Subscribe to Lemonada Premium for Bonus Content

Description

Andy explores what Omicron means for immunity with Harvard epidemiologist Bill Hanage. Andy and Bill tackle what we know about the kind of immunity Omicron may provide against future variants, what role layered immunity will play moving forward, and why we shouldn’t count Delta out just yet. While you listen, see if you can catch all the literary and Arsenal F.C. references Bill skillfully slides into the conversation.

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

Follow Bill @BillHanage on Twitter.

Joining Lemonada Premium is a great way to support our show and get bonus content. Subscribe today at bit.ly/lemonadapremium.

Support the show by checking out our sponsors!

• Click this link for a list of current sponsors and discount codes for this show and all Lemonada shows: https://lemonadamedia.com/sponsors/
• Throughout the pandemic, CVS Health has been there, bringing quality, affordable health care closer to home—so it’s never out of reach for anyone. Because at CVS Health, healthier happens together. Learn more at cvshealth.com.

Check out these resources from today’s episode: 

• Read Bill’s recent guest essay in The New York Times about Omicron and immunity: https://www.nytimes.com/2022/01/19/opinion/omicron-covid-surge.html
• Check out the Household Pulse Survey estimates of COVID-19 vaccine hesitancy: https://data.cdc.gov/stories/s/Vaccine-Hesitancy-for-COVID-19/cnd2-a6zw/
• Find a COVID-19 vaccine site near you: https://www.vaccines.gov/
• Order Andy’s book, Preventable: The Inside Story of How Leadership Failures, Politics, and Selfishness Doomed the U.S. Coronavirus Response: https://us.macmillan.com/books/9781250770165

Stay up to date with us on Twitter, Facebook, and Instagram at @LemonadaMedia.

For additional resources, information, and a transcript of the episode, visit lemonadamedia.com/show/inthebubble.

Transcript

SPEAKERS

Bill Hanage, Andy Slavitt, Kryssy Pease

Bill Hanage  00:00

But the point is, you know, the wider point is very large numbers of people are going to be infected with Omicron. At some point, you know, almost everybody is going to be having some encounter with the virus. And the immunity that will result from that is going to mean that the next time they see the virus, they’re less likely to be severely ill. And so that is an important factor. Now, I will point out that if the way to get that immunity is not to get infected, the ideal way to get that immunity is to be vaccinated, because you’re then acquiring the immunity without the risks of infection and without something that you can transmit to other vulnerable folks. So get vaccinated. I mean, I’m sure most of the people listening to this are vaccinated, if not boosted. If you are actually in one of those communities, which are under vaccinated or not boosted, and you are in a position of authority and trusted, please speak to your fellow citizens, please try and encourage them to be vaccinated and boosted because that’s going to do a huge amount to prevent the worst consequences of Omicron. And indeed, whatever comes after Omicron.

Andy Slavitt

Welcome to IN THE BUBBLE, this is your host, Andy Slavitt, who you just heard was Bill Hanage. He is our guest today on today’s show. He’s from Harvard, TH Chan School of Public Health. I had a lot of fun talking to Bill, I think you’re gonna have fun listening to Bill, we’re really exploring, I think the one central question that is going to be front and center for all of us, which is what comes next? And what comes from the fact that we have now so much immunity built up both from vaccines, and from prior infection, mostly with Omicron, but also with Omicron and Delta. You know, it’s a question that we probably had a few years ago, which is, we then thought about his herd immunity? I don’t think that’s the way we’ll be thinking about it today. People use other terms, are we headed toward something called an endemic? Do we have a clean year ahead because of the fact that we have so much immunity now in the public? Or is that a false flag? I don’t know. False flags are a term but I’ll say it anyway. Is it a false flag in the sense that we could have another mutant variant from some other strain, say, alpha, or something else that doesn’t get a lot of protection from either the vaccine or from prior infection from Omicron. The truth is, nobody can say for sure, I think all things are possible. But I don’t think that’s the most useful analysis you’ve ever heard that all things are possible, all things have always been possible, what’s likely, that’s what we have to focus on. And I think we spend a lot of our energy being consumed with the fact that things could go wrong, because over the last couple years they have.

Andy Slavitt 

Depend how you look at it over the last more than a couple years, maybe things have been going wrong, maybe for centuries seems to be going wrong. But some things have also been going right. And we have to take stock and what those things are as well. I’m excited because Bill is very good communicator, very thoughtful communicator, and has been willing to kind of go take go on a limb and stake himself a little bit of talking about what the future might look like. So I go right at the heart of that question, and try to bring you some thoughts on what is likely to come next, what’s likely to be the benefit of all this horrible infection in cases we’ve been living through. And he offers great perspective on lots of other things. So I think you will enjoy this, I really enjoy talking to him. It made me think about just how much I enjoy doing the show. And particularly days like today, when I get to do interviews, like this one, it really is fun. I learned a lot. They’re enjoyable conversations. I meet new people, I did not know Bill before, although I think maybe we’ll become friends. I like to become friends with English people. It’s one of my goals in life, but also makes me want to ask you, as you’re listening into this, to think about that same question, like what is it that you enjoy doing? And are you getting to do enough of it? Are you getting to be involved in the things that make you happy every day? And I think that’s one of the things that got me through the pandemic was actually doing the show, having to come out every Monday and Wednesday, sharing with you learning, etc. And I realized that I was very, very fortunate and have been in that regard and I hope that all of you have something similar in your life. Besides the things that bring you the normal amounts of joy, like your wonderful kids, spouse, partner, family, friends, but just other things, going outside and getting sunshine, playing a sport, reading a book, just making time for that stuff, I realize, we don’t always get to do, but it’s kept me sane and balanced as I could possibly be.

Andy Slavitt 

And I wish that we all get a chance to do some of that as much as we can. For a kick in two more things, I think you will, many of you responded to the request that I put out that I get some input on where we should donate, latest of our show profits to $40,000. So we’re now reviewing a number of those places you send in so many worthy organizations. Hope to have an announcement next weekend where we’re sending that money. Now, as we kick into this interview with Bill, we start to tape as Bill’s getting settled, and he’s talking to Chrissy. You’ll notice that he and Chrissy have a little fandom in common as the interview kicks off, and then we’ll get right into it with Bill Hanage. Again, he is the associate professor of epidemiology, and-the co-director of the Center for communicable disease at […] at Harvard’s T.H. Chan School of Public Health.

Kryssy Pease  06:33

Bill, hi, apologies for us being a little tardy, but thanks for understanding.

Bill Hanage 

That’s all right, what’s over my shoulder?

Kryssy Pease 

Look at that. Yeah, Andy, that is how I booked Bill. Just so you know, we are fans of the same soccer team.

Bill Hanage 

The same soccer team, I have announced it soccer because nobody else understands when I call it football.

Andy Slavitt 

You’re an Arsenal fan. That’s what you think this is about, right?

Bill Hanage 

Absolutely. Yeah. I’m here to talk about the Arsenal.

Andy Slavitt 

My son lived in London for the semester, and I’m trying to remember what his team is, but I’m blanking on it. But he was listening to my podcast anyway. So he won’t care. He will care. We’ll call it the Arsenal podcast. What the hell.

Bill Hanage 

Just call this the Arsenal podcast and we’ll find working something about, you know, building up our arsenal of immunity.

Andy Slavitt 

Yeah, that’ll help. You’re an associate professor at Harvard epidemiology. You’re also like one of the more literary people in the whole sphere of science. We want to talk a lot a lot today about post Omicron with you, but because we’re not done with it yet. What are people’s biggest misunderstanding is you’ve seen or heard some of the most surprising things that are kind of well discussed around this Omicron wave.

Bill Hanage 

I think the biggest misunderstanding about Omicron, which goes right back to the start, that goes back to a few unfortunate pronouncements from CDC, is that the whole mild thing? You know, mild is really in the eye of the beholder. If you have something that is mild, but still takes out large amounts of your healthcare workforce, that’s pretty serious. Because the number of beds you have is pretty much, is dependent upon nurses, you know, you can make another bed for a mildly sick person to lie in, and you cannot make another nurse who’s able to, like, serve an ICU bed. So these issues are, I think that’s a really big misunderstanding. The other thing is the role of previous immunity, prior immunity in terms of the types of infections that we see with Omicron. And I think that’s something that people have missed a lot.

Andy Slavitt  08:41

And the definition of mild or milder, which I understand what people mean, when they say it, that on a population basis, our likelihood if we roll the dice of any one hospital is lower. Man, I tell you, I’ve talked to four or five people recently who have just been recovered from Omicron. And they’ve all said, Man, I don’t want this again, this was not pleasant. They didn’t go to hospital. But they were like, 8, 9 days of misery. And people’s experiences tend to vary. But it really is kind of very tough to put a label like that on something so broad, isn’t it?

Bill Hanage

Yeah. I mean, when you hear people say mild. They don’t mean a walk in the park. They mean, you’ve not gone to hospital, you haven’t need supplemental oxygen, that kind of things. It’s like, and, you know, I know a lot of people I was talking to a friend of mine yesterday, he recovered from it and just had announced that it was the first time he drank a cup of coffee. That tasted like coffee in a good few weeks. And it wasn’t even quite like coffee yet. So I mean, it’s still not a trivial illness. It’s a lot better than it would be in the absence of immunity. Sure. But optimism is a relative state.

Andy Slavitt 

Right. And hey, you’re talking to a guy who winds want to get the flu like a baby just like a baby. I expect to be waited on hand and foot and nobody’s In the mood for that, solely a lot of men do that. Our wives could probably tell each other about that. Now, we’ve had this sort of practice of having to analyze data in real time before it really exists. And so we’d never ask you to do that, except that I’m going to ask you to do that, which is extraordinarily challenging practice, which is to try to help us think about when we get past a submicron wave, what kind of immunity will likely get built up in the population? What will it protect us against, will it provide more blanket immunity that we’ve had before? How will that impact waves. How long was that likely to last? You have some perspectives on that?

Bill Hanage  10:42

Sure. I think the most important thing to know is that Omicron is not going to burn out, it’s not going to disappear, we’re not going to be left without SARS-CoV-2. We may be left with a very different sort of disease, which is caused by the virus there. But it’s not going to get rid of the virus. I mean, I think the one of the basic misunderstandings right at the start, which was kind of unfortunate, is that all of the rhetoric around flattening the curve, and all of those epidemic curves that you remember seeing they kind of led people to think, oh, it’s going to go away, or the kind of folk epidemiology that people learned about suggested that we’d reach a point at which herd immunity would kick in, and that would be it’d be over bang. And that was brought in by some as a finish line. And so they just wanted to get to it as quickly as possible. As it is, we’re never going to get that amount of immunity, which will exclude the virus, we will get an amount of immunity. Indeed, we probably do have an amount of immunity, which completely transforms the sorts of waves and we see and their consequences. But we’re not going to get to the point where it’s excluded. And that’s important to say, we’re not even clear whether or not Omicron is going to drive Delta extinct. In some combinations of parameters, it does and others it doesn’t. And that’s before we talk about the fact that Omicron is not even itself a single thing, we had there are two deep, branching lineages within it. BA1 and BA2. And we don’t know yet how they’re going to attract.

Andy Slavitt  12:05

So let’s take that piece by piece because you said some really important things in there, one of which was that Omicron will continue to persist in another one, which is that we’re not yet sure whether Delta will be able to come back and compete against Omicron help people understand kind of, in layman’s terms, using your Caymus analogy from your Twitter handle.

Bill Hanage

Yeah, it’s kind of you to say that my friend Mark describes me as literary. I’m not sure if that’s just his way of saying that I’ve got a British accent.

Andy Slavitt

That adds at least 30 IQ points to everything you say. But yeah, absolutely. It makes me sound really right. But then you throw in a few throw in a kind of obscure-ish type literary reference, that I’m hook, line and sinker. So everything you say, is completely gold.

Bill Hanage 

Can I give you a triple that if you really want to sound clever, you should subscribe to the London Review of Books and the New York Review of Books because then you can, you know, talk about two different reviews. And then people think that you’ve read the book, and you’re really smart. Sorry, that was just a teaching.

Andy Slavitt 

Don’t I won’t do that. I’m doing it. I’m doing it right after this show.

Bill Hanage

So the way to explain this is, Delta is a pretty serious virus. I mean, delta is no slouch at causing breakthrough infections itself. I mean, and Delta’s secret sauce is not so much that it manages to evade antibodies, as it replicates really fast early on an infection. And so before the immune system has fully kicked in and started to expel it, and you know, work to bring the infection to control, it’s got to a high enough tighter, higher viral load that it transmits. Omicron is different. And it is, you know, I don’t want to pretend that I know more about this than I do. I’m not a virologist. And so it’s not exactly where my area of expertise lies. But Omicron has way more in terms of those mutations that evade immunity, that mean that some of our monoclonal therapies don’t really work against it. And because of that, when immunity starts to kick off, Omicron goes meh, and it doesn’t have much of an impact. I mean, yeah, it does in Omicron is not a complete escape variant, it is still controlled to an extent by the immune system, but the nature of the way that it is managing to get around it is different from Delta.

Bill Hanage  14:22

So, once Omicron has come through, there will be a whole kind of commercial of different things in the population, different people, there will be those who have been not infected, vaccinated, boosted, infected, boosted, vaccinated, a very small number of people who are completely unvaccinated. And of course, there will be some folks who have never been vaccinated but have been infected. And some of those are going to be interactable by Delta, still, some of them are still going to be intractable with Omicron. And so you can imagine these two viruses, it’s going to be like Godzilla versus […], whatever the particular references, and they’re going to be fighting for those remaining pools of hosts, who they are capable of, were they able to infect, and I think that we’ve been sort of overwhelmed by this extraordinary spike of Omicron. And we’ve been so fixated on that, that we haven’t really thought about what’s going to happen afterwards.

Andy Slavitt 

Okay, so let’s get into this a little bit if you’ve been vaccinated, put aside boosted or not boosted. But if you’ve been vaccinated, regardless of whether or not you’ve got prior infection from Omicron, Delta comes back. First of all, how does it come back? Does it make its way back in those few people that haven’t been vaccinated or have had prior infection with Delta, in other words, if you’ve only had Omicron, is your kindling, the folks who have just had Omicron and nothing else?

Bill Hanage  16:17

It’s just wherever Delta is able to hold out because Omicron isn’t actually going through everywhere. At the same time, there’s likely to be a refuge, a little places where it’s able to hold out at the moment, I mean, even now, you find occasional examples of the previous variants, even if the Delta dominated,

Andy Slavitt

You think it is possible for Delta to survive for a time before it gets out, competed for Omicron? Or you think Delta well could have a resurgence? Which are you saying?

Bill Hanage 

According to some combinations of the way the world is delta could come back and be somewhat stable, a little bit less common than Omicron. According to others, it could actually mount quite a serious resurgence, I think it’s always going to be less common than Omicron. Perhaps it will be completely out competed. But also, you know, something Andy, this is one of those bizarre situations, where in the time, it would take me to thoroughly model it on a computer, the empirical reality will be playing out before our eyes. Because Omicron is just so fast. So at the moment, I just want to point out that you shouldn’t count Delta out.

Andy Slavitt 

Okay. So now let’s say we evolve to a place where, in most countries, the lion’s share people have either been infected with Omicron, or been vaccinated, or both. And certainly there’ll be a lot of people who have both, what degree of protection will that hold against future rounds of say, omicron? We’ve had for the last two years in a row in places like Florida, in the US we’ve had waves coming through in the summer. Is that likely to recur? Or does the protection from Omicron and the vaccination make that much less likely?

Bill Hanage  18:02

And I think that we’re likely to see waves of cases in Florida, certainly. And the consequences of those cases in terms of hospitalizations, etc, are going to be really useful to understand what we might expect in the fall and winter. I remember saying around this time last year, watch Florida over the summer. And then, when Florida started to take out various people said, oh, my goodness, he’s like a, he’s got such foresight. It’s like no, actually, it’s a coincidence that was Delta. I just happened to get lucky there. But Florida is going to be a guide to what happens because as you know, over the last summer, in the summer, before that, we’d saw a substantial transmission, possibly driven by the fact that that’s the indoor season in the south, where places get really, really hot. So as an important place to, you know, to keep an eye on, it’s also not incredibly well vaccinated. And it’s one of the most disturbing things that I know of that. I mean, I got vaccinated in May of last year. I’m not like in the frontline, you know, those who can’t see my face, you know, I’m in my 40s. I’m relatively healthy. And since then, Florida has had more than a third of its total deaths. And that’s a point when vaccines should have been there protecting people. And indeed they were in a lot of the country. They were here. They were in lots of other places, but in places which are under unvaccinated. There’s still a risk.

Andy Slavitt 

But Florida’s had a really big Omicron wave and I think the question is, how much protection will that provide to an unvaccinated populations.

Bill Hanage 

They may have gone a little more protection also from Delta, because they had a pretty big delta wave. So they’ve got relatively fresh immunity from that. Same thing might be true of the United Kingdom, which has done way better vaccination than anywhere in this country, and also had 5 million recent Delta infections. So Delta plus Omicron in Florida will help. But if you had the choice between building up immunity with a vaccine versus building up immunity with a virus that you can transmit to somebody else, you know, I think you’ll be unsurprised to hear that the public health guy says.

Andy Slavitt  20:15

Oh, I’ll get to that. But I’m going a little bit, something slightly different, which is to say, care just as much about losing somebody who dies from COVID if they’ve been unvaccinated as if they’ve been vaccinated. And there’s people who have made a choice for a variety of reason. And you know, actually, I think there’s a ton of needle phobes out there, I think a lot of sentiment here is people who I mean, well documented both in UK and the US, somewhere between 10% and 25% of the population has a very strong fear of needles. And when you’ve got a strong fear of something, you can’t always logic your way out of it. So there are people in the country who are unvaccinated. And they’ve had let’s say they’ve had prior infection of Omicron, at least, and maybe ever kind of Delta. Does that give us enough of a protection? That between that and of course, the vaccinated people were likely to see much of a wave, or you’re not convinced of that?

Bill Hanage

I’m not convinced of it. But I mean, we do actually have numbers here that we can use, which is, I like numbers like the next nerd. I mean, in some of the conversations we’ve had around this was discussions of layered immunity, which is a phrase that seems to have been going around a witch. I’ve been hearing a lot since I read a thing recently. The idea here is actually something which we have observed, empirically, if you look at the United Kingdom, and if you look at South Africa, where they’ve been doing very careful comparisons of Omicron, and Delta and so on, you can see that, roughly speaking, if you have been previously infected, but not vaccinated, your chances of hospitalization are cut by about 40%-50%. Roughly speaking. The estimates do vary somewhat, but you know, they are, it’s cut, it’s lower, it’s not as much lower as it is, if you have been vaccinated as well. If you’ve been vaccinated and boosted, this comes down to a reduction of 70%-80%. Those sorts of numbers. And while I don’t want to run away too far with those, because they are very much skewed towards younger age groups, who were very unlikely to end up in hospital anyway.

Bill Hanage  22:27

It does indicate the fact that the more times we have encountered the spike protein, the more robust our immune response when it comes to preventing against severe infection, even with a variant, which is as wild as Omicron. But this can brings us to a real issue in the United States, which is issues of vaccine access. Because you mentioned just earlier, there’s a whole lot of people who have not been vaccinated for very good reasons. And you know, I don’t like good reasons for them. There’s a lot of people who have been vaccinated. And I think it’s important to not point the finger and going to make people feel worse already. That’s not effective. In particular, if you look at the pulse survey of folks and attitudes to vaccination, you can see that lower income households are actually more open to the idea of receiving vaccination, but have not been vaccinated than higher income households. So if you’re in a higher income household, and you’re  unvaccinated, that’s a deliberate choice, if you’re in a lower income household and not vaccinated might be because you’re struggling to access it, you’re worried about taking a day off work, you’re worried about the side effects, worried about those things, you’d be open to it. And the problem is, like I just said, people who have been infected have reduced risk of serious outcome, but it’s not as good as being vaccinated. And so we are once again producing an inequity and the risks from the subsequent waves of variant infections.

Andy Slavitt 

Interesting. So this dissociative layered immunity. I think it’s worth exploring and explaining to the public because for some, it’s a new term. I think people could probably figure it out because they know what the word layered means. And we know what the word immunity means. But can you just make sure we understand the context in which people are talking about layered immunity now?

Bill Hanage  24:18

Sure. I want to preface this by quoting Ed Yong who did a really good thing in The Atlantic could give you a year or so ago by commenting that the immune system is where intuition goes to die. So, these are these are very much in general terms. The idea is that as we are exposed to these antigens, for things we can switch them out in the response multiple times. The nature of the immunity that we accumulate, grows, it becomes broader. If you have been infected, as well as vaccinated, you are not only mounting antibodies against spike, which is the title of all the vaccines, you will also be able to target the end protein as well. So You’re getting a wider range of immunity that is effective. And it may not be enough to stop you being infected. It may not be enough to stop you having symptoms, but it will be enough to stop the great majority of people winding up in hospital, because pandemic 101 is your protect health care. I mean, yeah, I know. We flunked that class multiple times. But, it remains the case that that is a goal we keep getting to retake it, we might have flunked it, but we keep getting to retake it. And as time goes on, we are going to get a helping hand from the immunity that has been generated by both vaccinations and prior infections.

Andy Slavitt 

So this in this sense, layered immunity, meaning having had multiple things to help your immune system, including vaccinations, including prior infections, and so forth, those things stack up on one another.

Bill Hanage 

Yeah, they stack up on one another and think about it. There’s lots there’s quite a lot of vaccines that require three doses. That’s not at all surprising. It’s also almost certainly the case that flu is off as a similar thing going on. There’s a lot of much less severe flu infections, which is one of the reasons why every year we have to estimate the real total of flu, because of the fact that we tend to see the more severe ones. And so if you have a mild flu infection, one of the reasons for that is that you’ve previously encountered flu, and so your immune response is broad enough and strong and robust enough to stop you getting severely ill.

Andy Slavitt  26:39

You know, I’m thinking that I should start a game or column or something, maybe you could do with me called pandemic catchphrase of the month. Yeah, it’s sort of like and January’s was definitely endemic or December’s one of them was people kind of, in order to qualify to win, it has to be word, it’s more frequently misused and use properly. Otherwise, okay, you can’t count it, which is almost true of every word that gets tossed around in the pandemic. But what I think a lot of people mean, when they say this, is that we’re going to see a phenomenon similar to what you’re talking about, take hold, which is that the cases of the virus continue to get more mild, because of these layers of immunity that are starting to exist around society. And that we end up with milder and milder cases that are just a part of live. And we are going to go back to some state where the viruses that obsess us all the time, I think that’s what a lot of people need  when they say that. But using that version of endemic instead of deed where you think we’re heading?

Bill Hanage 

That’s not as crazy to use an endemic as some of the ones I’ve heard. I think that is where we’re headed. But it’s not clear exactly when we’re going to get there. And that’s, I think, an important issue. The thing which a lot of folks don’t get about endemic. And I think I’ve commented elsewhere that, you know, the fact that endemic starts with the letters E, N, D, is a coincidence. It’s not like endemic is the end of the pandemic. No, it means that it is present in a population at roughly constant levels. It doesn’t show wild fluctuations, wild epidemic outbreaks, and the endemic amounts of disease can still be quite serious. You know, tuberculosis is endemic in large parts of the world. It kills millions. And that’s not a cuddly disease. Malaria isn’t a cuddly disease, and yet it’s endemic.

Andy Slavitt  28:52

It’s really more steady state that it is better or worse.

Bill Hanage 

Yeah, it’s closer to that. So we could have an endemic state of COVID, that would still be really pretty serious and have quite large, serious, seasonal fluctuate fluctuations. And I suspect that we will, but when I say large and serious, I mean, it’s going to be large and serious in the sense that people like me and watch flew, right. It’s not going to be something that your average, folks would necessarily be so concerned about. People who work in infection. Yeah, they would. But people who are you know, that’s a phrase that British people have the Man on the Clapham omnibus, you know, which just means your average Joe or Jane. Those people would not be worrying about it like they are now.

Andy Slavitt  30:05

What I think people are trying to exclude, when they say something that they consider to be optimistic when they say talk about endemics, and I think your point is important, which is that endemic isn’t necessarily an optimistic place. But what I think people are trying to say is that there won’t be any more variants of concern that get worse or than ever worse impact, they may be worse, or not be worse, but they won’t have a worse impact on us because of our built-up layers of immunity. And so I think they’re counting on the fact that whatever immunity we get from combination of things, we have Omicron, delta will hold up really well, no matter what variants come our way. So can you comment on that thinking? Is there some reason behind that? Is there’s a certainty behind that reasoning?

Bill Hanage 

Well, I think the reason behind it and the reasoning behind it can be found in the fact that when you look at the severity of infections among people who are immune, because they’ve been vaccinated, in particular that vaccines are boosted, or because they have some combination of that infection, it is less severe. This is just an empirical observation we’ve made. And it also probably feeds into one of the other great fallacies of evolutionary biology and epidemiology, which I’ve heard a lot in this pandemic, which is that, you know, pathogens evolved to be less virulent. No, they don’t, they really don’t evolve randomly, isn’t that correct, but they evolve in order to maximize their transmission. And if being virulent is in any way, assisting or aiding in that transmission or irrelevant to it, then it doesn’t have anything that has nothing to do with between transmission virulence evolution and virulence. I’ll point out SARS-CoV-2, the vast majority of people who are infected with it make a full recovery. So it’s not going virulent on the scale of myxomatosis, which would kill 90% of the rabbit certain facts, it’s nowhere near that. So talking that kind of misplaced, but what is worth noting is that when we talk about things like the great flu pandemic, in 1819, there were a couple of really there were three very large waves, the most important thing, the second one, and then over time, it became, you know, the severity of the waves and the accompanying infections became mother.

Bill Hanage  32:30

And a reason for that is not necessarily that the virus is evolving to be nicer. It’s that the populations are accumulating immunity, so that when their subsequent encounters with the virus, they’re less likely to be severely affected. I do want to kind of future proof this conversation a little bit. Because there are all kinds of extraordinarily strange things that can happen in immunity. There’s a stuff called antibody dependent enhancement, which means that you can sometimes find subsequent infections with closely related things are more severe than they would have been following the first infection. The classic example is Dengue, Dengue fever caused by dengue virus, the issue I have is that the fact that something can happen or could happen, doesn’t mean it does happen. And we haven’t seen evidence for that in those variants that we have observed so far. Instead, we have seen variants that have in fact, up until Omicron been generally getting a bit more dangerous, a little bit more likely to land you in hospital mitigated against by building immunity. And that has been consistent. And there isn’t really any a priori reason to think that at some point, it’s going to flip and start changing. Having said that, I never bet against natural selection. And if natural selection comes up with a way in which a virus will be successful, while also being more virulent, then well, we can expect it to be selected.

Andy Slavitt  34:07

Yes, it does. The fact that this is a virus that multiplies so frequently, and somebody parts of the world just give it so many more chances to mutate in ways that help it evolve.

Bill Hanage 

Indeed, although I’m always a little bit surprised at how many people are still surprised, and something happens. It’s like, don’t count out Delta. Don’t count out even Alpha. Remember, the Omicron lineage branched off from everything else before Alpha was even a thing before Delta was a thing long ago. There might right now be some long-term infection somewhere with a Delta variant or an Alpha variant, which at some point could lead to a more divergent successor to Omicron. But we’re just going to have to keep keeping a very close eye on it. Keep surveillance up and remember that if and when such a thing happens if we have a lot of immunity in our population, we are much less likely to see serious spikes of serious infections which challenge healthcare.

Andy Slavitt 

And our new business, Bill, you and I started around the monthly catchphrases

Bill Hanage 

Once this month’s misappropriated word. We’ve had herd immunity, we’ve had endemic. That was I’m looking forward to when variance is a technical term and statistics again.

Andy Slavitt 

Yeah, exactly. I think one that may get there. Because it’s not always an epidemiological term, it’s a term that’s borrowed. And then I think […], maybe February, as a candidate for February, I’m starting to see […], everywhere, like we are about to enter a […] after Omicron. Meaning that you know, it’s going to be a decline, there’s not going to be a lot of cases, and then […], I think will be at least it represents some sense that it’s that we’re not in a period where it’s gonna last forever. Where we were earlier, and I was in the White House, I used to tell folks this, when they were puzzled by people’s responses, when case rates are climbing on the epidemiological curves going up, everything we’re doing is wrong. And when it’s going down, everything we’re doing is right. So just start with that as a baseline, and recognize that we’re looking through, you know, a three-week-old lens at any given moment, and how we’re being evaluated. But I think there’s this sense of folks, maybe it’s because of what they see in South Africa, maybe it’s because someone thinks we’re talking about in terms of layered immunity, that we’re gonna have a good clean period, here in 2022, or that we’re highly likely to, for some period of time.

Bill Hanage  36:38

We’ll have a good clean period, probably in terms of cases, I suspect that they’re going to plateau somewhere, you know, middle relatively middling compared to what we’ve seen.

Andy Slavitt 

Under 100,000.

Bill Hanage 

I’m not going to speculate that I mean, one thing I am going to speculate on, because I think I predicted it a few weeks ago, and we’re starting to see it, is that we’re getting this sort of long, long, slow burn in healthcare because the vast majority of early Omicron infections were in young, healthy people. And we are now seeing the consequences of being introduced to older hosts networks. And in places where they are very well boosted. That’s something you can handle in places where they’re not very well boosted, which is a large part of the country, we’re going to see more severe infections, we’re going to see and that’s going to carry on for a while. And for all that, you know, every time I hear somebody say, oh, we shouldn’t count cases, we should count hospitalizations, I was saying, well, yeah, obviously, we should do both. And if we have a lot of cases and few hospitalizations, we should use it to reassure people. You know, we should, we are learning things about the virus, it is possible that we’re going to have a relatively long, slow burn of Omicron for the most likely to be severely affected individuals.

Andy Slavitt  38:00

I think that’s a really useful thing for people to get their heads around. And I want to restate it before you get to your butt. So please don’t forget it. But I want to restate it. What you’re saying is we’re used to this period of a few weeks, before hospitalizations and hospitalizations kick in, then we’re done. What you’re saying is, and we’ve seen this in other variants, too, we just haven’t been able to measure it as well. We actually have two periods, the first period where there’s a lot of cases, but they’re younger people, older people relatively prospective, then you get family spread. And the second evidently spreads, at least to someplace where people do a better job hiding out. And then you get another set of cases. And then those are people that are even more likely to be hospitalized. So that if you’re looking for the hospital curve to drop down just like the case curve, and if you’re looking for the death curve to drop down the same way, that there’s reason to think that might not happen.

Bill Hanage 

You might be disappointed. Yes. I mean, I think the hospitalizations from this particular various sharp spike will come down probably comparatively quickly. I think a lot of the hospitalizations don’t last terribly long. And so hopefully it’ll turn around. But we still haven’t seen a lot of those older people. In fact, it might be that we see fewer hospitalizations overall, but they are more consequential they have a higher acuity and they are more likely to be severe. So, these are all the things which are going into the mix. The other thing though, which is really building on something you said is human beings have this extraordinary tendency to look at the know when things going up, they panic and then when things are going down, they instantaneously say oh my god, it’s over. It’s like, no, it’s not over. It’s going down. But that doesn’t mean it’s over. And then they act surprised when they go back to how they were and things pick up again. It’s just it’s absolute. It’s so freaking obvious to anybody.

Andy Slavitt 

It’s the same reason why when the stock market’s going up a ton everybody’s buying on Robin Hood or wherever and when the market is going down a ton everybody’s selling. And that obviously has a bore, has also a self-fulfilling component to it just to a degree, but it’s the psychology that we should be paying attention to. We’ve all been the roller coaster.

Bill Hanage  40:13

I mean, I think there’s one other thing that I should say, because it’s really important for people like me to remember this, you know, a lot of my friends don’t work in science. The place I really want to go is the local sports bar, where I can hang out with my mates and, you know, talk to my friend who tends bother, as a result of maybe of this, or maybe I don’t know, I’m acutely aware that while there are people like me who start their days, with Zoom calls, in which I hear things like, Oh, we ran out of ICU nurses last night, or who get questions like, why is it that the per capita mortality in the US at the moment is so much worse than in the UK? Answer? Boosters. I’ll get these things all the time. And it’s 24/7. And it’s been continuous, I have a very, very few opportunities to relax. That’s me. There’s also a load of people for whom the pandemic has a mysterious far-off force, which has come wandering close to their lives at one point, made them on pleasantly ill at one point, but then they’ve got over it. And they’re just sitting there saying, What’s this got to do with me? Why can’t I go and do the things I want to do? Why? Why is this happening? And it’s because I’m not criticizing those folks. I’m just trying to point out that the kind of population level thinking, which is what you need, in order to be able to come up with an adequate response to a pandemic, and a successful pandemic management strategy is something which is not easily come by. It’s not common sense. And so you need remember that.

Andy Slavitt 

Well, yeah, there’s also just multiple right answers. Like I think for policy makers, there are wrong answers, like Ron DeSantis, like wrong answer, like just always the wrong answer He’s always the kid with the wrong answer in class. Right? He’s always that good. But there are many things that underneath the level of the politician, where they’re very reasonable, it’s very reasonable to say, I view my risk as extraordinary low. There’s so many things in my life, I value, I don’t know why I’m obsessing about this, I if I get sick, I don’t really mind it, whatever the calculus is, I love going to sports events, and I’ll take the occasional once or twice a year, flu, whatever that is perfectly reasonable. And in fact, it’s I think, also true. And people haven’t said this enough, as they probably should. That is, soon as vaccines stopped being very protective against transmission, they’re still obviously protective against getting in the first place, which makes them more protective, and they’re still somewhat protected when people are boosted. But the vaccine became a little bit more of a personal decision than it did a societal decision when that happened. Because if you are vaccinated, the most important person who you affect if you get vaccinated, is you. And so if you get vaccinated, and someone else doesn’t, it could bother you. But it should bother you less. And there’s there are lots of corner cases and lots of situations where that’s just patently not true. If you’re an employer, and you have a bunch of people in the back room, and it’s unventilated and you don’t care if they’re vaccinated, you know, situations where you’re doing really putting other people at risk, our problems, be situations where immunocompromised people or kids under five are exposed or are trickier and more complex situations. But for the most part, I tell most political leaders, that if they have constituents who feel a certain way, about the virus right now, based on their individual experience, how could you possibly say that it’s wrong or irrational for them to take that view, people are pretty well, intuitively informed. Nobody wants to die. And so people make decisions that others could call good or bad, but in the scheme of things, there’s a lot of very acceptable interpretations of where we are at the present moment. And at least in my opinion.

Bill Hanage  44:04

I think it’s really important to be empathetic to other, you know, to other individuals, to listen to them and to try and you know, you don’t need to agree with them, necessarily. But I think I want to be very, you know, there are obviously some extremes who can become very noisy and vocal, in particular on social media, arguing either for if the pandemic no longer exists, which is sorry, false. Like I said, 2000 Americans die, on average every day, or saying that we have to eradicate the virus and anybody who doesn’t try to eradicate the virus is an apologist for mass mortality or something like that, which is really tough for folks who spent their entire adult lives working to reduce mass mortality to here, but there’s also the position of pandemic grown up, which is the point in the middle where you’re trying to balance harms, and you realize that you’re not going to be able to win everything. You just went enough.

Bill Hanage 

It’s like the Albaka and Sisyphus, Sisyphus is the guy cursed by the gods to roll the stone up the hill. When it gets to the top of the hill, it rolls back down to the bottom again. And that sounds like a sounds awful. But can you said, well, basically, it’s actually what our lives are like, it’s, you know, we keep trying to do this, and we will always fail, we just have to make sure that while we’re failing, we have a good time doing it, you know, this, and that’s kind of the attitude which I think we have to pick, you know, to come up with another quote, which I might butcher a little bit from memory. But basically, you know, in life, there are pestilences. And it is up to us as far as possible not to join forces with the pestilences. And that’s the kind of that I think that is a really relevant thing right now, we should be focused upon if not defeating the virus, then limiting its dreadful consequences. And I cannot believe that two years into this, we are still in a situation where we have this many cases, this many people dying, we are still trying to explain to people that we are trying to protect health care. But I do have a relative state of optimism, that over time, we will build up this bulwark of immunity within us, which means that we may have subsequently significant surges. But they’re not going to necessarily roll into the severe illnesses. But I want to be careful about that. Because there’s a lot of people who, as far as I can tell, have never admitted they were wrong, who have confidently asserted at various points earlier in the pandemic, we have herd immunity, and then they’ve ended up with it.

Andy Slavitt  46:42

I hear what you’re saying is being very distinct from that. And I think you’ve done a great job articulating the difference between what you’re saying, and herd immunity, and I don’t think it should be easily confused. There’s one thing that neither of us I have talked about as a factor here as well, which is we have another called good guy on our side, we have another if the virus can do wildly shapeshifting things for survival. You know, we’re building up our immunity gates. And we have one more thing on our side, which I think has been implied here, which is science. And that, you know, we are also have really brilliant people, really brilliant people working to outsmart anticipate this with new vaccines, new antivirals, new prophylaxis, oral antivirals, oral vaccines, nasal vaccines, multi-Vaillant. I mean, lots of things.

Bill Hanage 

As an extra ordinary array of tools in our arsenal, we’ve got loads of weapons there, we can figure out how to use them better. I think it’d be good to link up rapid tests to prescriptions for antivirals, in particular, you know, you get a positive rapid test, you get your antiviral if you’re in a vulnerable group early on, because it’s really important to give them early on, we can still be smart about using them.

Andy Slavitt 

We get those processes right probably a year after they’re introduced, usually, I mean, if we’re if we’re if we’re on our game, I mean, but eventually we do. I mean, this is meant to be a positive statement. Eventually, we get those processes figured out. That doesn’t, but it doesn’t happen right away, unfortunately. And by the way, you keep using the word arsenal, like I mean, it’s something going on with you or Arsenal.

Bill Hanage  48:18

Yeah, I confess, I’m a fan of Arsenal Football Club in North London. I had a season tickets in the past, I went to see a lot of games. My wife once announced that I was I thought I was an intellectual, but I wasn’t. And I kind of said, well, what do you mean? She said, you spend all of your spare time thinking about watching or playing football? That was the case. I mean, now I spend almost all my I don’t really have spare time. But what little I have I do spend a lot a bit watching the Arsenal. You came up with something else that I was going to say there about the about, oh, yeah, we have science, the mRNA vaccines, as I’m sure you’re aware, because of their very nature have a sort of plug and play aspect to them. It’s very easy to make an Omicron spike, put it into the contract and start running with it. That’s phenomenally good. In more than that, though, I think science has been as Carl Sagan called Science a candle in the dark. And I wrote way back the start of the pandemic, I asked a question on social media about how people felt about fear. And a really, really, I got a really sweet email from a member of the public, saying that she felt like fear was really caused by not understanding or by feeling that there’s something out there and dark. And she told me how she had talked to her grandson and explained that once you understood things, things that seemed scary, weren’t that scary. And that science was a way of trying to keep that fear at bay. And that’s certainly something that I have felt many times over the last few years. I just wish that more people were able to join me in that science.

Andy Slavitt  50:00

Well, if I were to sum up, the absolute worst title for this episode would be the literary epidemiologist, no one would listen to it, but I would do it 1000 times. So I’m not going to call it that. But what you are saying, and I think this has been a great conversation for my concern. You know, I probably wait these episodes based on how much I learned, and how deep we really go, and how much of where we started, we end up and I think we did that. And I really thank you for that. But it’s because you know, the way your mind works, and evolves and integrates, which makes you a pleasure to listen to. And what you’re really talking about is, you know, science is one way of describing the world. Literature is one way of describing the world. Numbers are another way of describing the world and using them all somewhat interchangeably. It’s kind of what it takes to understand something as complex and multifaceted and touches as many things as this pandemic does. And so, I appreciate your gift for kind of mixing and matching, and kind of appropriately using those things. And I do agree with you when you describe the world to people, it helps us solve these problems. But I think you’re right, it also does help us overcome this fear of the unknown, to a large degree. And I feel for a lot of people who are going through this, because I have felt a lot of things during this pandemic, personally. But I haven’t felt as powerless as probably other people have. Because I’ve been able to just get up in the morning and do things that are helpful, and it’s just makes you feel better. For a lot of people, though. They’re just very much on the receiving end of what the hell are we going to hear about next? And I do think that what you’ve done here today is a bit of the antidote. Yeah. Thanks for coming on, Bill. Thanks for being on IN THE BUBBLE.

Bill Hanage 

Thanks for having me on the bubble.

Andy Slavitt  52:10

Some great shows coming up next Monday, you’ll be meeting Dan Diamond. If you read the Washington Post, you’ve probably already read Dan Diamond. He is the journalist who covers the White House in Health and Human Services in the pandemic. Really closely. He’s a great reporter. He used to cover me when I was in the Obama administration, the Biden administration got to know him, then he interviewed me countless times. I’m really looking forward to interviewing him. Then we have Caitlin Rivers, who you may remember, if you’ve listened the show for a long time has been a guest on the show a number of times in safe or unsafe. Now she has formed a new group within the CDC to help forecast new outbreaks and pandemics. So if you’re the kind of person that’s like, wait, I don’t want to have this again. How are we making sure that we’re out in front of it. You’ll want to know with Caitlin because that’s what she’s charged with doing which is just so relieving. So glad to have her at the CDC. And speaking of the CDC, we have another guest from the CDC coming up in a couple weeks. Rochelle Walensky number of you have asked we’d get the CDC director back it will be her third trip to the show. Quite sure that ranks us up among the most. And we’re going to be talking about where we go from here in new strategy and kind of where the CDC has been criticized and where the CDC is been under thought of and over thought of and all those lovely things. Rochelle has a great treat to interview. for that will be coming up too. Okay. With that, enjoy the rest of your week. Remember to do something fun.

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.