Vaccine breakthrough infections, Moderna vs Pfizer waning immunity, boosters for the elderly, and more.

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– [Zubin] Hi everyone, Dr.Z, real talk. What’s going on with these vaccines? Are they actually working ’cause reading some of the news now, reading some of the data that’s coming out, there are concerns, out of Israel that there are, there’s considerable evidence of some vaccine breakthrough cases here in the United States. Looking at the differences between between Moderna and Pfizer and a preprint Mayo clinic study saying, Ooh, both of them actually lost efficacy against preventing infection over time since the beginning of the pandemic. Moderna less so than Pfizer, we’ll talk about that. So do these things work? Are we seeing vaccine leakage where vaccinated people are transmitting disease? Is it worth getting the vaccine or is this pandemic just gonna go on forever? Between variants, vaccine failure and all of that? So let’s just really hash this out right now because I have strong thoughts about this.

I’m gonna link to an article by David Wallace-Wells. You’ll recall his article was also the basis of my Delta variant video from recently. I think he does a very good job of nuancing some of these details and challenging our existing beliefs about what’s going on based on data. And he interviewed a Harvard epidemiologist, Michael Mina. It was a very good, challenging article. I shared it on my Locals platform and there were like 300 comments from subscribers there. And they were very, very interesting, thoughtful, critical ideas of how this pandemic is gonna proceed. All right. If you look at the vaccine studies, right, you saw 90 plus percent efficacy at preventing infection. And that means like, you know, infection with symptoms where you’re like, oh wow, you actually didn’t get infected. Now these trials were done back in the day when the circulating variants were not necessarily the UK variant, Alpha or Delta, right?

In fact, they weren’t. And so you had a different type of virus that was less transmissible, more susceptible because it was the basis of the design for the vaccines when they designed them in the first place. So it’s not surprising you saw high rates of efficacy. There may also be a little bit of a bias there because the people who tend to enroll in those trials tend to be more careful, more thoughtful of their health, et cetera. Now as they start rolling out the vaccines in December, January, February, the first people to get vaccinated were the highest risk people. But they’re also the people who are the most engaged, like they wanted to do this. They were also highly health-conscious and tended to avoid situations where they were gonna be put in harms way. Mitigation, masks, distancing, avoiding crowds, that kind of thing. So you saw again, high efficacy at preventing infection and of course the very high efficacy of severe disease. So when you look at those months, what you see is, wow, vaccinated people almost never end up in the hospital. They don’t seem to get very infected and so on and so forth. Now as time marches on, looking at the datasets, more and more vaccinated people are showing up positive for COVID testing. And the vast majority of them have mild symptoms or moderate symptoms, right? The cough, runny nose, a little fever, muscle aches, feeling bad, that kind of thing. Very small percentage of them still are getting hospitalized.

So still very, very effective against severe disease, but not so effective against infection. And there’s some evidence that the people that they test who are having a lot of symptoms have just as high a viral load as someone who is unvaccinated, what’s the difference? What changed? Why are we now talking about this? Well, there’s at least two things that are going on and probably more if you read the article. But two major things, one, is Delta variant. So Delta variant was not happening during the vaccine trials and in fact you’ll see some misinformation circulating online. See, Geert Vanden Bossche and these guys who were talking about vaccines causing variants were right.

Yeah, how’s that ace? You think that Delta was caused by vaccines? It was actually described prior to the widespread release of the vaccines. So again, misinformation spreads faster than information. But this idea then that Delta comes on board, it emerges in India, it’s very, very, very effective at reproducing in humans and spreading. So it has a very high reproductive number, almost close to chickenpox. I believe it is around seven. So one person infects seven other people. In addition it probably evolved in an environment where a lot of people had natural immunity to the previous strain, not vaccine immunity, natural immunity to the previous strain because they’d been exposed in India, say. And so it happened to also evade a little bit of that immunity. So it’s a little better at evading the antibodies that were made previously. So you now have this variant that is just a little better, maybe a lot better, right, at certain things. So what do we see now in the data in say Israel and the US, what’s starting to happen? Well, you’re starting to see as more people get vaccinated, a fraction of them get infected. So infection versus severe disease. What’s the difference here? This is a respiratory virus. It replicates in the nasal passages and the upper airways and that kind of thing. So it can start replicating really before your blood-based antibodies have a chance to really do a lot. So you start that process of replication and it may be that Delta replicates more easily in those upper airways, higher viral loads up there.

And so it… The vaccine and your previous immunity even natural immunity doesn’t really prevent you from having that infection. But here’s what it does do from everything we can see. It actually prevents people from getting very sick because when that thing starts to replicate then you have that blood antibody barrier. And even if the antibodies don’t fit as well as they did for the wild type Wuhan strain of the virus, they still fit good enough to prevent you from getting very, very sick, which is why we don’t see our hospitals fill up yet with vaccinated people, yet with vaccinated people. We’re seeing mostly unvaccinated people in ICUs and so on. Younger people because they tend not to go and get vaccinated.

And since Delta is so contagious, you actually see a lot of kids too just because of sheer numbers. Kids that might’ve brushed off that before because lower viral inoculums circulating around now can get sick. But again, both young people, young adults and kids are less likely, vastly less likely to get severe disease that ends up in the hospital. But as a numbers game, if you infect enough of them, the small percentage that do get sick will end up in hospitals. So you see the news reports about there’s kids in the hospital and ICUs are full and so on. Now, I said there were two things. So you have this Delta variant, that’s just much more robust. And I think CDC’s messaging early on was like, hey, get the vaccine, you know, take off the mask and I actually agreed. I was like, yeah, take your mask off, dude. You’re vaccinated. If enough people get vaccinated, why are we wearing masks? Well, part of the problem was enough people didn’t get vaccinated.

So that Delta coming from abroad starts to become the dominant strain very rapidly and tears through the unvaccinated population. So what’s the collateral damage of that? Well, vaccinated people start to get infected because again, that vaccine is not gonna necessarily prevent infection and they can spread it too. And that’s why CDC comes back and says, oh, put the mask back on, right? Of course, the data for all this is so sketchy but that’s another subject. So now you have a situation where you have a very, very, very contagious virus that is tearing through an unvaccinated population. And there’s the collateral damage of the vaccinated. Well, I said there were two reasons, the vaccines showing decreased efficacy now. The second reason is probably what they call the waning of immunity. Meaning as we get months out from the original dose of the vaccine, remember even back then, nobody knew how long this is gonna last. You could only tell how long the immunity was gonna last by measuring immunity over time because you don’t have a good predictive model of how it would work. There were suspicions that it was gonna be at least, you know, six months to a year, maybe longer. Others had said even longer than that.

Well, it depends on what you’re talking about and what population you’re talking about. So it turns out there’s something called immunological aging, immune aging. What does that mean? It means as we get older, the architecture, the physical architecture of our immune system starts to get, as Napoleon Dynamite would say, decroded. So what used to be very robust and you could actually be exposed to an organism and develop an immune response and memory for that, that would last few years now starts to fall apart. This explains why older people are at risk for Shingles. Shingles is varicella zoster virus that you were exposed to often as a kid that stays in our nerve root ganglion and so on. And our immune system keeps it at bay but as we get older and there are certain stresses and so on the immune system starts to get weaker and then Shingles comes back out. That’s why you see it predominantly in older people and the recommendation is for older people to get the Shingles vaccine, which gives the immune system that booster because it’s forgotten. Well, it may be that we’re seeing immune memory waning, particularly in people who have immunological aging. In other words, older people, not all older people, but a fraction of them.

And this article really spells it out nicely. Michael Mina kind of speculates well about what could be happening. Well, what does that mean? It means the original folks that were vaccinated back in January, February by about now in the setting of Delta, which is a much more reproductive virus that’s a little resistant to the original IgE antibodies, well, now they might get infected. And actually some of them are gonna break through and get severe disease and up in the hospital and possibly die. So if you think about that, you go, well, shucks, that’s terrible. What’s the point? I thought the whole idea was the vaccines were the way out of this mess. Why should I even bother to get vaccinated now? They don’t even work, we’re all gonna die, blah, blah, blah. Okay. No, this is what that means, all right? It means that our most vulnerable, the ones that are most at risk for death, which are elders or people with immune compromise are the ones who we ought to be talking about booster shots with, which we’re already talking about with immune compromised people. I think we should consider the elderly immune compromised because what we wanna do now is give them a booster. Even with the original vaccine that hasn’t been modified for Delta, a booster will refresh their immune memory. You know, another way you can refresh immune memory actually get infected but don’t die. That’s another way. And so if you look at what’s been happening in the United States with say younger people that aren’t elders, okay.

First wave comes through infects a bunch of people. They get some natural immunity, other people don’t get it. Second wave comes through, they get natural immunity. Other other people don’t get it. Then you have the vaccine. Now you have a chance to cheat without having to roll the dice and get sick and run the risk that you’re actually gonna get a case of long COVID or end up in the hospital or die because that’s always the risk. Instead of that, that you get the vaccine, which gives you that cheaters immunity without having to get infected naturally. And by some measures that immunity may actually generate higher levels of neutralizing antibodies. So it’s a very robust immunity. So now what you have is a population that’s had a pass through this first exposure to coronavirus now comes Delta. Some people will get reinfected, who’ve been naturally infected. Some vaccinated people will fail the vaccine and get a natural infection that won’t be severe. Each time that happens, they’re building their immune system’s memory on and on and on and on. Now there is a segment of the population, the elders, that have more trouble with that and people with immune compromise, et cetera. And of course our youngest kids cannot be vaccinated but it turns out typically they’re used to experiencing a cesspool of virus, which is probably part of the reason they don’t get very sick from coronavirus. Typically, it’s not always true. You can have risk factors. So that being said now we’ve been hiding behind masks and lockdowns and closures and all, just different degrees. If you look what’s happening in Australia now, they’ve been locked down. Delta comes, oh my God, it’s a crap show over there. Because no one has any immunity and they haven’t caught up on vaccinations.

So you see then what happens? What happened in India. No vaccinations, Delta comes through. Even though some people had natural immunity, Delta just ravages through the unimmune population and even can take out some of the immune. But what’s happening? You’re slowly building this body of immunological memory. Now what’s happening in the US? Now this is setting a case for what I think is ultimately going to happen here. What’s happening in the US? You saw after the original waves of vaccinations a massive drop-off in cases, people were like celebrating. I was telling you, hey guys like this for the vaccinated, this pandemic is effectively over. Come on, go get vaccinated. If you don’t wanna get vaccinated, you run the risk of getting infected, whatever. Well, I’ve actually had to rethink some of that because now what’s happening is you have a surge of Delta that’s, this is the United States. So if you try to treat it like one thing, you’re making a mistake. It’s the South, the Southwest, the Northeast, the Northwest, very different climates, very different behavior patterns, very different politics, very different mitigation strategies. Everything’s gonna be different. So instead of what you see in Great Britain, where Delta goes up, Delta comes down because they kind of almost behave on mass. In the US you’re gonna see Delta goes up in places like Florida, Arizona, the Southwest, the South, where it’s warm in the summer. People are indoors and there’s a lower vaccine penetrance, although not necessarily in Florida. But the unvaccinated population still large enough that you can get a ton of transmission and then it comes down. And then what happens is more people get vaccinated because they see what’s going on. And then some of those are gonna get infected.

And some of those because they’re older, they don’t have a good immune response, they’re gonna get sicker. But back and forth you start to develop immunity so what’s gonna happen in the winter? Well, the South is probably gonna be okay ’cause they pass through it. The Northeast is gonna catch up with Delta, tearing through an unvaccinated population first. Throwing tons of people in the hospital, filling up the hospitals because they’re unvaccinated. So their chance of severe disease are worse. And then again, people will modify their behavior. It will peel down and then you’re gonna see nursing home patients with waning immunity get sick even though they were vaccinated, if we don’t do boosters and mitigation strategies. So that’s what’s gonna happen. Then by next year what’s gonna happen is we’re gonna have more collective immunity. And a new variant will happen maybe because a variant has to be better than Delta in order to succeed now. That’s hard to do, it could happen. But at some point the virus runs out of tricks and it becomes happy living in an immune population where it causes occasional infection yearly, mostly seasonally, not many people die, some do, but not many people die. It’s kind of like a cold or a flu and it lives with us forever. The idea of stamping it out, no way. But turning it from a pandemic to endemic, yet another coronavirus in the arsenal of things that cause severe annoyance every year is probably what’s gonna happen. So the question is, and we’ll go back to Moderna and Pfizer, the question is, how do you expedite that? Is there anything we can do here? I’ve been thinking about it this way, and again, if anybody says they know the answer to this, absolutely, oh, this is absolutely the answer. It’s ivermectin or it’s masks or it’s close schools or it’s vaccinate.

They’re just not right. Maybe true but partial and maybe less true and more partial. So what ought we to be doing? Well, here’s probably what we ought to do. As many people as can be vaccinated should be vaccinated because that takes away the natural risk of rolling the dice with COVID. You don’t really, I don’t even know that you have to mandate that, you just tell people, well, at some point you will be infected. You’re going to be infected with COVID. Would you rather have a shield of a vaccine which still has above 80 odd percent protection against severe disease and hospitalization even with waning immunity in a lot of younger people still or would you like to roll the dice with natural COVID? That’s your choice, that’s the choice in front of you. And I’ll tell you if people really understood how actually safe the vaccines were relative to natural COVID, rolling the dice, I think a lot of people would say, well on balance, if I’m really understanding risk and it’s not politicized and people aren’t trying to shame me. And make me feel like I’m stupid for actually asking questions that matter to me, that actually matter objectively, then maybe I’ll go get the vaccine. Maybe I’ll just get one dose, I don’t know, but I’ll get something that puts a little shield up.

And if we do that, we expedite how runway we have before this thing becomes endemic instead of pandemic. Now think of it this way, this is how I’ve been thinking about it. So far we’ve had like 600 odd thousand deaths from this thing. If you believe the data that says the infection fatality rate for coronavirus, and remember this is a changeable thing because as we get better at treating it et cetera, amount of fatality per infection in the community is gonna drop. But the rate of death for everyone who gets infected whether we test them or not, in other words we’re just saying this is how many people have been infected based on various data points is about 0.3 of a percent. It’s much higher for older people, much higher for people with co-morbidities and disease. But across a whole population on average it’s 0.3 let’s say, give me that, that means 0.3% of the American population of 350 million, back of the napkin calculations, oversimplified is about 1,000,050. We’ve lost 600 odd thousand. So we still have 400 odd thousand lives at stake if you believe those numbers. So 400,000 Americans lives are at stake. How do we save them? Can we save them? Do we have the hubris to think that masks and distancing and washing hands can help? I think they do help.

I don’t think they’re the full answer, they do help. You can argue about mandates or not. You can argue about individual choice or not. I think to some degree they help. Vaccines, do they help? Yes, they do help. Every single data point says vaccines not only reduce, so here’s the thing even with the decreased efficacy, it’s still a 5 to 10 fold decreased risk in even getting infected so far from the calculations in the David Wallace-Wells article. And that’s lower than what CDC would say. So this is speaking truth. CDC is sugarcoating a lot of stuff and fear-mongering other stuff. CDC and these public health guys have to say what they think they need to say to get you to do what they think they want you to do. It has nothing to do with telling you the damn truth, which is, here’s, what I’m telling you is the best understanding I have of the truth right now. That article by David Wallace-Wells is the best understanding I’ve seen yet. It could be wrong but it’s the best understanding I’ve seen of where we are. And that’s not what CDC is gonna tell you because they need to tell you a public health message that’s gonna get you to behave the way they want. And this is too nuanced in their mind. I think that’s a terrible way to treat the American public. The way you treat the American public is you give them the facts and the nuance and the perspective. And then you say, this is what I think you should do. So how do we say 400,000 Americans? Get vaccinated. Use common sense. If you’re going into a crowded place and Delta’s surging in your community, throw a mask on. It’s not that hard, right? Just use that common sense. If you don’t want to, hey, then you’re taking the risk of getting infected. If you’ve been naturally infected, you could say, you know what?

The next exposure in Delta is gonna give me a booster but you could be one of those rare unlucky ones that gets very sick. I actually think getting at least one dose of the mRNA vaccines or the J&J vaccine probably a good idea. Okay, next, what can we do? Kids, I have no idea about masks and kids, I really don’t. If you’re asking me, honestly, do I think they help? Should we mandate them? I just don’t know. Do I think they hurt? I just don’t know. My kids wear masks to school. They wear masks to their camp. I don’t think it’s totally unreasonable but I just, if I’m being honest with you, I just don’t know. Okay, next, so we talk about kids. Young people and kids are still statistically gonna be just fine so take a breath. Nothing is perfect, you’re never perfectly safe. There’s a culture of safetyism, where we wanna save every single person from every single thing at what cost? The cost of our sanity, the cost of our way of life, the cost of anxiety.

All right, forget that. How do we save those 400,000 lives? A lot of them are gonna be elders and people with immune compromise. Work on boosters for them, make sure you have mitigation strategies for them. Probably old people who have been vaccinated, who go into a supermarket should wear a mask. If they care about being alive, that’s all. If they don’t, if they’re like, you know what, I wanna live my life and I don’t care. That’s my risk calculation, fine. Sure, you could spread to somebody else so there is the communal aspect of that. But the truth is we all have in our power some ways to mitigate for our own personal safety, right? We do have that choice. It’s very different than your kid going to school with an unvaccinated kid who ends up bringing measles and so on. This is a little different and you really have to look at risk. All right, I said, I’d talk about Moderna and Pfizer. So the datas, the preprint data out of Mayo, and there’s some flaws in that but let’s look at it. It says that over time the Pfizer vaccine has decreased in efficacy to around 42% at preventing infection, infection, which we talked about. Moderna is still 76% efficacious at preventing infection and they are both pretty much equally good at preventing severe disease, hospitalization and death. And it hasn’t really declined that much, which is what we really care about. That’s what the vaccines were designed to do. So what is, why, why would that be? Well, one speculation is that Moderna is a higher dose, it’s just more copies of the mRNA.

I had Moderna when I took the second, I didn’t choose that it was what was available. When the second dose hit me, I made a video about this. I was knocked on my ass for 30 hours with immune response symptoms, just felt horrible. And then at hour 30 I took, you know, a gram of Tylenol and slept it off. And the next day I felt like a million bucks, but that was pure immune response. Well, that’s a lot of mRNA. That’s a lot of spike protein locally in the arm. And so, yeah, maybe now months later, it’s a more durable immune response. Makes sense in terms of even preventing infection because you’d just have a higher antibody concentration. And it’s a numbers game with this virus. Now, what about, you know, this idea then that should we be giving booster shots to everybody? Well, you really have to think about who’s gonna need them. What are you trying to do? And how much viral suppression are we really gonna have? And one thing because again, if we’re naturally infected and you’re vaccinated and you don’t die, you can spread it still to the people at risk from you are unvaccinated people. How much do we change our policy based on people who’ve chosen not to be vaccinated? We’re talking about trying to save 400,000 lives. If a hundred thousand of those choose actively to take the risk that they’d rather get COVID than get this vaccine, how much do we alter our nation’s behavior and our protocols and our mandate to kowtow to them? I’m just throwing it out there.

So this is the kind of thing you really have to think about now. So is this good news, bad news? What’s going on? Should you get vaccinated? Okay, I think the punchline is, I think you should get vaccinated. I think vaccine immunity wanes in the elderly. I think we’re gonna see more breakthrough cases and transmission in vaccinated people then CDC and others have been letting on. Because the data again was skewed. You’re looking at, you know, read the article for the nuance. But you’re looking at a numerator, number of people getting infected, over a denominator, which has changed. The denominator, it used to be there were hardly any vaccinated people and hardly any Delta. And now it’s there’s lots of vaccinated people and lots of Delta. So all those numbers are skewed. We keep terrible records of it. We haven’t even properly been testing breakthroughs. CDC kind of stopped looking for a minute and so now we don’t even know.

But you can look at what’s happening in Israel, that their cases are surging even among the vaccinated population. But still the majority of people in hospital are on unvaccinated, all right? Can we just be honest and talk about this stuff? It’s not, you know, and you’ll, you know, I have to, part of the thing with this guys, like if you go, okay, if you sign up on Locals, you can actually, even I think without signing up you might be able to see this. Maybe not, may it’s for subscribers only. You can see the conversation that was had over this article that’s full of nuance. Americans are capable of understanding complexity when it’s given to them correctly, with perspective, compassionately. And they’re capable of having a discussion about it in the comment section, if there’s leadership that says, this is how we behave, that’s looking to find truth and understanding. And wisdom and a better way to be in the world. It’s possible. It’s not just possible, It’s, I think, our fundamental nature if we’re allowed and encouraged to be like that. So that’s my final pitch, come join us. Be a part of the solution. Let’s stop yelling at each other and shaming each other and speaking in absolutes.

I believe it was Obi-Wan Kenobi who said, “Only a Sith speaks in absolutes, Anakin.” In one of the worst movies in the series. All right, guys, I love you so much. Read the whole article if you get a chance and tell me what you think in the comments. Share the video. If you’re on YouTube, subscribe and click that little bell to get notifications and we are out, peace.