Winter is Coming. Are We Prepared? (with Katherine Wu)
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As booster shots roll out across the country, Andy calls up Katherine Wu, who got a Ph.D. in microbiology and immunology before joining the stellar science writing staff at The Atlantic. They discuss what we know about how the boosters will work, what to expect during our upcoming second pandemic winter, and what the future of COVID looks like. Plus, how Katherine approaches effectively communicating about science in real time.
Keep up with Andy on Twitter @ASlavitt and Instagram @andyslavitt.
Follow Katherine @KatherineJWu on Twitter.
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Check out these resources from today’s episode:
- Watch President Biden get his booster shot: https://www.youtube.com/watch?v=188toSUMRNk
- Read all of Katherine’s articles in The Atlantic, including the one she co-wrote with Ed Yong about winter: https://www.theatlantic.com/author/katherine-j-wu/
- Here’s the CDC statement on ACIP booster recommendations: https://www.cdc.gov/media/releases/2021/p0924-booster-recommendations-.html
- 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
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For additional resources, information, and a transcript of the episode, visit lemonadamedia.com/show/inthebubble.
Andy Slavitt, Katherine Wu
Katherine Wu 00:00
Like I did in my first and second COVID-19 vaccination shot, about to get my booster shot and do it publicly. That’s because the Food and Drug Administration, the FDA, the Center for Disease Control and Prevention, the CDC, looked at all the data, completed the review and determine the boosters for the Pfizer vaccine. Others will come later, maybe I assume, but the Pfizer vaccine are safe and effective. They’ve had all the data they need. And last week, they laid out who is eligible for those boosters for now, you’re eligible for a booster, if it’s been six months, since your second Pfizer shot. And if you fall into one of these categories, people over 65, which is hard to acknowledge, adults, I’m only joking folks, adults with certain underlying health conditions like diabetes and obesity, and those who are at increased risk of COVID-19 because of where you work, or where you live, like healthcare workers, teachers, first responders, grocery store clerks. If you fall into these categories, you’re eligible for the booster. Now I know it doesn’t look like it, but I am over 65, I wish, way over. And that’s why I’m getting my booster shot today.
Welcome to IN THE BUBBLE. This is your host, Andy Slavitt. That was President Joe Biden, who got a booster shot. And why did he get a booster shot? Well, as he likes to tell us playfully, he’s actually over 65. I think he said I’m well over 65. And so booster shots are going around. Now, among people who are over 65 among people who are under 65, but have an underlying health condition, or about people who are under 65. But are working in environments where they could give a lot of exposure to COVID. I had my second shot in February. In February, it was a Pfizer shot, I got it in the White House. And so it’s been for me 7, 8 months, something like that 7, I guess 7 months? I am 50 something, 50 something, I believe it would be 54. So it is booster season for people my age. If they’re feeling like they’re potentially exposed, or at risk, or what have you. It’s a lot of people have the question, should I get a booster because it’s kind of ambiguous, it kind of left it ambiguous. And a lot of people want to know this, because they remember the time when we only had a certain number of booster shots.
Andy Slavitt 03:10
And they didn’t want to take a booster from anybody else. Because the people who listened to the show are very conscientious, very thoughtful. And so the answer that I would provide you is if you need a booster shot, if you think you need a booster shot, get a booster shot. If you had Pfizer, that’s gonna be the easiest case. But the reason I say this is because we really are not at a zero sum situation. Unfortunately, we have a lot of extra doses sitting around, that, you know, ideally would be going towards people’s first shot. But while it’s not, you know, it does not have a shelf life of forever. So if you feel like you need a booster shot, it’s been past six months, you’re kind of in one of those categories, you feel at risk. It’s okay to do that. Now, some of the people that ask me this question are younger, maybe they’re in their 30s. And I would tell you based on everything I know, you know, a booster shot is not going to do a lot for you at this point in time, your chances of getting very sick, getting COVID into your lungs are quite quite low. And so they don’t make them appreciably lower. Maybe they’ll prevent the sniffles.
Andy Slavitt 04:25
And look, eventually, we could be taking booster shots once a year, right around the time we do the flu shots, because it’ll help us prevent the sniffles. In particularly if we maybe we have a new variant emerging or what have you. So that’s one of the things that was said this week by one of our prior guests, Albert Bourla, the CEO of Pfizer, he said, he thinks within a year we’ll be back to normal and we’ll be taking booster shots annually. So you know some people hear these things and they think that they’re self serving, they think that Pfizer is saying within their own interest, of course, they want us to get boosted every year. And you know, he doesn’t really know. But I would tell you that, while it’s always fine to look at something with a fair amount of skepticism, he may not be wrong, and an annual booster shot. You know what, that’d be the worst thing in the world?
You know, it would be certainly hard to get full compliance. But look, if what happened was the booster shot prevented you from getting sick, even if you weren’t at risk of getting very sick. You know, would it be worth doing? Certainly if you’re older, or immunocompromised? It seems very worth doing. So, the other thing, Albert said, which is that a year from now, we’d be back to normal, which they could kind of surprise to me people don’t, in this environment predict the future very much, and certainly not optimistically. But, you know, I would say that there’s a reasonable case, not that things have bottomed out. But the things are likely to round the corner and could be getting conceivably better until we get to the spring. That’s what the CDC modelers have said that things will continue to improve until we get to the spring. I don’t think they have a prediction after that.
Andy Slavitt 06:28
Okay, so that’s what the modelers say. That’s what Albert Bourla says. But most of us want to know, as it comes to this winter, what does Katherine Wu say? Katherine Wu, is a staff writer at the Atlantic, she covered science, and she just wrote a piece on the coming winter with COVID. And I gotta tell you that like, I don’t know about you, but I have bad memories of last winter with COVID. That’s when things got really, really bad. That’s what we ended up with a really horrible amount of COVID on the scene, it was our biggest peaks. It was not fun. And, you know, if you live in a northern climate, then you kind of indoors all the time. It’s pretty lousy. Pretty lousy. That’s why we moved. I’m gonna lie to you. I’m not gonna miss being in Minnesota this holiday. I know my friends in Minnesota are gonna be like, Andy, come on, where? Where’s the camaraderie? Where’s the ice fishing, 12 feet of snow shoveling all day through May? Well, I’m sorry. I’m in California now. I don’t have those problems. I don’t have those problems whatsoever. I got more California problems. Which I can explain to people in Minnesota.
So when Katherine says, here’s what’s gonna happen in the winter, I kind of smirk and say, you don’t know what’s gonna happen in my winter. Because I’m not living in a northern climate. Yet, one of the worst places last winter from a COVID perspective. California. California was bad. But thankfully, we don’t have Larry Elder here to top it off. So let me just say that we don’t know what’s gonna happen this winter. I explore that with Katherine Wu. She is on the podcast. expressively because she knows these things. She’s an amazing communicator. We were turned on to her by Ed Yong, who I thought was awesome. But that I think is only like the second most awesome person. Because Katherine’s amazing. She covered science for the Atlantic. You’ll love this episode. By the way, if you want to go back and listen to the full episodes with people like Ed Yong and other great interviews. There’s something you can do. You can get something called Lemonada Premium. What is Lemonada Premium? Well, it’s this thing you get through Apple podcast subscriptions. And yes, that’s right. You pay money. But I still think you should consider it. After all, what’s your money for? It’s for stuff like that. Through stuff that’s very whimsical like that. Anyway, I hope you think about it. It’s good idea. It’s a good Christmas present. And let’s go talk about winter. And here is my conversation with Katherine Wu, I think you’re really gonna be quite charmed and impressed.
Andy Slavitt 09:36
All right, where are you living Katherine?
I’m in New Haven, Connecticut.
And have you always been there, what brought you there?
Oh, it’s a long story. I started the pandemic in Boston, which is where I did my PhD. And I sort of stuck around there for a little while. I was going to move to New York when I joined the New York Times and then the pandemic started and I became fearful of New York rent without the New York perks. I moved to New Haven to be with my husband who is doing his medical residency at Yale.
Andy Slavitt 10:08
Got it. And what did you get your PhD in?
Microbiology and immunology.
Microbiology and Immunology? What caused you to want to be a journalist, instead of a scientist or journalist scientists or scientists, journalists, or however you want to put it?
Yeah, it’s a good question. I, I don’t know, that I ever knew for sure what I wanted to do. I sort of started graduate school knowing that I really liked bacteria. And that was just very..
I mean, who doesn’t like bacteria?
Oh, everyone’s forgotten about bacteria.
We should be like the forgotten plague bacteria.
I mean, yeah. So I studied tuberculosis in grad school, which is like a big forgotten bacterial disease, still the greatest infectious killer in history. And I hope we don’t forget about that post pandemic. But yeah, no, I always knew I liked talking about science. And I think what sort of pushed me slightly out of academia was the sort of charter of academia is learning more and more about less and less as you progress from grad school, the postdoc to faculty, and I kind of get bored easily, I wanted to learn new things every day. And journalism, focusing on science seemed like a really great way to do that.
Wow, that’s fascinating. I mean, I was presenting to the National Academy of Medicine yesterday. And one of the things I was talking about is how there are people who are focused on STEM in the sciences, but many of them have lost their ability to think about the more social sciences, communication, sociology, psychology, and that as you have written, and that is written about the things bringing us down is actually not a failure of the hard sciences. We’ve actually done a pretty good job with those. But you know what I tell them, as I said, all the classes that you probably paid a little less attention to in school like sociology, psychology, culture, communication, like that’s where the danger has been during this pandemic. So you’re interesting, to see you’re interested is in science, but also in how to communicate about it.
Katherine Wu 12:16
Yeah. And I mean, it’s kind of weird, because I really got no formal training on communication when I was in grad school, which is, it’s such a shame, right? Like I, I feel like graduate students, all scientists would benefit from this, as we’ve seen during this pandemic, it’s critical to be talking about this stuff. And yet, there’s not good infrastructure for it. A lot of scientists that I still know think that it’s a totally useless pursuit. And I wish that weren’t the case.
I want to talk to you a little bit about this new segment we’ve tried out called, can we just please move on people? Which is like, yes, things change. Yes but we can, we don’t spend all our time talking about it. But it’s fascinating that like, you have people around vaccines that are like, well, it’s 95% effective. Okay, well, its this 90. Okay, well, Johnson, Johnson’s last, okay. It prevents against everything. Well, actually, if you get a little bit sick, well, no, but it still prevents hospitalization, but it’s at every stage, they say the same thing. As we always said, The job of the vaccine, it’s no, it’s that you didn’t always say that that’s under the public hears that the public hears that it’s the story is changing. And so people believe they’re being very consistent. But the truth is, the way the public hears it, is you’re changing the story. And I mean, people are dancing, as we always said, we may need a booster. It’s like, it gets you off the hook by saying, as we always said, when the truth is, people listen that and say, you are just covering for yourself, because you were wrong. And people well, I wasn’t wrong. Science evolves. Well, you know, to some people, that’s just person words.
Yeah. I mean, what drives science, it’s kind of about everyone before you being a little bit wrong, or not having the complete picture. We, you know, scientists wouldn’t have jobs if that weren’t the case. And you know, at worst, I think you’re right, advancing the narrative of as we always said, I worry that some people are feeling gaslit or betrayed and I would love to see just more discussion of like, this iterative evolving process being totally natural and just part and parcel of science.
Andy Slavitt 14:19
Yeah, no, I’m sure that if what I said happened and everybody said, okay, I was wrong about that, like that would get abused. And you know, Tucker Carlson would say, see, they’re wrong. So like, you know, there may be no winning in this scenario, but I do think it comes across as arrogant to say that nothing has changed, or expecting people to just understand that, well, of course, in the scientific process, we’re gonna say things that are going to be different later, but that doesn’t make us wrong. And it’s like, yeah, maybe. I don’t know.
Yeah, and also, what’s wrong with saying, hey, I was wrong. Haven’t we all been wrong during this pandemic, I’m okay with that. I’ve been wrong plenty of times. And I think the best thing I can do is just say that I was wrong, admit that I was wrong and trying to incorporate the new information and move forward with what information I have now.
Yeah, well, I don’t really like wrong people because I’m not wrong ever. But I understand I mean, I’m empathetic to people who are occasionally wrong, but this doesn’t happen with me. Now, of course, like, nobody saw Delta coming. And we saw the pandemic winding down with 10,000 cases, a couple a day 200 deaths. And you know, everybody who believed in that whole land layered Swiss cheese approach was like, and I said this in conversation with the head, I was like, yeah, we thought we found a block of cheddar cheese. And, you know, of course, there are a small number of people who, at the time, were probably saying otherwise. But this hindsight bias is fascinating, because everybody’s now like, well, obviously, that was stupid. Well, everything that turns out to be wrong, looks stupid. But you don’t know at the time. You just don’t know. You don’t know what your things are gonna be right. But you couldn’t be wrong. And of course, in the hindsight of history, it’s like, well, of course, Delta was gonna happen, Delta wasn’t inevitable. Delta was random, right?
Katherine Wu 16:11
Absolutely, though, you know, we do have to, oh, I think, recognize that Delta did not have to be inevitable, right? Like Delta was partly a product of us, not containing things early on, and Delta don’t have to get this bad. Delta could have been a blip. It could have stayed relatively contained. We did unfortunately, let it get more out of control than it had to be.
Yeah, no, it’s true. I mean, when I was in the White House, like we were racing against Alpha, but we were like, Alpha’s coming, Alpha’s gonna run fast, we need to vaccinate faster. And my very neat, compact narrative, right, which is obviously much more complex than that is we kind of beat alpha with getting the supply out there. But we lost to Delta, by demand being less than we’d hoped it was. And that’s where that’s where the game kind of played this. We’d like, okay, we felt really good. We have enough vaccines we’re getting out there there in 80,000 locations and Delta’s coming if we keep going. We could be ahead of it. And then, you know, of course, large swaths of the population, large parts of the country. It just didn’t, just didn’t happen. Yeah. So let’s talk about the future. You wrote an article, you co-wrote an article, as I’m sure you would say about the coming winter, winter is coming. It sounds very ominous. winter’s coming. And last winter was crappy. It was really bad. It was both a surprise and a disaster. And no one was watching the store. And people, then we’re kind of at their wit’s end. And we lost a lot. I mean, we lost massive amounts of people sometimes 5000 a day. So we got what you’re coming up again, tell us what to expect.
Katherine Wu 18:04
Yeah, I mean, so much has changed since last winter, both on our side and the virus side, you know, we have a more transmissible variant that is already very deeply ingrained into our population. We also have vaccines on our side, you know, now we have boosters rolling out, we do have a large fraction of the population who is fully vaccinated. But I don’t think we are going into this winter that well protected. The truth of the matter is, vaccination rates are still too low in this country. And I think how this winter plays out, really hinges on how many more of the unvaccinated we can get vaccinated. A lot of the conversations right now are focusing on boosters. But really, I think it’s about first and maybe second doses, where we need to be focusing our attention, because that is where most of the transmission is going to be happening. That’s where most of the severe disease is going to be happening. And that is the way that the health system is going to get overburdened. That is I think the biggest factor that’s going to dictate how winter goes for us.
Okay, but we know enough we know more issues, right? And we know more about the virus, but we also unfortunately, or fortunately, probably unfortunately know more about each other. And we know that and I’ll say this and you can correct me or say it in your terms, but our unwillingness to take on even modest inconveniences, for a greater good, that’s diffuse and we don’t see Peters out at some level of the population. So we’ve got a stubborn 20% to 30% of population, and maybe some portion of it, I think a large portion of it, perhaps less than willingly get vaccinated because of requirements at work and so forth. But, Katherine, is it really realistic to expect that the final 20% are going to get vaccinated? And if not, then, isn’t that kind of we have to take that into our assumptions about the winter, right?
Katherine Wu 20:32
I think we are going to get stuck. But what I am hopeful for is, you know, the authorization for kids under 12 is coming, I do think that is going to lead to a big jump. I’m really hoping that the vaccine mandates do make a dent here as well. But you’re right. I think it has long been clear that we are going to be really, really struggling to get a sufficient percentage of the population vaccinated. And this all gets to you know, this idea of what level of vaccination are we comfortable settling for? What level of disease are we comfortable settling for? I would personally love to minimize that as much as possible. But I think there are a lot of questions about like, where do we put our efforts, knowing that we might hit the point of diminishing returns, especially in this country? Knowing that we have limited resources, knowing that we have limited time, limited human power? Should we maybe allocate those doses abroad? What are we going to have to live with in the future? So many people are fatigued at this point. Nobody wants to wear masks anymore. People want to get back to their normal lives. But we are stuck. Vaccination is our best tool and we’re not using it to the extent that we can, will
Will we end up as as the rest of the world gets more vaccinated? Will we end up as the world’s problem child as the world hotspot? Or at least one of them?
It’s an interesting question. And I think it depends who you are comparing against. I think the truth of the matter is, if we are looking at high income countries, the US is vaccination rate is kind of embarrassing at the bottom. Yeah, exactly. It’s not good. So many other countries are ahead of us. But also, let’s put that in perspective. There are countries in lower and middle income parts of the world that have barely made a dent in vaccination. And those are where hotspots of infectious disease tend to concentrate. Think about all the other infectious diseases that the world has had to contend with in the past decades, centuries. That is, unfortunately, where resources are low, where there’s less incentive for companies to send their vaccines. That is my biggest concern. I’m not thrilled with where the US is at this point. But I think global equity is a bigger picture.
Andy Slavitt 22:41
Yes, that’s for sure the biggest near term concern, and I guess I’m wondering if longer term, we have a different situation where unlike in the past, where Sub Saharan Africa, South Asia, etc, are breeding grounds, whether or not it’s like the southern part of the US, is the place with some among the lowest vaccination levels? You know, I’m talking about once we get into 2023, could we be the breeding ground for variants here? You know, I think we talked about how we need to vaccinate the globe, I think the globe was probably saying we need to vaccinate the US.
Oh, gosh, I mean, these goals are not mutually exclusive, right? I think we do run that risk. And, you know, let’s be clear about how and where variants arise. Variants arise when the virus has the chance to spread unfettered, it’s going to do that most easily, in people who are not vaccinated, and we’re seeing that to be an enormous problem now, I think that is one of my biggest concerns about the future. You know, if vaccination rates remain low in the US, that’s not good. A caveat here that, you know, we do expect actual infection with the actual virus to leave some immunity behind it. That is kind of one of the ways we march toward under necessity. But gosh, that is not the ideal way to sort of reach an eventual detente with the virus. I don’t want to see infection rip through this country and disproportionately affect people in the south as people of lower socioeconomic status. That is a nightmare situation for how we stabilize things here in this country.
Andy Slavitt 24:16
One of the things I think you have written and correct me if I’m wrong, if I don’t have this exactly right. But I think I remember writing is that most of us are going to get COVID. And you talk about this sort of post COVID disease, which I’d like for you to explain, but help people that the shocking statement to so many people in so many people who spend a lot of time doing everything they can to avoid getting COVID explain this statement.
Yeah, I think this is a reality that we have to grapple with. But it also means unlearning some of the things that we heard about last year, last year conversations were dominated by herd immunity and when are we going to eliminate this virus, and I think people really equated the idea of ending the pandemic with eliminating the virus that caused it. But to sort of frame this, I think it’s actually helpful to think about like a pandemic phase of our relationship with this virus, and then an endemic phase of our relationship with this virus. Right now we are in the pandemic. And you know, even thinking about what pandemic means it’s 10 demos, all people, this virus is ripping through the population, we had no pre-existing immunity when it first met us. And that made it really easy for it to spill all throughout our population, go everywhere all at once. But, you know, I think that also gave it the opportunity to really embed itself into our society, it’s going to be pretty much impossible to eradicate at this point, or at least that is an extraordinarily long ways off.
The good news is, is even if the virus is not eliminated from our population, our relationship with it does not always have to look like this, pandemics do end, this one will end. And the key to that is us building immunity on our side as hosts. If we think about our relationship with a virus that depends on the virus, but it also depends on us, we are sort of getting more and more well defended over time. And that’s the key to bringing us into the endemic stage, which kind of means in population. And that means that it’s going to look a little bit more like the dynamics we see with common colds, which also many of them happen to be caused by Corona viruses, or, you know, Influenza, these are viruses that hang out in our population at low levels, maybe they strike us more often at certain times of the year. But it is not a constant pandemic, the world will not always look like this. And so us potentially getting infected by this virus in the future, us potentially getting COVID in the future, it will not be this current threat level. And I think that is really, really crucial to get across.
Andy Slavitt 26:52
Do you think it will be will have the same level of severity? Will it be a lesser strain, as you said, like the common cold as some people are suggesting? Will it be potentially as bad or worse?
Yeah, I think what remains unpredictable is what exactly is going to happen on the virus side. And I don’t want people to mistake this idea of the virus becoming endemic that like the virus is going to magic itself into a less threatening form, like it’s not going to breed itself from a wolf into a puppy. That’s not what I’m talking about. This is more about like us through ideally vaccination, maybe a little bit through getting actually infected with the virus, which again, is not ideal, us getting more resilient to the virus over time in effect, and that making the average case of disease a little bit more palatable, not desirable. I don’t want anybody to seek out sickness.
But we’re already seeing like very gentle previews of this in the sort of post vaccination infections that we are seeing, you know the cases that people call breakthroughs, on average, we’re seeing a lot of evidence that like these sicknesses, they are rarer, they’re happening less frequently, they are much like less likely to be symptomatic. And when symptoms do occur, they resolve faster, the virus is sticking around in the airway for less time. And really importantly, the virus seems to be potentially less transmissible, that can make a huge difference. The average case of COVID in the vaccinated person is less horrifying than it has been this past year and a half when we had much less immunity.
Andy Slavitt 28:24
Right. So it becomes more tolerable. And I think we will also have hopefully more tools in our arsenal, we’ll have oral antivirals, hopefully, even the monoclonal will become more accessible as they are now being able to be delivered subcutaneously instead of just through transfusion. But you can imagine progress in that front, you can imagine, I suppose inhaled vaccines and things of that nature. Other prophylaxis. Right? So even if I guess the question there is even if the virus doesn’t get less potent, in other words, the wolf is still the wolf. You know, we’ll have other tools to help make it more manageable.
Yeah, that’s right. And this, I think, gets back to the Swiss cheese versus cheddar cheese analogy, which I love, by the way, because, you know, vaccines are again, just one tool in our arsenal. I think as long as people are not feeling lactose intolerant to the vaccine, we can keep using that in combination with treatments, ideally, you know, masks get used maybe intermittently throughout the year, maybe especially in the winter, where there all these other respiratory viruses bopping around like vaccines should not be the end of the line silver bullet. They are probably our most important tool but they can’t be our only tool, especially with a virus that is going to stick with us this long term.
Andy Slavitt 30:12
So, did we make a mistake? Go back to last November, December, when we said, hey, wow 94% Pfizer, 94% Moderna, against even infection, even against symptomatic infection, wow. And 100% against severe disease that set us into a mindset of expectation where, as you’ve written before, you know respiratory illnesses, particularly those that affect the upper airways in the nose, it’s very hard to protect against the things that affect you in your nose. Even if you could do a good job protecting against the other pieces. Did we kind of mess that up?
Yeah, this is one of those messaging problems. And it kind of goes back to what you were saying about, you know, we’ve been saying this whole time, it is true that I think when the vaccines were first conceived of, and here I’m thinking all the way back to last June of 2020, you know, 400 million years ago, when the FDA were sort of setting out standards for vaccine makers to meet, they were saying, okay, let’s reduce disease or severe disease by 50%. That is such a different bar, then, you know, what the clinical trials ended up using? And, you know, there were practical considerations there, it would have taken forever for clinical trials to run if we had only looked at severe disease, hospitalization and death. So, you know, that’s part of the reason why they looked at all symptomatic disease. But yeah, those results were amazing, right? Like they gave us hope. There were headlines that were saying vaccines blocked all transmission, you know, end of pandemic in sight.
And so yeah, like, we needed that injection of hope people wanted to see the vaccines as something amazing. And I think part of it was also, you know, literal PR, we wanted people to be excited about the shots, we wanted people to line up for them. But maybe maybe it was short sighted, I think thinking about like, how all vaccines really how whole immune responses really tend to work. We have this really big burst, this response at the beginning, when the body’s like, oh, crap, this is something new, let’s pour all our resources into getting rid of this thing. And like let’s stay vigilant for a few weeks, in case it comes back. But you know, that response contracts over time, imagine if we stayed amped up to every virus or bacterium or whatever we ever encountered, like we would have all exploded a long time ago.
Andy Slavitt 32:40
Our blood wouldn’t be able to circulate would it?
No, it would be this like sludge of antibodies suspended and like, I’m picturing like a, like a chia seed cambogia just impossible to move things around. So I mean, honestly, it’s beneficial for us that those responses contract, it’s like resource allocation. But that also means the frontline defenders, and here I’m talking about the antibodies that can, in theory, sort of block infection by heading the virus off at the past like right when it’s sort of entering our nose and mouth. If those contract for you know, resource allocation purposes, that makes it easier for the virus to clear hurdle number one in disease which is infecting us at all. But I think it’s actually really helpful to think about COVID as a two stage disease, you know, the virus has to do this order of operations, it infects us, it replicates, it spreads from cell to cell, and it’s also kind of moving geographically through us starts in the airway in the upper airway, the nose and mouth, and then it moves deeper into the lungs.
And the lung is really kind of potential hospitalization territory, that’s where some of the worst outcomes start to occur as it’s moving deeper into the airway and through the body. But that takes a lot of time, right? That takes several days. It’s why we see this lag between infection and hospitalization, and if your body has pre existing memory of the virus, thanks to maybe like a vaccine, again, get vaccinated, then that means the body’s more ready to react in a couple days, like memory B-cells will wake up and say, Okay, this is clearly something we’ve seen before and let’s make a new batch of antibodies. Maybe those frontline ones weren’t enough. We have the second string that can come in. And within a couple days, maybe that’s enough to block stage number two deep lung issues from happening. And that’s that’s what immune memory is doing. It’s it’s buying us time it is giving us a leg up in this race against the virus.
Andy Slavitt 34:28
Yep. And of course, it’s all of that we have a faster runner. Delta infects us more quickly. So if it took seven days to infect us, then that memory B cells might get there in time.
Yeah, and actually, you know, we see that with other viruses like you know, that have kind of the incubation time for when the virus enters someone and then really starts causing issues like Hepatitis B is actually a great example of that. People who have gotten the vaccine years ago, their antibody levels actually very often wane and you know, they’ll get tested for antibodies years out, and some of them won’t really have detectable antibodies anymore, but they’re actually still remarkably protected against Hepatitis B, because the virus takes so long to do its nasty work that the memory B cells have time to produce new crops of antibodies and clear the infection out. It’s pretty amazing. That’s not what’s happening here.
Is it the same with measles?
Measles is a pretty fast one. But I think what is great about the measles vaccine, well, first off, the measles vaccine is a very good mimic of the actual virus, it’s actually live attenuated. So it’s like a weakened, quote, unquote, live version of the virus that really really tickles the immune response into like, maintaining high antibody levels for a long time. So the measles vaccine is one of the most effective vaccines we have, a little bit different.
Okay, thank you for that clarification. It’s really, really interesting to compare some points. So we go back to like we were saying earlier about where were wrong, not wrong regarding what we thought the vaccine would do originally. So let’s, this is a feature on the show, I’m trying out what you’re gonna do together. It’s called Okay, can we just move on people? All right, yeah. And it goes like this. It goes like this. Instead of saying, well, we weren’t wrong. We just didn’t know at the time. We actually say this, okay, we used to think x. Now we understand why, we’re sorry. But can we just move on people? Like, how long do we have to talk about Tony Fauci in February of 2020, saying we didn’t need masks? Okay. Tony, was not correct at the time, say wrong, say that wrong, […], whatever reason. But okay, let’s acknowledge that. But can we just move on because now we know, that masks work? So is this an example, Katherine, of like, okay, we kind of overshot what we thought the vaccine could do in terms of preventing symptoms. And there may be reasons for it. There may be yes, nobody’s, we’re not trying to throw anybody under the bus. But let’s just say fine, it’s easier, easier for my mind to say, we were wrong, we were incorrect. But okay, guys, now we know that it’s September of 2021. We now know how we think the vaccines work a little bit differently. So should we continue to fight about what we wish were the case about how vaccines worked? About how someone said something that isn’t the way it is now? Or do you think Katherine, we should just say, you come on, let’s just move on people now we know better.
Katherine Wu 37:39
Oh, this is a very tough time to be, I think trying to move on from this particular question. I totally agree with you about the mask issue. I think that’s a great example of like, for the love of God, let’s move on. I think right now, because we are talking about boosters and like, what do boosters need to accomplish? And what do we actually need vaccines to do? and for how long to really end the pandemic. And again, that’s not eliminating virus, but just ending the pandemic? Oh, it’s so tough. I mean, like, from talking to immunologists for months, the expected like dynamics of the immune response after vaccination, like, no, those has actually been that’s surprising. I don’t think I spoke to a single immunologist throughout the entire course of this pandemic, it was like, Oh, we are definitely going to block all infections End of story like that is it. I think the we always have known that the easiest thing for any vaccine to do across the entire spectrum is to block the most severe outcomes, the late arriving outcomes. And I think, you know, we had hopes that this particular vaccine could maybe go beyond that. But is that necessarily being wrong if it made me accomplish it for a few months after people got their doses or if it was accomplishing it with Alpha?
Andy Slavitt 38:53
Well, we didn’t say it clearly, we certainly didn’t say it clearly to everybody else. I didn’t, I didn’t, on this show I said, oh, 94%. That sounds great. That’s really good news. Right? I didn’t say, but let’s remember that at the beginning, there’s a big rush, and that they clinical trial didn’t last long enough to see that, that we’d see some waning like, I didn’t say that. And I wasn’t alone. I’m sorry, I was not alone. Everybody can like, say what they want now about how they knew. But the reality is, at that time, people didn’t see Delta being the force it was I went back and listen to over 100 people that I interviewed and experts, etc. You know, how many people actually said we will see that the variants will get we will see various mutations that are worse. At the time I’m not talking about after the fact, one, one person. Some said nothing about it. Others said it’ll probably weaken. Now everybody’s saying of course, but you know, my point is just to try to make a very simple one and somewhat humorous which is we are all caught up in what we heard and feeling angry, that something turned out not to be the case that we thought was the case that we hoped and were angry at experts, and experts are unwilling to acknowledge that they may have overstated the case or not communicated as we if they clearly should have. So the fact is we didn’t know that if you were vaccinated, you would still need to wear a mask on occasion indoors. So if we’re not able to say, Come on, let’s just move on, then people are like, well, no, I said I would need to wear a mask. So but fine, we know differently. That’s my case. That’s my case.
Katherine Wu 40:40
I’m with you. I think that’s absolutely right. I think, you know, I certainly don’t want to waste time perseverating on the past and saying, like, oh, look, who was right, we are where we are now, let’s think about what our next step is. I think that makes a ton of sense. And I mean, it speaks to, I think, a general theme of this pandemic, which is, well, really a general theme of human behavior. We’re all very myopic, it’s very easy to say, look at the snapshot we got in time, you know, thinking about how the clinical trials were done, they had to be done quickly, which means we only had a couple months of efficacy data to go on, that couldn’t say a lot about how the vaccines were going to fare long term. Now, you know, we are dealing with a new variant that we couldn’t have fully predicted, given what we knew this time last year, that changed the equation. And I think, you know, this is like the iterative process of science coming again, we can’t project into the future. And the things that we know, most clearly are the things that have happened most recently, and the things that are happening right now. Like, it’s a mess to communicate, it totally is hard.
So how do you do such a good job of it?
Oh, gosh, I mean, this is the ongoing challenge, right? And I think I am still learning every single day how to approach this. One thing that I’m always thinking about is how can we normalize this idea that science is iterative, that science can be, you know, wrong, if we want to call it that, or science is always incomplete? That is just the way science is. How do we convey that during the time of crisis, when people want clear cut answers about what to do right now, what to do tomorrow, and whether or not that information is still going to be true six months from now, we can’t really, but what I tried to do in a lot of pieces is a couple things. One is like signal with the language that I’m using that this is what we understand up until this point, that things could change. And sometimes that means using words like might could be in this specific circumstance, using this specific population to sort of signal to people, but our knowledge is always limited.
Katherine Wu 42:49
It is a function of who is doing the science, like where the data was collected, and up until which point the data was collected, that is always going to be a mess, and like signaling that everything we’re experiencing now depends both on the virus, and on us. Like for instance, you know, take vaccine effectiveness, that’s both about how well our bodies remember the virus. And you can call that, you know, waning immunity or lack thereof. But our bodies could remember a version of the virus perfectly and still be bamboozled by a new variant that it doesn’t recognize very well, that’s more to do with the virus than it has to do with us. Another thing that I’m always thinking about is, you know, when I write about science, I’m always trying to write about the people doing the science as well. And like they have the authority to say more than I do, because they are doing this in real time. Like, I don’t know, or I am still figuring this out, or this is something that we are looking into, like this always being iterative. And the idea that.
You’re second sourcing the things you write to, the expertise with a degree of confidence.
Yeah. And this is always, always always always tough. I am always looking for better ways to do it. I mean, if people have suggestions, I think this is the time to be hearing them.
Andy Slavitt 44:06
Let me give you one and it’s not exactly right. But there will be an analogy or a way of unlocking some thinking here. In national security memos, confidential national security memos that are written to the President. They come with two markings on them always. One is essentially the strength of the view. And the other is the level of confidence. And so you will see in the report that it seems it’s only there’s only three categories, low, medium, high, for both of them. I’m wondering if there’s some signaling that’s explicit, instead of you know, saying well of course science is always iterative. You should know that people and saying that every time because it almost gets lost. The phrases you use around when around to get lost when the headline gets written, and it gets on to Twitter and it’s like, you know, 94% against severe disease. Like all that nuance is lost. But if you had some symbol, like, in the confidence level, and this is moderate, you know?
That’s really interesting. Yeah, I’m not sure how I feel about that. Because what that did remind me of is I believe it was Public Health England that has been releasing a lot of really excellent numbers on vaccine effectiveness recently. And they use a rating system similar to that, they’re looking at, you know, we have gathered data on how effectively the vaccine is blocking symptomatic disease, how well it’s blocking hospitalization and death. And each of those carries a rating like one to four sort of our color coded, like we have high degree of competence, because we have this much data. And like this many confounders in the data. And I think that is incredibly useful. A lot of that is like internal communications. And it sounds like that that’s a rough mirror of what is happening with security correspondences is. It’s so different. When we move to public communication, and people are scrolling through on their phones. I wonder what signal it sends to people when they see a headline, signaling lower confidence, or even reading the body of an article that signals lower confidence. You know, how seriously are people going to take those? Does that make it easier for misinformation to you know, enter a conversation and spread? I don’t necessarily have answers to that. And I do think this is a really interesting thing to consider. But it’s tough.
Andy Slavitt 46:24
Let’s finish up by talking about the waning a little bit and talking about. So do you expect that based on everything we know now that people have started to get boosted? Do you expect that the booster shot and the those antibodies that’s gonna weigh in just like the first two shots did and so we’re going to only be able to protect against kind of symptomatic infection for a short time once again?
I think at this point, the answer is we have no idea. We do not have enough data on this at this point. So there are many ways that this could go. And I think, to lay those out, basically, we have the situation where we know antibodies are going to spike after pretty much every dose you get that’s typical, and then they are going to start this slow decline. There are questions about how long does that decline last? How steep is that decline? And where does the decline stop? Are we going to hit a plateau and just stick with it there? It seems like after…
I’d love to know the answer to those questions.
Yeah, no, and this is a huge question right now. Right? Like, okay, let’s talk about dose two for the mRNA vaccines where more most people are right now who are vaccinated. We know that that’s exactly what happened, there’s a peak, a decline. And then it seems like a fairly stable plateau that, you know, kicks into place like several months after you get that second dose. This booster, we have early evidence from places that have already started boosting that antibody levels do go back up. And that’s not surprising at all, right? Like you woke up those memory cells. And they were like, oh, okay, this is we know this is a big deal. But boosters can do a lot of things, they can affect immune response quantity, they can affect immune response quality, and they can also affect immune response durability, like that’s the trifecta that we would want to see.
Katherine Wu 48:12
And the best boost possible would boost all three of those, so we’d get more antibodies, better antibodies, and the antibodies would stick around for longer. And another way to put that, the plateau that you get after those three is going to be higher than the plateau you get after those two. We don’t know if that’s gonna happen yet, right? Like, it could totally be that this antibody bump is temporary, it could last two months, it could last 10 months, it could last longer than that we just don’t have the data yet. And we don’t know where it’s going to stabilize after this point. It is different for every vaccine, like think of the vaccines we get, some of them are delivered as three doses to begin with. And it’s not even really considered a boost when you get that third dose. But sometimes it takes the body three times to learn something and then it remembers it basically for life. Or, you know, you have something like a tetanus booster where you need it every 10 years because your body forgets pretty easily.
Do we believe that at the end, that the boost is going to be effective at hitting all of the parts of improving all the parts of our immunity?
I think the best way to look at it is we have very good confidence that the boost is going to at least temporarily increase the number of antibodies we’re able to detect in the blood. So that is the literal production part of this. The bigger question is, is it going to increase our long term capacity to produce antibodies for months or years or more? I would expect there is a little bit of boost in terms of like B-cell capacity to make antibodies, there’s probably going to be some little bit of increase in T-cell capacity to like hang around and kill infected cells if they appear in the vicinity again, but I don’t know I mean, is that small bump going to be enough? Is it going to translate to a functional difference in our ability to prevent disease and infection, that is a huge question. And maybe it is that the antibodies that are sitting, you know, near our mouth or maybe even directly in our mouth are the biggest difference in terms of making a functional difference in preventing infection and disease. If that’s the case, and those antibodies only go up temporarily, then, was there a point to boosting? It’s really unclear right now, I think what we have to do is wait and see long term, is the boost over the course of many months, actually preventing more disease and death and infection.
Andy Slavitt 50:36
Well, Katherine, thank you. You’ve made an amazing conversation. And you’ve let us wander around the topics. And I really appreciated that. I think you have a really good gift for doing exactly what we talked about that we’re not doing that great as a country, which is explaining things, honestly, it in simple terms, qualifying what we know what we don’t know. And we’ll attach some links into the show notes to several of the recent pieces that you’ve written. But you know, you tend to write about the exact things that are on people’s minds or that are actually even about to be on people’s minds. Because you’re kind of been one step ahead.
Well, thank you. That is very kind. And, you know, I obviously want to thank Ed for recommending that I come on here. Very grateful to him and everyone else I’ve been working with.
And maybe the best thing he’s ever done.
I won’t contest that now. He’s great. Thank you so much.
Alright, let me tell you about our next several episodes. They’re some great ones. Celine Gounder, who’s a great, great doctor in New York. She was senior person on the Biden transition team. She’s wonderful. It’s got to be a really good good, good episode. Following that, Dr. Ashish Jha. He’s a doctor. He’s the Dean of the School of Public Health at Brown. You see him on TV all the time. Almost too much. I’m sure you’re tired of Ashish. So we try to fix that we tried to remedy that on the show. Two more shows I want to tell you about. One is something called an AMA. What does that stand for? It stands for ask Lisa, anything. That’s right. Dr. Lisa is going to be with you to answer your questions. You can ask her anything. And I think it’ll be a really fun show. Lots of questions coming in. And we’re really looking forward to that one. And then one of the best guests we’ve ever had, of all time. Larry Brilliant. The epidemiologist who inspired every movie by the topic, who helped us get rid of smallpox. He’s amazing. Look forward to all of that with you beginning next week, have a great rest of the week.
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. Jessica Cordova Kramer and Stephanie Wittels Wachs still rule our lives and executive produced the show. And 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, most importantly, please tell your friends to come listen and please stay safe, share some joy and we will get through this together.