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All Podcasts Toolkit: Safe Or Not Safe

Toolkit: Safe Or Not Safe

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Description

Can I hug Grandma after her vaccine? It’s time for Dr. Bob’s first Safe or Not Safe with Drs. Caitlin Rivers and Farzad Mostashari. This time, they cover post-vaccine activities. Can you go to the gym? Hang out with friends? Have Grandpa over? Go to Burning Man? All that and more on this toolkit episode of Safe or Not Safe.

 

Follow Dr. Bob on Twitter @Bob_Wachter and check out In the Bubble’s new Twitter account @inthebubblepod.

 

Follow Caitlin Rivers @cmyeaton and Farzad Mostashari @Farzad_MD on Twitter.

 

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

 

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To follow along with a transcript and/or take notes for friends and family, go to www.lemonadamedia.com/show/in-the-bubble shortly after the air date.

 

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Transcript

SPEAKERS

Dr. Farzad Mostashari, Dr. Bob Wachter, Dr. Caitlin Rivers

Dr. Bob Wachter  00:07

Welcome to IN THE BUBBLE. I’m your host, Dr. Bob Wachter. Today we’re doing another version of one of our favorite episodes called—Safe Or Not Safe?—on this show we cover a lot of important issues. But this is one where we cover the issues that are really most central to all of us as we try to live our lives. And the questions are safe or not safe have changed in the last month or so, because of vaccination, we now find ourselves increasingly in situations where you may be vaccinated and you have to ask yourself, Is it safe or not safe? Or probably more commonly, some people are vaccinated and some are not. And the question is, what’s safe in that circumstance.

Dr. Bob Wachter 

So, a lot of interesting, rapidly evolving questions that we were all grappling with and to answer those questions we have our safe or not safe epidemiologist to help guide us through this changing world. They are Dr. Caitlin rivers and Dr. Farzad Mostashari. Caitlin is senior scholar at the Johns Hopkins Center for Health Security, and an assistant professor in the Department of Environmental Health and Engineering at the Johns Hopkins Bloomberg School of Public Health. Farzad is co-founder and CEO of Aledade, which is a company that he founded a few years ago to bring groups of primary care doctors together to provide better care.

Dr. Bob Wachter

He was also the National Coordinator for Health Information Technology within the Department of Health and Human Services. Before that, he worked as an epidemiologist in the New York City Department of Health where he established the Bureau of Epidemiology Services. So let’s dive into the next edition of—Safe or Not Safe?—with Caitlin and Farzan.

Dr. Bob Wachter

Also want to warn our listeners, Farzad and Caitlin have been on with Andy several times before. I didn’t give people a warning that there was going to be some math here understanding the prior episodes with Andy there was very little math. It was mostly from the gut.

Dr. Farzad Mostashari  02:06

Yeah, with Andy Slavitt we didn’t have to worry about him talking about facts. It was just pure opinion at the time. And it was usually he’s on Team Caitlin. That’s usually what it was about.

Dr. Caitlin Rivers 

You get more points, but I get the game. Amen.

Dr. Bob Wachter 

this is different. There’s gonna be very fact and science base. So prepare yourself it might be a little jarring.

Dr. Farzad Mostashari 

Oh my god, evidence-based podcasting.

Dr. Bob Wachter 

Round one—activities of daily living. Let’s get started. This is a combination of questions that came from Marty, Carol, Sarah. And this is now after vaccination, can I? So this is no longer unvaccinated unprotected, but now I’ve been vaccinated, let’s assume second dose 10 days out from the second dose. So I’m as protected as I’m likely to be. Can I now, fill in the blank. The first one is going to the gym. Farzad why won’t you start with that?

Dr. Farzad Mostashari 

I think yeah. I think we should, being vaccinated, we should be talking about it. As you get to change your behavior. It’s got something good can come of this. And I think that, yes, you can go to the gym now, because you are much more protected, and you’re much less likely to pass it on to anybody else. I will say, yeah, when you’re there wear a mask. Why? Not only because it will help you reduce the likelihood of being infected, or passing it on, but also because of the messaging that we’re sending, because people don’t know that you’re vaccinated or whether you have immunity or whether you’re not respecting the social norm. So I think it’s important to respect the social norms. But yeah, I think that if you get vaccinated, you can do things that you wouldn’t have been safe for you before.

Dr. Bob Wachter  03:54

We should put it in there that this is assuming you’d like to go to the gym. Maybe, maybe find something else to do. But okay, and let me just hit on that theme for a second sort of you made the point that not only at the level of your individual behavior is being getting to do some things important. But did I get the sense that partly around the marketing the vaccines that we should be letting people know that after you get vaccinated, your life will change in a positive way?

Dr. Farzad Mostashari

I think so. I think that we have screwed up the messaging. We in the general sense that the excess out of an excess of caution, we don’t all the data isn’t in yet. Well, why don’t we just not change our behavior and just keep doing what you’re doing? Even if you get vaccinated. And I think that misses I think an important aspect of why people are going to want to get vaccinated if it’s just doom and gloom and with no, and no respite insight even after you get vaccinated until every human being has been vaccinated, then I think we’ve missed an opportunity to make this a very positive experience for people and you know, society, we will all benefit if people can feel like getting vaccinated is a really, really good thing to strive for.

Dr. Bob Wachter 

Great. Let me stick with you for a few more of kind of, I think similar flavor and then we’ll turn to Caitlin for some. Once it a little harder, I think visit a dentist?

Dr. Farzad Mostashari 

Yeah.

Dr. Bob Wachter 

Same?

Dr. Farzad Mostashari 

Again if you want to. (laughs)

Dr. Bob Wachter 

If you want to. Well, dentist probably at some point you need to but same theme. Okay. Get a haircut. I know it’s been a great concern of yours. (laughs) But yes, same thing. It was actually that’s the first thing I did once I was fully vaccinated. I got a real haircut as opposed to a haircut for my wife while she’s watching the YouTube. How to get a haircut video. Manny […] I don’t even know how to pronounce that. Is that Manny Petey Manny PD? I don’t. Not even sure but so Farzad, are you going for your mani pedi?

Dr. Farzad Mostashari 

Yes, I am going for my petty.

Dr. Bob Wachter 

You’re up for that. Okay, good. Okay, Caitlin’s turn to you, eat at a restaurant and then indoors and or outdoors?

Dr. Caitlin Rivers  06:06

Outdoors, yes, I think that is a reasonable level of risk, kind of in any case. Indoors. Yes, I think that is reasonable when you’re fully vaccinated.

Dr. Bob Wachter 

So the restaurant thing gets a little harder because Farzad said, when he goes to the gym, he’s still gonna wear a mask. And now I go to a restaurant and I can’t, or I can, I can wear it while I go in. But it doesn’t work all that well while I’m eating. So now we’re talking about me being vaccinated, in the restaurant, my mask is off. And it’s okay, I’m not gonna die of COVID that that’s good. I can enjoy my meal. But this whole issue of could I get it? You know, the waiter has it or whoever Could I get it and now spread it to other people. So here’s sort of a practical question that it gets at this issue of we don’t know for 100% certain that you’re incapable of a spread. So how are you thinking that through as you sit down in the restaurant?

Dr. Caitlin Rivers 

Actually, why I hesitated was sort of the opposite reason I think you as someone who is vaccinated is sufficiently protected. Although it’s true, we don’t really know maybe you could be asymptomatically infected. But is it fair to potentially put at risk the waiter who is presumably unvaccinated and the other people in public, you contributing to a network of transmission, including for people who don’t have a lot of choice about whether or not to be there? That’s a tricky one. It’s really hard to navigate. I think that I’m gonna kick it to Farzad and see how he feels. (laughs)

Dr. Bob Wachter 

We’ll see if the editing how long we let that pause last but that was, let the listeners know, that was a long pause there. So this obviously tricky question. Farzad, go ahead.

Dr. Farzad Mostashari 

it is, well, I’m highly qualified to answer this question. Because since March 12th, I had not been to a restaurant. And I just went for Valentine’s Day with my wife. So I have tons of experience eating in restaurants in an era of COVID. What I would say is, I would do what we did, which was we were really careful to wear the masks, as was the waiter when they were near us. So every time the server came near us, we stopped eating, we put on our masks, we spoke with the waiter, and, you know, they certainly did their best to keep their distance from us.

Dr. Farzad Mostashari  08:18

So I do think that we have an obligation, as Caitlin said, for those who particularly from in a work context, you know, have to be around people, and to expose them as little as possible. But again, I want to emphasize the effect of being vaccinated is greater than the effect of being double masked. Right? So if you say, if you would have eaten indoors, or like been in the room with that waiter, double masked, right? Being vaccinated is probably better than being double mask in terms of the reduction in the likelihood of you passing it on to somebody.

Dr. Bob Wachter 

So we might as well stick with double masking for a second does the fact that you’re vaccinated, change your masking practice, you already mentioned that you will wear masks in places even though you’re vaccinated largely to protect other people and also send a message. But now the recommendation is out there to wear better or and or double mask. Does that change once you’re vaccinated?

Dr. Farzad Mostashari 

I mean, I again, I think the messaging is important and  I think we should also do things that we can do without it being some much, you know, much of a trouble and for me wearing an N95 mask, certainly if I’m indoors anywhere, and I generally do it if I’m outdoors, and that’s really safe, right? Yeah, but doesn’t bother me. So it doesn’t bother you then yeah, wear a mask.

Dr. Bob Wachter 

Okay, got it. Caitlin, you’re getting the hard ones fly domestically.

Dr. Caitlin Rivers

Yes. I think again, this is the same tension. I think for someone who is vaccinated, the risk to yourself, while traveling is low. You are contributing to the network of people who are connected by which the virus could theoretically spread but I think on balance. It’s reasonable.

Dr. Bob Wachter  10:02

Okay. And as you let’s say you might have flown several months ago, maybe during a lull in the pandemic, I flew once or twice in August. And I an N95 and a face shield and I basically, as I got off the plane, I said, if the virus got me, it deserves me, it was really well protected. Does your level of suiting up for a flight or another sort of potentially risky indoor activity? Does that change once you’re vaccinated?

Dr. Caitlin Rivers 

I think I would still reach for the mask as much to let everyone else know that I’m being conscientious of their safety as much as for mine. The face shield, if you’re fully vaccinated, I think is more on the optional side.

Dr. Bob Wachter 

All right. And Farzad how long can I spend with someone with a mask on but less than six feet? In other words, this sort of the general ground rules that we’ve had about lengths of time and distance? Do those change to your mind once one is vaccinated?

Dr. Farzad Mostashari 

Look from a numbers point of view, yeah, they should change. The question really is who’s that other person? If they’re an unvaccinated elderly person, I’m going to stay the heck away from them no matter what. If it’s a younger person, if it’s someone who’s been vaccinated, then the equation changes a lot.

Dr. Bob Wachter 

But if it’s someone who’s been, who has not been vaccinated, but perceived to be at lower risk, and of course, it’s hard to tell sometimes you can might be able to guess their age, but not guess their underlying conditions, for example, but it sounds like you have a somewhat different attitude if it’s a matter of visiting someone who’s 80 versus visiting someone who’s 25.

Dr. Farzad Mostashari 

Definitely.

Dr. Bob Wachter 

That’s the end of round one. Round two—right after the break.

Dr. Bob Wachter  12:10

Round two—friends and family, different combinations of people and whether they can get together and how to do it when some of them are vaccinated, and some of them aren’t. Let’s get started with round two. This question came from John O’Brien. “My husband has received both doses of the maternal vaccine. Next month he is going to visit my mom” That’s nice. “For a few days, she is not vaccinated. Is it safe for him to be around her unmasked?” I think this is a pretty common scenario playing out all over the place. So Caitlin, you want to start with that?

Dr. Caitlin Rivers

I thought about this a lot because I wanted to do a good job on the podcast. I think there are three different scenarios. The one that is most safe for everyone is if everyone in the group is vaccinated, the one that is moderately risky is if the person who is at highest risk of severe illness is vaccinated, and the other people aren’t. So grandma is vaccinated and the kids aren’t that’s going to be moderate. The one that is most risky, the one with the highest consequences will be if the healthier person is vaccinated, and the more vulnerable adult is unvaccinated. So if an adult child is vaccinated and grandma is not, that one would be the most riskiest because grandma could get in theory sick.

Dr. Bob Wachter 

Yeah. So John didn’t say for certain that her mom was unvaccinated, but she didn’t say she was. So this gets into your sort of more risky category if the younger person is vaccinated, the older person is not, is that right?

Dr. Caitlin Rivers 

That’s right. I think in that scenario, I personally would reach for a mask just to reduce that risk a little bit more and protect the person who is at higher risk of severe illness. But just to be clear, the fact that vaccine has been introduced into this scenario is a big deal and reduces risk a lot.

Dr. Farzad Mostashari 

Yeah, that’s what I was. That’s what I was gonna say is of the three vaccinated scenarios. It is the least protective, and it’s a heck of a lot safer than the unvaccinated scenario from before.

Dr. Bob Wachter  14:10

Right, so scenario four is neither person is vaccinated, all of these scenarios, both people or either one being vaccinated is much, much safer than where we were a few months ago. But these are levels of risk, assuming one party is vaccinated. Okay. That’s very, I think that’s a very helpful framework allows us to have a little bit of scaffolding to think about these decisions.

Dr. Farzad Mostashari 

Let me put it in personal terms. In the past year, I’ve visited my parents a very small number of times, and it’s very hard not to and when I have, you know, I’ve been, you know, in N95 mask and I’ve almost entirely kept my distance from them. And my mom keeps saying, will you give me a hug, and if I’m vaccinated, I will give her a hug, which I haven’t dared to get really close face to face, cheek to cheek with her since March 12th. So that to me is the difference between being vaccinated and not.

Dr. Bob Wachter 

Yeah, I’m in similar boat. My parents are 90 and 84 in Florida and I visited them in August and not since and my mother is now fully vaccinated. My dad who is pretty bed bound is not and so I may have to navigate and I am being a frontline healthcare worker. So, navigating that when I go is gonna be tricky. Okay, next, let’s hear a voicemail from Lexi.

Lexi 

Hi, my name is Lexi. I’ve been lucky enough to have gotten my second dose of the Moderna vaccine. And some of my friends are starting to get vaccinated too. And I’m just wondering, can we hang out inside without masks if everyone is vaccinated? Thanks.

Dr. Bob Wachter 

So this is Caitlin’s sort of best possible scenario. And let’s just put a pin in it. Are we saying that if everybody is vaccinated, life has returned to 2019? In terms of the things that you can do precautions or are we not saying that? So, Farzad, why won’t you start with that, and then we’ll see what Caitlin thinks.

Dr. Farzad Mostashari  16:11

I think that it is safe, it’s pretty safe. And this is my whole point about life after vaccine should have its perks. And I think if you’re in public, you want to send the message wear the mask and all that but if you’re in private, and you’re with your other friends who are also say health care workers are also elderly, like, yeah, enjoy it, enjoy the fact that you’re in a different situation now. And the likelihood, the theoretical likelihood that there could be a you know, hop of like someone there got infected from someone who was unvaccinated and is going to give it to someone else who’s vaccinated isn’t, isn’t give it to someone else who’s not vaccinated. Like that hop becomes really, really, like astronomically unlikely. If everyone’s fully vaccinated.

Dr. Bob Wachter 

Does you’re thinking about that change, depending on the hotness, and I don’t mean temperature, I mean, COVID of the community. So you know, one of the points that people have struggled with all along is that the chances of getting it is related not only to the activity, but the chances the person you’re coming in contact with has it. And so if you’re in a place where the test positivity rate of 20% versus 2%, those are probably somewhat different in terms of the risk of that interaction to you at this point. Is that not matter?

Dr. Farzad Mostashari 

Let me give an example, right? The CDC recently changed their recommendations for quarantine. And they said, If you spent more than 15 minutes within six feet of someone who actually has it 100% prevalence rate in that community, right? And your fully vaccinated, you do not need to quarantine.

Dr. Bob Wachter 

So that would say the number doesn’t matter that the CDC is basically saying that, yeah it’s your interpretation.

Dr. Farzad Mostashari 

What is your interpretation of what that means?

Dr. Bob Wachter  18:01

Same, I keep waiting for them to then come out and address this scenario that vaccinated people can go back to normal because I’m with you, the quarantine thinks that it awfully close to saying that. Just ask you one more question on the CDC. In general, I’ve seen places including my own institution, not endorsing all of the health care workers getting together for a party or a dinner because they’re waiting for the CDC to say that, or do you feel that way? Or you feel like it’s common sense. Now, it’s fine to go ahead and enjoy yourself. Because we know the science?

Dr. Farzad Mostashari 

Yeah, I think that it is all public health. Communication is always hard. And if you say it’s 100% safe, and then the unlikely at scale will happen. Then people will say, Oh, you know, you weren’t careful enough. But I think we have to balance this and what that’s what this podcast is about, right? It’s saying like, it would be easy to just say nothing is safe. Right? And do nothing, right? Take no risk. Right? But I think the point of this podcast is can we put some perspective behind personal decisions that people have to make? And you can’t always say, I’m going to take the maximalist approach.

Dr. Bob Wachter 

Got it. Caitlin, how are you feeling about? So you gave us those three scenarios? Very helpful, and we’re talking about the safest one everybody’s vaccinated does do you think life returns to normal in all regards?

Dr. Caitlin Rivers 

Like Farzad said, I don’t think we can say with confidence that that is a zero-risk scenario, but it’s low risk. I think I would feel comfortable doing that. And I’m jealous. I haven’t been vaccinated at all. I’m not eligible yet. So I’m looking forward to having to make these decisions for myself.

Dr. Bob Wachter 

Yeah. I had my wife on the podcast a few weeks ago, and I’m vaccinated and she is not. And this issue of marital vaccine dissonance is really tricky, and I didn’t help matters any when I told her I might need to go out and look for a vaccinated wife and find that she didn’t find out all that amusing.

Dr. Caitlin Rivers  20:01

You can go on vacation […]

Dr. Bob Wachter 

Yeah, no, I’m not gonna do that. Because I

Dr. Farzad Mostashari 

Did she say that she needs to go look for a more charming husband?

Dr. Bob Wachter 

She says that pretty much every day. That wasn’t any different. Let me just didn’t come up with the questions. But let me throw it out there. Because I think listeners may wonder and worry about it with a 1 in 20 chance still of getting infected, not a zero chance of getting infected. We talked about how, you know, it’s essentially 100% chance that you’re not going to die, and, and even to get really sick. But do we know anything about long COVID? I think there are people who say there’s a small chance I’ll get infected.

Dr. Bob Wachter 

And it does seem like some people get infected and have this illness that goes on for a while. And maybe in the beginning. It wasn’t that he said that that’s symptomatic, but it causes consequences. And there may be some long-term consequences even in people with asymptomatic disease. Can we say anything about that? Or is that another thing that? Yeah, you know, there is there’s not a zero chance, but it’s got to be so low, that it’s not in a shouldn’t be an important part of anybody’s decision making.

Dr. Farzad Mostashari 

Yeah, and I think long COVID is poorly defined still. And we don’t know what long really means. And we don’t know a ton about it. So I think that causes people to, you know, uncertainty creates caution, right? In people. But I do think that if you have a reduction in total infections, you have a dramatic reduction in more severe illness almost, you know, it would stand to reason, and again, these are kind of clinical and epidemiologic priors, it would stand to reason that the very infrequent long COVID would also be even more reduced in people who are vaccinated. So, you know, again, like, we’re not talking here about throwing off all caution. We’re talking about taking measured, measured changes in your behavior that is equivalent to, you know, the lowest risk activity you could do before now becomes even safer.

Dr. Bob Wachter  22:08

Caitlin, anything to add on that?

Dr. Caitlin Rivers

I agree, we hardly know anything about long COVID in the first place, let alone when you add in the possible dynamics with vaccination. And so it’s really difficult to say, I think this is part of where understanding your own personal risk tolerance factors into if you were not worried about long COVID before, you probably don’t need to adopt this as a concern in the setting of vaccination. But if your risk tolerance is quite low, and you don’t even want to go there that can factor in here as well.

Dr. Bob Wachter 

Yeah, I mean, this whole issue of risk tolerance is fascinating, because we, you know, we have all gone through flu seasons for the last 100 years without wearing masks with levels of risks that are probably higher than some of the things we’re talking about, for example, I’m vaccinated, and I’m somehow gonna get long COVID and regret having to change my activity. So, you know, this idea of completely maximalist approach like zero risk is just not the way we live our lives. If it did, we’d never get in a car, we’d never go anywhere. We’d never do anything.

Dr. Farzad Mostashari 

Yeah, I mean, I think the perfect analog to that is I had a friend who’s vaccinated who was worried about his kids. And I was like, well, just check with you here. Like, you do realize that the chances of them getting sick from COVID is objectively less than if for influenza, right? You wouldn’t like not kiss your kids, because you might give them influenza during flu season if you didn’t have it, right? And it is funny for us where we, you know, we take these mental shortcuts and we’re like COVID is more dangerous, so therefore, I have to act differently. without considering the particulars in this case, the children really are at much lower risk.

Dr. Bob Wachter 

That brings us to Marin’s question. This is actually a non-vaccine question. “Is it safe to allow kids to play outside with friends from another house who are following similar safety guidelines? And she has with and without masks, and also our first variant curveball, have the new variants changed your thinking about how safe this behavior is? And I might generalize that to how the variants change your thinking about kind of all of these risk decisions. So Caitlin, that’s a hard one, but so I’ll throw it to you.

Dr. Caitlin Rivers  24:25

I would feel comfortable letting children play outside with other children. I would require them to wear masks, in part because I think it’s important for children to learn to wear masks. They’re going to have to do it when they go back to school most likely, so might as well get in the habit. But yeah, I think that’s a low-risk activity. The variants particularly the B117, which is the variant that was circulating in the United Kingdom is more transmissible and that doesn’t mean we need to be more adherent to the mitigation measures that we know work. But that doesn’t change my judgment on letting the kids play outside with masks. I think that’s still fine.

Dr. Bob Wachter 

And just more generally, do the variance change your recommendations about sort of any of the risk strategies that we’ve been talking about? And maybe particularly in the vaccinated person, we’ve said a whole bunch of things are safe enough. But now you have these variants, including the South African variant haven’t been reported in the United States. And it looks like, at some level, it’s a little bit maybe a lot resistant to the vaccine. So how does that new level of uncertain seems like COVID always throwing us a curveball? Just when we think we figured things out? How does that new factor, change your thinking about what you can and can’t do after vaccines?

Dr. Caitlin Rivers

As far as we can tell, the two variants that show some degree of immune escape are circulating at very low levels in the United States. So I don’t think it would change my immediate calculus, but it is something we will collectively have to keep our eye on and adapt our mitigation measures appropriately. I would say that these curveballs, as you call them, are reinforcing the need to continue to take sensible mitigation measures, we can have a lot more flexibility in our lives as incidents falls and as people as individuals become vaccinated.

Dr. Caitlin Rivers  26:12

But as Farzad said, about the masks, they’re not that hard to wear, at least for me for Farzad, hopefully, for most of our listeners, and so I think it’s sensible to continue to reach for them. I think, General, thoughtful social distancing, is still something we’ll keep in our toolkit. But for now, those two extra concerning variants, I think, are quite uncommon.

Dr. Bob Wachter 

Okay, Farzad do you want to add anything?

Dr. Farzad Mostashari 

Yeah, I want to underscore the outdoors part. I was shocked to see I think was UC Berkeley.

Dr. Bob Wachter

It was Berkeley, yep, of course.

Dr. Farzad Mostashari 

Yeah. Say like you shouldn’t, college students shouldn’t exercise outdoors. That is..

Dr. Bob Wachter 

Alone. Alone.

Dr. Farzad Mostashari 

I think that’s malpractice. Honestly, like that’s ridiculous. We want to encourage people to be outdoors. Everything we’ve learned about this has been that it is incredibly safe to socialize, outdoors, if you’re outdoors wearing a mask, gosh, darn it, like, let people have some […] to you, where they can feel like they can live and I just I think this has been one of the most under emphasized, I think aspects of this. We still have people today who feel like I can’t go outside my house. I’m like, No, no, you can go outside your house. Please go outside your house. So outdoors, absolutely. Kids should be playing outdoors.

Dr. Farzad Mostashari 

And Farzad, Caitlin discussed the variants and how the at least, to the limits of error detection. The South African Brazilian variants, which we know are somewhat resistant to the vaccine are at high a very, very low prevalence, the B117. The UK variant is at a higher prevalence and seems to be growing very quickly. Does that change any of your recommendations as to what people can and can’t do? Yeah, B117 doesn’t, I think in terms of the likelihood, in terms of the certainly the Moderna and Pfizer. Protection still seems quite good. I do think that the we should be very vigilant. We need genomic vigilance on the other the South Africa variant in particular.

Dr. Farzad Mostashari  28:20

But as Caitlin said, exactly right, until and unless we see that being a significant contributor to your local epidemic, then I wouldn’t change that wouldn’t change my calculus. I do think what it does say is like, as some have characterized as a race between the vaccine and the virus and the variance, I do think that this again, lends more pressure for us to get the vaccine out there as quickly as possible. And I’m very concerned that pretty soon the tide is going to turn from a scarcity of vaccine into a scarcity of arms who, who are willing to take the vaccine, and that’s part of my equation of having a very kind of pro health messaging around the vaccine, not the it doesn’t change anything, keep you know, keep being maximally safe.

Dr. Bob Wachter 

So this is a question from Andrea […]. And Andrea asked “what if you’re a vaccinated grandparent? Who wants to visit your unvaccinated healthy kids and grandkids? Can you stay in their house? Should you wear a mask inside? Can you eat a meal inside? Can you eat a meal outside without a mask at the same table?” So that’s, there’s a lot going on there. So Farzad, why don’t you start with that so this gets at the question of the older, or more vulnerable person is vaccinated. The kids and maybe the grandkids are not and what can and can’t you do?

Dr. Farzad Mostashari 

Yeah. I think with the grandkids, you know, the like, will you hug your grandkids test? Like yeah, hug your grandkid? You know, I do think that the healthy parents is not that clear cut right because you could be healthy and in your 50s, right? And not be at super low risk the way the children, the grand grandchildren are. So I would say yes visit. And sure, you know, everyone should wear a mask for kind of good hygiene. But like don’t be as freaked out about the occasional violations of that of the mask and distancing as you would normally be.

Dr. Bob Wachter  30:25

So just take a practical example. So three generations getting together 80-year-old grandparents, 50-year-old parents, 10-year-old kids, and should we have dinner together inside around the table without masks?

Dr. Farzad Mostashari 

I would do it. And I would put the grandparents that at a little bit of a distance while you’re eating and other times when you’re not eating wear masks. Very practically. That’s what I would do.

Dr. Bob Wachter 

Got it. Well, that’s what we’re trying to do here. Caitlin, what are your thoughts?

Dr. Caitlin Rivers 

I agree. And I do think this is an opportunity to keep up those general measures that we’ve been taking the slow transmission, this category falls in the middle of my three categories, sort of moderately risky on the vaccine scale. But I think if you add in masks as much as possible, maybe some ventilation, keep the windows open, you’re reducing your risk even further there.

Dr. Bob Wachter 

Alright, that closes out round two, stick around for the final round right after the break.

Dr. Bob Wachter 

Round three—a bunch of wildcards that didn’t fit into categories one or two. Let’s get started with our wildcards. Here, a few final curveballs that came in,  Sherly asked “if I’ve had both doses of the vaccine. Is there a point in continuing to get tested regularly? I work in person; my job wants me to get tested every week. But is that a waste of resources? Or are they trying to keep their case positivity rates artificially low by testing vaccinated employees.” I hadn’t thought about that twist before that the tests that the testing data is going to get influenced, at least by vaccination rates. I hadn’t put those two together.

Dr. Bob Wachter  32:31

But Caitlin, how do you think about the role of testing because this is going to come up as businesses or airlines or sporting events or theaters may insist on some evidence that you’re not infected and may have to choose whether it’s that’s a test or evidence of vaccination? So how do you think about this question?

Dr. Caitlin Rivers 

I can’t speak to her employer’s motivations, but I can say that CDC does not recommend testing after natural infection for three months. And they also do not require people to quarantine in the three months after vaccination. And so it stands to reason that you also would not need to undergo screening testing in at least the three months after you complete your vaccination.

Dr. Farzad Mostashari 

The one exception to that I would say is if whatever reason you happen to be, you know, a caregiver to an unvaccinated high risk elderly population in skilled nursing facility. Well, then, okay, like, sure, if you work as a sniff home health attendant, or a home […] like sure, get, you know, the screening testing, in the context of you interacting regularly with very high-risk unvaccinated people. That makes sense. But otherwise, I agree.

Dr. Bob Wachter 

And what if the data becomes increasingly clear as to the point you were making earlier that it turns out the risks that you can catch it and give it to someone becomes vanishingly small with that, that need for testing go away?

Dr. Farzad Mostashari 

I suppose so. We have to let the data guide us on that.

Dr. Bob Wachter 

Yeah. Okay. Nobody asked this, but I’m interested in your thinking about this. There’s some preliminary data that has come out about if you’ve had a prior case of COVID, that you may only need one shot. There are several studies out that show very high levels of immunity after a single dose, no epidemiologic studies that I know of that demonstrate its effectiveness in terms of the sort of ~ 95%, 94% 95% numbers, but they show equivalent levels of immunity, at least in terms of antibodies. Do you think that’s ready for primetime? Do you think the level of evidence is high enough? Either to change the recommendation about getting a second dose in that circumstance or for individual people to change their behavior after they’ve gotten a first dose if they know for sure they had a prior case of COVID. Farzad, any thoughts on that?

Dr. Farzad Mostashari  34:45

I was actually planning to do a tweet series on this one. I think it’s a, I think it’s a really interesting observation. And I think that we could free up potentially 10s of millions of doses at least in terms of the time pressure on them. You know, the 80 million or whatever, people who’ve already had it, if we said, let’s give you one dose now and we’ll hold until there’s more broader availability, before we give the second dose, I think that could really relieve a lot of pressure on the vaccine scarcity right now.

Dr. Bob Wachter 

Yeah, pretty tricky operationally, because if it’s 100 million people have already had it, only 25 million know that they already had it. So you’d be talking about maybe testing people for antibodies at the time they get their first dose. And you send them a note Three days later that either you’re coming back for the second dose?

Dr. Farzad Mostashari

No you don’t, it’s 15 minutes.

Dr. Bob Wachter 

Yeah, or 15 minutes lighter, So while they’re there, while they’re there?

Dr. Farzad Mostashari 

While they’re sitting there waiting to see if they have a bad reaction, the bars on that little $10 fingerprick serology test turns positive, and you say, “Oh, you know what, you don’t need me to reschedule you for a follow up appointment in 21 days.”

Dr. Bob Wachter 

Yeah, part of the question here is it’s operationally challenging, but also just the threshold for evidence is the evidence that we have now good enough to make that a thing? Or do we need more? And I think that’s a tough call.

Dr. Caitlin Rivers  36:01

There’s a whole kind of series of questions of this flavor. Can you delay the second dose? Can you give a smaller dose than the trials showed? And I think it’s not just about what the evidence shows, it’s also about trusts. How will the public receive these recommendations, particularly if the full suite of data we would normally expect it’s not presently available. And logistically, does it make sense to put those into practice. So I think it’s a really thorny series of questions that there’s no clean way to answer.

Dr. Bob Wachter

Here’s a non-vaccine question, but one that came up in my own family recently, the creation of a bubble today. So let’s say unvaccinated people are getting together, they’re coming into a shared living space or whatever, and you think everybody has been acting safely. How do you think about that now in February 21, versus last year, everybody being tested, quarantines, all that kind of stuff. Because I you know, people are still fluid on these things, and are still kind of creating bubbles and trying to sort out what they need to do to come into a bubble and be sure that everybody’s safe on day one. So is testing an important part of it? And how much testing and how much quarantine? It feels like a sort of an old question, but it’s still happening. And you know, until everybody’s vaccinated, it’s still going to be happening. So Farzad, if you have any thoughts about that?

Dr. Farzad Mostashari

Yeah, we had a good discussion of this in a previous IN THE BUBBLE episode where we joked about how, you know, people think they’re in the bubble with someone and they don’t realize all the other people who are in the bubble with them, the, you know, the babysitter’s boyfriend was in the bubble there with you. But I think the greater availability of testing two things compared to the previous composition, one, levels of virus right now are actually pretty, still pretty high, compared to historic. So it’s coming down rapidly. And this situation, I hope, we’re going to be in a very, very different situation a month from now. But right now, levels of virus are not really as high as on average, they’ve been in it this whole year.

Dr. Farzad Mostashari  38:08

So I think this is, in terms of the unvaccinated people making drawing imaginary bubbles like this is not necessarily the time to, to ease up on those assumptions. The second thing though on the more positive side is testing is much more widely available, we’re doing more tests, and the rapid engine tests that have recently been approved and are, you know, pretty, pretty quick and easy. I think those can be a significant contributor. If you’re coming together with another group for some period of time, when there’s not in and out all the time, getting antigen tested, rapid antigen tested. With these commercial, you know, over the counter rapid antigen tests, the first two three days that you’re together might be a really great way to do it.

Dr. Bob Wachter 

And you first two, three days meeting, meaning multiple tests a single test at the point of bubble, this is not enough?

Dr. Farzad Mostashari 

That’s right.

Dr. Bob Wachter 

All right.

Dr. Farzad Mostashari 

It’s expensive, but it’s a new tool that we didn’t have.

Dr. Bob Wachter 

Yeah, well, so was COVID. Caitlin, anything to add on that?

Dr. Caitlin Rivers

An alternate testing approach would be quarantine for seven days. And then test on day seven. This is similar to one of the CDC options for short and quarantine, that’s quite safe. So if that’s an option, I think that that’s probably a good way to go.

Dr. Bob Wachter 

Okay. Last question came from […] O’Donnell. And I love this question, “Is Burning Man safe if everyone is vaccinated asking for 10s of 1000s of friends.” So Farzad, we’ll take Burning Man as a metaphor for or an example of a mass event where people are coming together in very, very large groups, the kinds of things that we would not have blessed in the past.

Dr. Farzad Mostashari 

Ah, no.

Dr. Bob Wachter 

No, are you anti-Burning Man in general, or this is?

Dr. Farzad Mostashari 

Probably, I probably am. I think if the question is if you’re vaccinated, can you go? Sure. I think you can go and wear a mask. But if the question is, is that event a wise thing to put on at a time when we have the, you know, anywhere near the less than comprehensive levels of vaccine coverage? No, I don’t think it’s a good idea to put that event on.

Dr. Caitlin Rivers  40:14

Wasn’t the question if everyone is vaccinated? That was the theoretical

Dr. Bob Wachter 

That was the theoretical. That was a theoretical, yeah. I mean, how..

Dr. Farzad Mostashari 

If everyone’s vaccinated. Sure.

Dr. Caitlin Rivers 

It’s like Farzad, you changed.

Dr. Bob Wachter 

Your general rule that if everybody’s vaccinated, it’s fine. There’s no limit on crowd size there. That’s if it’s the two people getting together, it’s 10,000 people to getting together if truly everybody’s vaccinated, that’s fine.

Dr. Farzad Mostashari

If truly everyone’s vaccinated. Yes.

Dr. Bob Wachter 

All right. So that, of course, immediately brings up the question of immunity, passports and vaccine. So where do we go with this? Because as you say, nobody has a sign in their forehead that says, I’m vaccinated. And yet some of the decision making to go and hang out with a single friend might be you know, that that person’s vaccinated, but the decision to go to another circumstance in a public space might be different if you knew that everybody was vaccinated. So what do you think about this from a policy standpoint, and you know, ethics and all of those things, the use of immunity or vaccination passports.

Dr. Farzad Mostashari 

Pass it to Caitlin.

Dr. Bob Wachter 

Ah, good call.

Dr. Caitlin Rivers

It’s a requirement in some type settings that you have to provide evidence of testing and or previous vaccination. Like, if you are an international traveler bound for the United States, you have to show proof that you’ve tested negative. So it’s not hard to imagine that would be extended to vaccination coverage. But making it a requirement for sort of activities of daily living things are not that are not special, I think starts to get really thorny, particularly as it pertains to equity. And so I don’t know that we can make it really a central feature of how we structure our communities. But I think it will be coming when it comes to special events.

Dr. Bob Wachter 

Yeah, and this gets to something you talked about earlier, if an organization let’s say the airlines previously required a negative test within three days, in a world where a lot of people are vaccinated, is that the right call to require a negative test? Or can it be or you are vaccinated, you know, will vaccination replace testing as a mechanism to ensure that people are safe?

Dr. Caitlin Rivers 

the current recommendation or that you don’t need to be tested within three months of reinfection. So already right there. There’s something that needs to be cleared up. And then you don’t need to quarantine within three months of vaccination. And so it stands to reason you don’t need to test and so I don’t see how you could do it otherwise, except to allow vaccination in lieu of a testing certification.

Dr. Bob Wachter 

Yeah. Yeah. Let me thank Caitlin and Farzad, for a terrific session. I know you’ve done these before; I think this is harder, I think because they’re, in the old days, we were all in one boat in terms of you know, we were different in terms of risk by virtue of sort of who we are and how old we are and underlying conditions, but everybody was in the same state of vulnerability in terms of catching the virus. And now we have this new question of what happens when some people are vaccinated. Some people aren’t hopefully we’re on our way to a place where everybody’s vaccinated, but not quite yet. So, thank you. You’re both spectacular. I have been keeping score in my head and I wasn’t sure of the winner, but I just got a quick text from Andy and he tells me the winner has to be Caitlyn. So Caitlyn, congratulations. A little bit, a little bit rigged.

Dr. Caitlin Rivers 

Thank you so much. I graciously accept.

Dr. Bob Wachter 

Thanks so much to both of you.

Dr. Farzad Mostashari 

Thanks.

Dr. Caitlin Rivers 

Thank you very much.

Dr. Bob Wachter

Well, that was terrific. A special thanks to Caitlin Rivers and Farzad Mostashari for wonderful and truly informative episode. I personally am psyched about the possibility of bringing them both back in a couple of months and hope that by then we can talk about what happens when most of us are vaccinated, and we’re thinking about getting society back to normal. I think that’s, that is not a pipe dream and something that we may be looking at within the next few months, assuming that we can keep a handle on the variance and keep on vaccinating. So look forward to that. Also look forward to our next few episodes here on IN THE BUBBLE. One will be with Peter Hotez, who is a vaccine ologists from Baylor, I’m sure you’ve seen him on television on cable.

Dr. Bob Wachter  44:30

Peter is all over the place being a really thoughtful spokesperson for the role of vaccination, why we should be so excited about vaccines and he will update us on some of the new vaccines that are coming out now some of which may soon be approved and also how to think about this race between vaccines and the variants. We also have a really wonderful upcoming episode where we will have the members of the Platt family that includes Marc Platt, a very prominent producer, both on Broadway. He produced Wicked and in the movies, LaLa Land, Bridge of Spies, Philadelphia—with two of Marc’s sons, Ben Platt, who’s about as prominent a terrific an actor singer as exists on Broadway. He won the Tony Award for his performance in Dear Evan Hansen.

Dr. Bob Wachter 

And Jonah Platt, who is also a up and coming singer and performer will talk about their experience during COVID. Both Jonah and Ben had episodes of COVID and luckily you’re doing fine. But also the experience of theater and, and movies. During this pandemic. I think you’ll be amazed to hear what they’ve had to do in order to keep things going in the movies and obviously not much as kept going in the theater. Something that you’ll hear about the toll of that not only on those of us who love theater, but actors and producers in that world. So a lot coming up here on in the bubble. I hope you’ll join us for it and until then, stay safe and we look forward to speaking with you soon.

CREDITS

We’re a production of Lemonada Media. Kryssy Pease and Alex McOwen produced our show. Our mix is by Ivan Kuraev. Jessica Cordova Kramer and Stephanie Wittels Wachs executive produced the show. 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 @InTheBubblePod. Until next time, stay safe and stay sane. Thanks so much for listening.

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