingers I have, I’d be careful.

Dr. Farzad Mostashari 

They are a little bigger. So context is hard, right? Like how do we talk about risk tolerance, but blike what, like how much risk is that, right? And I looked up the statistics for you. On an average Thanksgiving holiday weekend 50 million people take the roads to drive more than 50 miles. 50 million people. And there are 500 deaths from car accidents and like 100 times that many injuries, right? Yeah. So think of that like, you wouldn’t not think about it like, okay, like driving 100 miles or 150 miles or whatever, like driving to my relative’s house in maybe there’s iffy weather and whatever the lot of people on the road, like, there’s a risk associated with that. But I can kind of titrate like, is it? Like, would I not go would I go like, you know, how much risk is there. So, for 100,000 people, one of them die on the road. Now, let’s do the COVID case, if you have 100,000 people, and you’re kind of in a community that has 10 or 20 per 100,000 cases, say three times as many infections, and then you have you know, three days of infectious period. And then you figure like each person, you come out to like, half a person dies.

Andy Slavitt 

Per 100,000.

Dr. Farzad Mostashari 

Per, 100,000, if you’re unvaccinated and if you’re vaccinated is 1/10 of that. So I mean, this is rough math. I’m sure folks on podcast can pick it but order of magnitude. It’s about if you’re not vaccinated, it’s about the same risk of dying. Now, again, like there may be other things that you’re concerned about long COVID what not but the risk of dying, just as a rule of thumb is about the same as the risk of getting on the road and driving, you know, 100 miles.

Andy Slavitt 

So it’s great context which are answer changed. If you were in a period where there was a high case count per 100,000, where instead of the 20 to 30, you were in the 200 level.

Dr. Farzad Mostashari

Yeah, exactly. Now it’s 10 times that risk, right? So that to me was a useful yardstick. And then again, if you’re vaccinated, it drops by a factor of 10. Right? So now you’re much lower. Now you can, if you take, if you do a rapid test drops it by another factor of 10. Right? You have at least 90%. So that’s kind of a way to think about it. So in this instance, like it’s risky, it’s the risk. It’s as risky as getting on the wet roads and Thanksgiving and driving, you know, driving couple hours to see grandpa.

Andy Slavitt  22:26

Got it. Got a question from Stephanie Ching. She says that in Oregon and Washington, they both had recent cases of outdoor transmission. And given these two recent occurrences, I think they were both at concerts have not mistaken they’re both at music festivals, given these two recent conferences, how are maskless outdoor gatherings with talking in close proximity is still considered to be safe, Farzad?

Dr. Farzad Mostashari 

You know things happen, right? Like it can happen, but it is much more unlikely to occur. And we’ve seen it time and time again, in the EPI studies, that outdoor is so much safer. So, you know, can I imagine that a close talker and you know, no one’s wearing masks and people like breathing right in your face? That is a risk. But it is. I would say it is one of those, you know, order of magnitude changes in your risk if you’re outdoor versus indoor. Certainly.

Andy Slavitt 

Okay, Jennifer, anything different?

Jennifer Nuzzo

Yeah, I mean, first of all, we don’t use the word safe, you’ll probably hear us use a lot, the safer and the fact of the matter, it is safer. Now, people may choose to try to eliminate to the greatest extent possible, all the risks. One of the things that I’ve, you know, been mindful of in all of this is that, this is a long slog, you know, we are now approaching two years into this and maintaining that, you know, zero tolerance for assuming any risk position is really hard. Some people are great at it, but a lot of people aren’t. And I think pointing people towards safer activities, I have been very believing of the fact that it has more likelihood of having an impact than telling people no, continually, I mean, just you look at your kids, right? When you talk to your kids if you say no, no, no, nothing, they don’t do it. I mean, you can do that for so long. But eventually you learn that you know, it’s probably better to redirect them to other things.

Dr. Farzad Mostashari  24:21

Yeah. Can I kind of jump on that? I think one of the really kind of deeper questions here that people are starting to ask is should we just only do things that we can sustain like literally for years and years from now and like is this it? Is this like a phrase from like, if it becomes an if we’re saying endemic is it basically like there is no finish line? Right and so we should just do things that we think, there’s no longer because it used to be, right Andy? We were like, well just hold on, just hang on, hang on and then the vaccine will come and all will be soft. Just hang on and then the R-naught go RT will go less than one and then it’ll be extinguished and it’s like a renewal with Delta in a just hold on kind of scenario. And so one, I think really, really valid point is like, is this something that I can sustain for the rest of you know, for years? The one exception to that that might be like, just hold on? Is Andy Slavitt the pill, right? Like, should we just hold on until like, if you do get it, you can take the pill and it knocks down again 90%, your risk of dying further? What do you think, Andy?

Andy Slavitt 

First of all, I sense that the two of you have a slightly different attitude than I think we were generally hearing about a year ago. For precisely the reason you describe, which is to say, I’m hearing, it’s time to take some calculated risks to live our lives, things aren’t necessarily going to get a whole lot different than they are today. They might of course, but that would be happy to the upside. And of course, they get a whole lot worse, we can always dial back, I try to think about what we’re in now very much as an area where we have a lot of tools, we have five or six tools, between ventilation, between therapies, between vaccines, masks, monoclonal antibodies. And if we use these tools intelligently, which I think a lot of what these questions are really all about, there are very few things we can’t do safely. There may be some. And I think they particularly happen when there are high amounts of transmission in the community. But other than that, I think we should be thinking about these tools. And if we have people who don’t like vaccines, but they’re willing to partake of every other tool, then you know, we probably ought to figure out how to include that as part of the equation conversation.

Jennifer Nuzzo  26:40

What I thought Farzad was gonna say, that just hold on was, and I think to the earlier question of, you know, what changes your risk tolerance? You know, if you’re in a place where the health system is being crushed, I mean, obviously, my personal risk tolerance in that situation gets trumped by the fact that any additional stress that I could potentially add to the health system is possible, probably not worth it. So my calculation changes based on what I think is happening around me and not wanting to inadvertently contribute to the problem. That said, if you’re not in that scenario, in that place where we’re really worried about, I mean, I think we have to acknowledge that the vaccines guess the other tools too but particularly the vaccines have changed the game. I think we’re underselling that point. And the fact that we have tools that take this virus from something that had a chance not, you know, for most people not as bad as it could be, but still like enough of a worry that we changed our lives, chance of killing us to something that, you know, could make us feel lousy for a few days, but likely won’t send us to the hospital. And to me, that’s absolutely changes the game. Because listen, if this virus never sent people to the hospital, most people would have never heard of it.

Dr. Farzad Mostashari 

Yeah, that’s true.

Andy Slavitt  28:01

Let’s go to some of the more specific types of situations that people are facing, because even granted, what I think we all three just said, there’s still nuance that people are feeling in their own situations, for example, how recently they got boosted what their health status is, and then wondering whether or not those things have a play on the answer. So one question from lire who says, should I attend Thanksgiving if anyone is not vaccinated in our family event? I have vaccinated three times I’m 64 years old, and a cancer survivor. So it’s that last bit the fact that she’s 64-year-old and a cancer survivor. Does that make you think differently, Jennifer?

Jennifer Nuzzo 

So that doesn’t tell me enough information, I would actually ask her to talk to her provider, because survivor, you know, if it was 10 years ago, that’s probably not as relevant to like, I just went through chemotherapy, and we’re worried about my body’s abilities to mount an immune response to the vaccines, provided the provider says, I’m not worried about you because of your past cancer history, then yes, I would think she should go. I mean, I don’t see a glaring reason not to. But if she’s, you know, very recently or still going through trials, that’s a different story. And I think, you know, again, it requires more information than we have to answer that question.

Andy Slavitt 

Got it, Farzad?

Dr. Farzad Mostashari 

Yeah, I agree. I do think that there are a number of folks who can’t mount a good immune response. And it becomes really, really hard that the hold on becomes really, really hard for them. My father-in-law, passed away two weeks ago. He had congestive heart failure, and he also had a blood cancer. So he did not have a great immune response. And he knew it. He was an infectious disease doctor, and he said, I know I don’t have much time I’d rather see my grandchildren this summer. And he, you know, we were careful. We tested, we, you know, we did all the precautions, and he didn’t, you know, he didn’t get COVID. But he took that risk because that mattered to him that he have a good summer. And when you know, Jennifer says these are individual risk decisions, I think we can’t. It cuts both ways. And we can’t not think about the other side of this. It’s been two years we’re sick and tired of this and predicting some of the older people and where Thanksgiving is like, how many times a year do you see your grandpa or your you know, your elderly parents, right? Like it is there is something that we need to think about here of how much longer are we going to sustain this isolation?

Andy Slavitt  30:56

Well, sorry to hear about your father-in-law. And thoughts to you and your wife and your kids.

Dr. Farzad Mostashari 

He as a great guy.

Andy Slavitt

Want tell us about him?

Dr. Farzad Mostashari 

Yeah, his name was Harris Berman, and he was a Peace Corps doc, he, he started one of the first staff model HMOs in the country. He you know, the oldest dean of the US medical school at Tufts Medical School. When he became Dean, and then he was dean for another 10 years. So he didn’t get any younger. He was an amazing human being. And he really wanted to emphasize quality of life, and he did.

Andy Slavitt 

Well, it sounds like one of the things that that story teaches us is, there are all kinds of risks. And there are dumb risks and smart risks. And then there’s just risks worth taking, and risk not worth taking. And, you know, the holidays and seeing our families, particularly after prolonged absence. Sounds like one of those risks that we should try to take in a smarter way as possible, because the cost of doing it can be quite high. Okay. Carrie asks, do we know yet how effective tripled vaccine doses are for the immunocompromised, particularly with a third dose, I would love to visit my family on the other side of the country, but I’m still worried about flying and potentially spreading it to a vulnerable family members. We’ll start with you, Jennifer.

Jennifer Nuzzo  32:23

It this is a tough question asked to answer because third doses for different conditions are, you know, likely, and I have different effects. So one thing you could do is if you’re worried about spreading it to vulnerable relatives. That’s where the rapid tests are useful. You know, it’s hard, but it’s going to be hard to tell what her level of protection is or what the relative’s level of protection is just based on that information. But that’s where these other tools can add a layer of protection, given the uncertainty about how well protected these particularly vulnerable people may be.

Dr. Farzad Mostashari 

Yeah, I’m a huge stand for these rapid antigen tests. I will say that anyone who does the test should have a plan for what do they do if it’s positive. And there is a false positive rate for them. And you should be and this is one of the reasons why we asked people to test before they got on the flight. Because then now if your boss, if you want to get back on a flight game, maybe stuck out there and wait for the PCR, you know, PCR reflex to then make sure that you know, some false positive. But I would go and as Jennifer said, test before you get on the flight and then test when you’re there and see your relative.

Andy Slavitt 

So we got a few questions on the test coming up. Before that, I want to ask one more this kind of apropos of your story Farzad, it’s an email that came in, this is my mother, she’s 96. She got her second dose of Moderna in February 2021. I tried to get her an in-home booster from the San Diego County Health Department, but haven’t received a response since October 25. Now I found that the one drive up site in the county and gathered appointment for the 17th. Okay, so now we’re talking about the 17th of November, a person who will be attending our group Thanksgiving is unvaccinated. Should my mom’s booster kick in by November 25? Or should we skip it completely? I’ve kept us both safe since March 4 2020. And don’t want to screw this up. This is the best part of it. Thanks for being wise, smart, kind, funny and compassionate. And for helping us through this mess. I think she’s talking about Jennifer. This is a very specific situation with someone who has expressed their values and their values or that they’ve been working off there to keep their mother safe and want to keep keeping her safe.

Dr. Farzad Mostashari  34:47

And sorry, the other part of this is someone’s listening to this episode and it’s the 17th or the 18th of November and they got a week to go. Should they run out and get a booster I think is the other form of that question. Right? Is it going to help you within a week or not? Jennifer, what do you think?

Jennifer Nuzzo 

I think you’re gonna have some additional protection in a week, not full. But some additional protection for sure. I mean, it shows that the right antibodies will ramp up fairly quickly. So I think it’s helpful. But in the circumstances of a 96-year-old mother don’t cancel. I mean, again, this is where rapid tests could help. The woman is 96, she probably wants to get together with her relative’s. Farzad, what you said about the very moving comments about your father-in-law, at the end of life, we may prioritize quality over quantity, I don’t think we’re really putting this woman at extreme risk, particularly if you use rapid tests, particularly with the unvaccinated.

Dr. Farzad Mostashari 

I will see on the booster side of this, the boosters are incredible, like it actually really does, you get better than the original two shot after the third shot after two weeks after. So the data we have is two weeks. So I think it’s a pretty good bet that it does start to kick in and it will have some effect. But you’re getting now up to like 95%-96% effectiveness is pretty, pretty incredible. We never have those kind of results with like flu vaccines or anything else like that. So yeah, let’s get the booster, get the booster.

Andy Slavitt  36:10

So I just want to say for the record, we have a great friend who’s 113 years old, and so 96 years old is not necessarily end of life.

Andy Slavitt 

Question now about how we use these tests that you guys have both been talking so much about, from Rachel, what should we do if a family of multiple generations is coming together to stay in the same home? For a week or more during the holiday? How often should we do rapid tests daily, more or less? And over how many days until we know we’re in the clear, so, Farzad, you want to start?

Dr. Farzad Mostashari 

I think that you should like again, I don’t want to be insensitive to the cost part of this, because it gets expensive, right? And I said every test is 10 1011 bucks. But if you’re testing every person every day, it gets really expensive. So if you can afford it, and you want to reduce your risk. Yeah, I think I think from a science point of view, you would want to test every day.

Andy Slavitt 

But it is true isn’t it Farzad that it takes a couple of days for the test to actually detect positivity. So if you were in the house, and not leaving, and you took it on a Monday, and everybody was still there, presumably been there for a couple of days? You know, let’s say you get there on Monday, you take it on Wednesday, there’s no real reason to take it again on Thursday, unless someone leaves the house, isn’t that right?

Dr. Farzad Mostashari 

Well, I think there’s a bit of an assumption there that between, you know, Monday, Tuesday, Wednesday, you didn’t re-expose yourself at all. So if that’s true, right, and that some people make that recommendation, it’s like before, like two, three days before you might meet your elderly relatives, basically, you know, get in the bubble, after point for the use in the bubble. But if you can’t assume that people did that they maybe they got infected on Tuesday, and it’s not gonna show up on Wednesday, it’s gonna show up on Thursday or Friday.

Andy Slavitt  38:28

Right. But once you’ve been together for a couple days, if there’s no new exposures, if there’s no new exposures, then there’s no need to continue to take daily tests. Okay, Jennifer, anything?

Jennifer Nuzzo 

So I think that tests are excellent tools, and are particularly useful, I think, for adding a level of protection in certain scenarios, but I don’t want to panic people because they’re still hard to find. And, you know, some people might be like, we have to do this level of testing in order to be able to get together. Otherwise, we’re being irresponsible. Again, if these are all vaccinated people, you’re gonna have to decide if that’s enough for you. Given that it’s like, you might want to add the test beforehand, getting together. I think, again, it’s comes down to, you know, is there a risk that we could still contract COVID in this gathering? Is the risk worth it? And if I did contract COVID, could I handle it? I personally feel like I could isolate myself, and I could deal with it. You know, my, you know, as long as everybody in my household is vaccinated. So anyway, I might be a little bit more permissive in this scenario than other people. Maybe not fully in the bubble. But just to say that, you know, this virus isn’t going away. And you know, if you’re like, I’m just going to do this level of testing until we get our case numbers down, reduce the probability of coming exposure, that’s fine. But I also think we have to think of our long-term strategy and how we want to live and what level of protections we’re going to erect around ourselves, given the fact that this virus is with us. You know and it will continue to cause infections you know in years to come.

Andy Slavitt  40:07

Okay, we have voicemail.

Carrie 

Hi Andy and staff. We are going to a small family gatherings that nine people all of us will be triple vaccinated except for my son and his fiancée coming from Texas to Pennsylvania. My son is recently J&J vaccinated about three weeks, but his fiancée is not vaccinated. So I will do a rapid test on her before we go to my parents who are in their 90s. My bigger concern is that Saturday, we are having a casual engagement party for them with about 16 to 18 people. Everyone else is vaccinated, I will open up windows and doors again that morning. I’m hoping she will take a COVID test. I know there is a risk. But how much should we worry being that she is not vaccinated coming from Texas. And how accurate is the binax? Now chest? Thank you so much. I appreciate hearing your answer.

Andy Slavitt 

This is what we call a mixed marriage, it’s a new interfaith marriage.

Dr. Farzad Mostashari 

You know, it’s funny, I’ve seen someone look like being vaccinated. It’s not like, can’t get infected or you can’t be infectious. And they were like, yeah, but if someone hasn’t been vaccinated, what does it say about their risk-taking behavior? So I think people are putting weight on that aspect of it of like, if you’re defiantly unvaccinated coming from Texas and don’t want to get a test, does that mean that you’re likely also, you know, doing other things that put yourself at risk is kind of some of what I’m reading into the question.

Andy Slavitt 

Yes. Did you just answer a question with a question?

Jennifer Nuzzo 

So I wouldn’t assume that I mean, I have talked to people who are not yet convinced of the benefits of vaccines, or they’re not yet convinced of why the benefits exceed their perception of the risks. And a number of I mean, a number of them are incredibly cautious. And they cite the fact that they’re incredibly cautious an alternative. So I wouldn’t assume there are so many different elements to that question. I will just say, above all, I’m most worried about the unvaccinated person. And maybe then the relative, the older relative, just because, you know, we know that vaccine protection can be a little bit not quite as robust in older folks. And that age is the single biggest risk factor for severe illness. But a rapid tests again, could add to that, you know, what else could help? I mean, you know, everybody masking, et cetera, et cetera. But you know, the question is, how much risk are people willing to take to have this gathering at their life events? One would hope that you could encourage her sweetly to become vaccinated, but we don’t know.

Dr. Farzad Mostashari 

Yeah, there were so many little things to pick up on that. First of all, your kid got vaccinated just recently with J&J. Like, why would you get J&J now, don’t get a J&J now, get the mRNA vaccines now. The second thing was you don’t air out the room, like before guests come, you got to air out, like while the guests are there. And then in terms of the binax it is, as I said, it’s really pretty good for detecting weather today, you have a lot of active particles in your nose, that you’re going to pass to somebody else, right? If it’s not detectable on that, assuming good technique, and I think that’s the underscores, like, the way in which you get false negatives with these tests run infectiousness is bad technique. And so you know, study up on it, like, watch a YouTube video on how to do it, make sure you’re using the right technique on it. But if you do that, then it’s the binax is pretty darn pretty darn good. And availability has improved significantly in the past.

Andy Slavitt  44:00

Okay, well, we’re heading towards our final section, which is kids, I just want to say so far, just to just take stock of where we are from the scoring standpoint, Jennifer, so you know, this is the best game Farzad’s ever plays.

Jennifer Nuzzo 

Is that a relational score?

Dr. Farzad Mostashari

This gonna be our last one. I keep saying Andy, this is gonna be the last safe or not safe because we’re gonna be through this, right?

Andy Slavitt 

It always feels like Farzad is really bringing out all the guns, but it’s very, very close. Because I think you have more natural talent. And I think the one thing I could say for sure, is that you’re leaving Caitlin Rivers in the dust Jennifer. Last section, always okay to talk about the people that aren’t here. Okay, maybe seagull. The 9- and 11-year old’s in my family got their first vaccine in early November, November 6. How protected are they thought to be from the first shot? What level of protection might they have by Thanksgiving, Jennifer?

Jennifer Nuzzo 

So I’ve got two kids who got vaccine that same week. They’re not fully vaccinated. I feel comfortable taking them to a Thanksgiving gathering where everybody else is vaccinated knowing that they are the least vaccinated among us. And I say that one because they don’t have any underlying health conditions. And two, because their risk prior to vaccination of developing severe illness was quite low. And now it is, I believe, even lower, given the fact that they have one dose. Two doses is going to be nice; it’s going to end for me my worries about my children. But I’m feeling much, you know, much less worried than I was before. And, I was not as worried as maybe some people were to begin with.

Andy Slavitt 

See very clear, that’s a natural talent I’m talking about, Farzad.

Jennifer Nuzzo  46:01

But he was mad.

Dr. Farzad Mostashari 

There you go. This was actually a point of disagreement between Team Caitlin and team Farzad, I was I always felt like kids, even unvaccinated are just, it’s like me with a vaccine is still probably riskier than that 9-year-old without a vaccine. So I get that people are really worried about their children. It’s just a natural instinct. But the reality of it is that they don’t seem to be at you know, even without the vaccine at that bigger risk. And then the other factor for me is, what is the increment in their risk? So for that 96-year-old, this is the riskiest thing they’ve done in the past year. And we got it, we got to kind of acknowledge that for that kid. That’s not necessarily, you know, any increase in their risk.

Andy Slavitt 

They’ve been doing risky stuff all year long. Let’s face it.

Jennifer Nuzzo 

My five-year-old wish she was four at the time spent, you know, the pandemic years in daycare. So, which is not known for its infection control practices. And fortunately, it was without incident. But yeah, so I feel quite comfortable with thanksgiving.

Andy Slavitt 

Final question. How long after vaccine until kids can wear surgical or cloth masks instead of N95 or KN95? If they’re vaxxed, but in school, should they wear masks at all? Should they wear medical grade masks? If they’re around somebody who’s vax but high risk? I’ve gotten this question a number of times, including on CNN a couple times is that once kids are vaccinated, do they still need to wear masks in school? And then of course, there’s a couple of other iterations of that question. Farzad, what do you think?

Dr. Farzad Mostashari 

The people who seem to care the least about wearing masks in school tend to be the kids who I’m amazed at how comfortable they are and how it’s not in their top three or four things that bugged them about school is not wearing masks. I will say I think the surgical masks people do as I mean; I’m not saying anything, you don’t know that people do find them much more comfortable and lightweight in terms of the surgical masks than the N95, KN95 or even cloth masks. So I think we do have to revisit this question of what is our school masking policies? And what is the goal and what in and also how does that relate with testing policies in schools. But a big part of kids masking in schools is to protect not them, but the older teachers, custodians, staff and others. And so I think the key question there is, you know, are all of those folks, you know, vaccinated and boosted.

Andy Slavitt  48:50

Jennifer?

Jennifer Nuzzo 

So my kids wear cloths masks, they don’t wear and 95 masks? I don’t, I can’t actually imagine putting on a N95 on a five-year-old, maybe people do it and they’re fine. I just that seems more than my kids would have been able to handle. And maybe that’s wrong. I don’t know. They wear cloth masks. You know, they’re fine. But I do think it’s really important for us to figure out when they can take it off. Because while they don’t mind, some kids do struggle with masks.

Andy Slavitt 

When do you think they should? I mean, legitimately, they’ve gotten vaccinated the teachers, what do you think?

Jennifer Nuzzo 

Well, first of all, I mean, if everybody that they’re around is vaccinated, I don’t really see the need for it. Frankly, now, with the exception of if there are vulnerable kids in the school, you know, I mean, suppress people and the disease in the surrounding community is really high. I think then there’s a justification. There’s also an operational benefits in that a number of districts are not going to quarantine kids that have been wearing masks, again, you know, with the expansion of vaccine to include now all school aged children. I think some of that those policies are going to change hopefully because I think People need to see that there’s some incentive to get their children vaccinated other than nothing will change. But I do think that once, you know, levels, you know, we’re less worried about, you know, huge outbreaks happening in school settings. We should talk about when they can take the masks off, we do lose something I don’t, I think we can’t be glib, even though they can tolerate it, and they’re fine with it, and they’re perfectly happy they do lose something that’s been not the priority for the last, you know, nearly two years. But at some point, it will be, because at some point, what we lose, will become greater than what we risk.

Dr. Farzad Mostashari  50:36

I agree with that. And Jennifer didn’t mean to imply that it’s not a big deal. It is a big deal. And I think not being able to see people’s lips not being able to hear well, does have an educational impact, for sure.

Andy Slavitt 

Okay, so we’re ending pretty much at a dead heat. So I want to give a final bonus question. Now, here’s the bonus question. This is kind of like double jeopardy. So you tried to write down if safe or unsafe would be broadcast once per quarter? How many more safe or unsafe’s to project there to be based upon the length and public attitude towards the pandemic? give you all a minute to jot down your answer.

Andy Slavitt 

All right, let’s see what we think here. Let’s start with the challenger, Jennifer. Jennifer. Jennifer says that there will be two at the most so possibly one, possibly none. Two at the most but by third quarter. Next year. No more need for safe or unsafe. Farzad Mostashari?

Dr. Farzad Mostashari 

I don’t think there’s any more need for safe or unsafe. I think the world has had enough of Andy Slavitt and Farzad Mostashari talking about safe or unsafe. However, Jennifer Nuzzo does add a new dimension. So she gets to additional, I think we please let this be the last one.

Andy Slavitt  52:08

Well, there we have it, Farzad is resigning. Well, thank you both. You’ve been such great sports. But more importantly, I think it’s a really common sense and fun way you’ve helped educate people about what can be a stressful time. But also, I think, as you pointed out multiple times a very meaningful time, at a time where I think the message that I’m hearing loud and clear from both of you, is to encourage people to take advantage of the opportunity to reconnect with their loved ones with their family, that there are safe ways to do it, there are tools to do it. And many of the things that didn’t seem safe a year ago, may well in fact be worth doing now that we have the ability to use these tools. So thanks a lot, guys.

Jennifer Nuzzo 

Thank you.

Dr. Farzad Mostashari 

Wisely said Andy, and thank you.

Andy Slavitt 

Alright, I hope that that episode, has you feeling more informed, possibly more optimistic? Possibly not. But hopefully more informed? I have found them to be quite common sense. And of course, look, if you disagree with anything, they said, that’s your right. I mean, you know, you can be more conservative, you can be less conservative. It’s good to hear what two experts have to say. And, you know, I think they’re carefully, Farzad’s a little more, as you can tell a little more careful on the risks, than Jennifer, but both of them are very, very reasonable, helpful points of view, and I appreciate them coming on, let me tell you what’s coming up. After Wednesday, we have the number three person at Facebook. That is someone I talked to earlier in the year. It is a very challenging interview. It’s about misinformation. I urge you to listen to it. If you haven’t heard it before. Let me tell you that we have some really great guests coming up after Thanksgiving as well. And I expect you to remember all this because you know, after all, again, nothing else going on this week with your family and friends.

Andy Slavitt  54:07

We have Mike Osterholm in a live session that I did with him, that was a fundraiser for his organization CIDRAP and I interviewed him for this. And we’re going to rebroadcast that to you because it was a fun episode and people love listening to Mike and I banter. He’s of course the great epidemiologist. Then on Wednesday, of next week is our episode, that focuses on monoclonal antibodies with the head of Regeneron Leonard Schleifer . And you’re gonna hear all about how to get monoclonal antibodies, how they work, what their background is, what their story is, I think it’s a really fascinating story a little bit punchy. And then we have an episode on some things that have changed in the healthcare system. And we’re starting with virtual care. That is care you can get virtually, virtually getting care through the internet, things like that. So there’s going to be a cool episode. Coming up about how care is transforming in communities and how you can access care differently and what the promise is for getting care virtually going forward. That’s it folks be talking to you on Wednesday. Thanks

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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