Posted on Aug. 5, 2021
A conversation between Vanderbilt Health's chief hospital epidemiologist, Dr. Tom Talbot, and infectious disease expert, Dr. Bill Schaffner:
Tom Talbot, MD: Hello, I'm Tom Talbot. I'm the chief hospital epidemiologist here at Vanderbilt. And I'm here once again with my colleague, Dr. Bill Schaffner. Bill, good to see you. Good to meet again to talk about our, maybe not favorite topic, but important topic, COVID. Before we start, I think there's something we need to do.
Bill Schaffner, MD: Yes.
Talbot: I believe you're vaccinated.
Schaffner: I certainly am vaccinated.
Talbot: I'm vaccinated, so we can actually take off our masks, so actually see each other's face, which is nice to do.
Schaffner: And we're out of doors.
Talbot: And we're outdoors.
So we wanted to meet again because there are a lot of things happening around COVID, around the vaccine. People have questions. So I thought we could have a dialogue about some of the common questions that are coming up.
And I will contextualize this, that I think if we were meeting four weeks ago, our conversation would be a little different than it is today. And I think the month of July is when we started as very excited, we were kind of back open, people were vacationing, and it kind of felt like we had gotten through the tunnel.
And it seems like in the last few weeks, we've got a new tunnel that's arriving. And so we don't really know what that means and have uncertainty. So I think we need to talk about that as well.
So let's start with that. What are we seeing across the country with infections and COVID? We're hearing things west of us in Arkansas and Missouri, down in Florida, what are we seeing across the country?
Schaffner: Yeah. So Tom, as you were saying, previously, cases were coming down. Oops. And then that curve flattened out, and I'm afraid new cases are increasing all over the country. Some places, such as Missouri, more than others, right?
But there is this sense that this Delta variant that's extraordinarily contagious is out there spreading, particularly among unvaccinated people. It's almost honing in on them.
And here in our own medical center, I think 98% of the patients who have severe COVID, who are being admitted, they're unvaccinated. It's really pretty unusual for a vaccinated person to have severe disease and require admission.
Talbot: Yeah, that's a good point. So we looked at our data, and I think the medical center just released a press release about that, and said, so from June 1st to last week, we had I think 107 patients admitted who were diagnosed with confirmed COVID. Of those, 12 had been fully vaccinated, but of those 12, eight of them didn't know they had any, they had no symptoms. They were just here for other things and got tested. And none of the folks who've been fully vaccinated were in the ICU, got intubated, or died. And those were folks who had been unvaccinated.
So we are seeing that locally, what's been reported across the country, is that the severe infections, most of the hospitalizations, the severe, needing intubation to breathe, deaths are happening in those individuals who have not been vaccinated. So it is definitely what we're seeing.
Schaffner: So something else, you know, at the beginning of the outbreak, we all knew that this virus disproportionately affected older people. Of course, it still can, but a lot of older people are now vaccinated. And so if we look at the ages of the people who are now being admitted, unvaccinated, they're in their thirties and their twenties, and there's some adolescents, and the children's hospital is seeing cases now, too. So there's a bit of a myth out there that children are [safe]. That's not the case.
Talbot: Yeah. Arkansas, who's I think a little bit ahead of us in terms of rates of infections right now, their children's hospital this week has come out talking about the cases they're seeing in the hospital and kids in the ICUs. So I think we're definitely seeing that in our kids.
You may have seen this story in Georgia of the 24 year old healthy individual who has had to have a double lung transplant. And now his family is coming out saying, gosh, he was not vaccinated, he went to concerts, we really wish he'd been vaccinated, using it as kind of a plea.
Talbot: And so the challenge is, many young folks don't have that complication, but we don't know who will. And it's really kind of a lottery at that point. And it's clear, if you're vaccinated, your likelihood of having those complications are far, far, far less. In fact, COVID seems, not to be glib about it, more like a bad cold at worst, than what we're seeing with folks that are unvaccinated.
Schaffner: Yeah. Just to stay with the kids just for a moment, I mean, it was yesterday that I heard about a child in Knoxville, 5 years old, perfectly healthy, died of COVID.
Now, here's some numbers. Over 400 children in the United States have died of COVID, over 13,000 hospitalizations, and get this, in this last year, COVID has become one of the 10 leading causes of death in children. If it's your child, it's a hundred percent.
Talbot: And we don't think, 400 deaths, oh, that's not a lot. In kids, from a respiratory virus, that's a lot. And then that doesn't even also include the inflammatory syndrome that we've seen I think in thousands of kids, as well.
So it'll be really interesting as we move to the fall and kids will be coming back to school, which I think is good for them to be social, but many may not mask. They won't be vaccinated. And I'm nervous to see what happens to disease in kids. And I'm hopeful that, again, the message goes back to getting vaccinated to protect those who can't be vaccinated.
Schaffner: Right now the recommendations are if you're 12 years of age or older, please get vaccinated. And the parents haven't started to bring the kids in for that 12 and older group. A small number have, but boy, do we have a lot of children to vaccinate. I would hope we could vaccinate them all before school starts.
Talbot: Both of mine are vaccinated.
Schaffner: Well, my grandchildren are vaccinated. They're a little older. One's in college. One's just starting college. They come from a vaccine family, but they were first in line. They wanted to get vaccinated.
Talbot: Let me ask you, so before we go to more vaccine questions, talk a little more about the Delta variant. What does that mean? What does that mean in terms of how is that different compared to the virus we saw last summer? Put that in some context for people.
Schaffner: So let's go back to some basics. You have the parent strain that came over. Every time it infects somebody, it multiplies. It reproduces itself billions of times. And when it does that, you can get some genetic changes. We call them mutations. Most of them are harmless. They fall by the wayside.
But every once in a while, you get a distinctive mutation or a series of mutations that can have, in effect, a child of the original strain that has its own personality. And this Delta variant is one of those children strains, and it's distinctive characteristic, although the parent was very fast, that is, highly contagious, this one is even more contagious.
I've just seen a study to show that in comparison, the Delta with the parent, the amount of virus that's back in your throat, the Delta is a thousand times more than the parent. And you can imagine if people exhale and there's much more virus that comes out, obviously it's going to spread to other people much more readily.
Talbot: Yeah. I think it's like any child trying to outdo the parent, I guess, but not in a great way. I mean, it's true. So I think the transmissibility, the infectiousness, is just the key piece, and may answer folks, you know, why are we seeing the surge, is that this virus can find those folks that are susceptible, and even finding some folks that are vaccinated. So let's talk about that, as we move to vaccine.
Schaffner: Let me do one more thing, just to close this thing. Although this Delta variant is a child of the original, one of the good things is that our current vaccines will protect against the Delta variant.
Talbot: Yes. Very important point. Very important. Now, we do hear, and part of my frustration with some of the stories that come out about you hear, oh my gosh, there's fully vaccinated people getting COVID, some of that is that we know the vaccine is not a hundred percent, and this virus is higher viral load so will get to those folks.
But it does seem that fully vaccinated folks are not having the severe infections, maybe even mild infections, or they may feel like kind of bad cold. But talk about that because I think that gets a lot of attention and maybe more so a perception that oh, the vaccine is not working. So talk about that, where we see these quote breakthrough infections in fully vaccinated.
Schaffner: Well, my bottom line is the vaccines are working. Here's the point. The vaccines were designed to prevent serious disease, to keep us out of the hospital. And as we've been saying, they're very successful in doing that. That's what they were designed to do.
Now, we got a bonus. In addition to preventing serious disease, we discovered later that the vaccines reduced our chance of just getting milder infections. I said reduced, I didn't say eliminated.
And so now we are seeing some vaccinated people who are exposed to COVID and they get milder illness. They don't have to be hospitalized. Some of them have no symptoms. Some of them have kind of a cold. Other people are sick enough to go to their bed for a day or two or three, at home, not in the hospital.
Yes, we have to recognize that there are milder forms of COVID you can get, even though you're vaccinated, but they kept you out of the hospital. I used to have patients who complained after the flu vaccine. Gee, I got the flu.
Talbot: I still got sick.
Schaffner: Right. And I would say, Charlie, I'm so glad you're here to complain, because you didn't die.
Talbot: I mean, not to be glib, but you're right. You're right. So one thing to remember, too, with these people that are vaccinated that become infected, we don't treat them any differently in terms of how we manage them.
Are they infectious? If you're a close contact, do you quarantine or isolate? We've gotten questions that say, oh, I got it after a vaccination, it must be a lesser infection, so I don't need to do that. And that's not true. So once you get COVID, no matter your vaccine status, we manage you the same way. So just remind folks.
Schaffner: So Tom, help me understand this or help the viewers understand it. So I've been vaccinated. And now I come down with some symptoms. I've got a scratchy throat. I don't feel so well. Maybe I have a little bit of fever. You know, I used to blow that off. Do I need to get tested?
Talbot: You do. And I think one thing we've seen is that people who are fully vaccinated may think, oh, it couldn't be COVID, so I don't need to worry about it. And that's not true for the various things we've talked about. The vaccine is not perfect. Folks can still have mild infection.
And importantly, you may not get sick, but there are others you could spread to, whether it's our little kids, or don't forget, and I think lost in a lot of the vaccine questions, should I get it, it's my choice conversation, are those around us that even if they get vaccinated and when they do, they cannot mount a response.
So our cancer patients, our transplant patients, they need us to protect them. So that's another reason that maybe someone in your household, someone you have contact with, that they're vaccinated, but don't have the protection. So we have to protect them.
So yes, if you have symptoms, get tested. If you're a contact of someone with COVID, even if they were vaccinated, you need to be evaluated. Hopefully you're vaccinated, too. But yes.
I want to, as we move into vaccines, I want to talk a little bit about some things related to Delta that we're seeing and other things. So one question that comes up is the issue of people that have had COVID infection. Do I need to get vaccinated?
Talbot: There was an interesting study that came out that looked at the level of protective antibodies in Britain and found while [inaudible] people that got infected and not vaccinated could not mount the protection against Delta that you saw with two doses of vaccine, and even one dose of vaccine wasn't enough.
So really, to me, it was a good example where you said there's some immunology that says two doses of vaccine, protective, one dose, not really, no dose, not really. Don't rely on natural infection. Do you agree with that? Or when you hear that, what do you counsel?
Schaffner: Oh no, no, I agree with that completely. And the way I tell people is, you will get some protection, obviously, after natural infection. Why do you have to get vaccinated despite that? And that's because after natural infection, if you look at the antibodies, they're here, but after vaccination, they're here.
Does that make a difference? In two ways. Generally, the more antibody, the longer the duration of protection, and we hope that that's the case. It is with other vaccines. And the other is just the thing that you said, more antibody seems to provide better protection against the variants that are going around.
So there are two really good reasons, even though you're recovered from COVID, to get vaccinated nonetheless.
Talbot: Absolutely. Absolutely. So a couple other vaccine questions, maybe not Delta related, but are out there in the ether. So number one, these vaccines are still under emergency use authorization, particularly the mRNA vaccines. Some individuals are reticent to get vaccinated until the FDA has given their full blessing. Any sense of when that's going to happen or response to that?
Schaffner: Personally, not quick enough.
Talbot: I agree.
Schaffner: Quite frankly the Food and Drug Administration is a bit of a black box, and a biological license application is a huge amount of information. Of course, the FDA has been looking at some of that information as we go along. But nonetheless, it's a meticulous process, and we have to give our friends at the FDA time.
But I have to tell you, I wish they would hurry it up, because we often hear that people are reluctant to get vaccinated because it's not yet an official vaccine, or they still call it, erroneously, an experimental vaccine. I would love to take that issue off the table.
Talbot: I agree. And I think the other factor that we're seeing is you hear more and more businesses, but particularly medical centers and hospitals, move to where they're going to have as a condition of employment vaccination. One thing that's been espoused as one piece that they're waiting to happen is move to full licensure because that is just, it's a block, just so you can remove that block.
And so I know that's also, as more places are looking to require, some are requiring or a condition of employment with our healthcare workers, that's one other piece, too, that I think is a piece.
So I'm like you. I want them to do their diligence, make sure it's safe. We've vaccinated in the U.S. alone 162 million people with at least a dose of vaccine. We have really, really robust data, more than I think any other emergency use medication in the history of the emergency use authorization, by logarithmic scale.
But I want them to do their diligence, but I also want them to recognize that that is, I think, a stumbling block for some individuals.
Question two that comes up, and there was a little confusion, a little back and forth in the press about this issue, between the manufacturers and the government, booster shots. So a couple weeks ago we heard Pfizer say, yes, we're moving forward with booster shots. We heard CDC and FDA say, well, wait. We've heard folks also argue that they're doing what they need to do and parts of the world haven't gotten even their first dose yet, and we're all in this together.
Talk about booster shots. And what do you see? What are your thoughts?
Schaffner: It's the question of the week for sure. I've heard it many times. So the CDC has said there are two considerations regarding boosters. The first is, if we're vaccinated and our protection begins to wane, and we start seeing people who are vaccinated having to be admitted to the hospital, that would suggest, you bet, that we would need a booster. It hasn't happened yet. We're up to nine months, a year, and the protection is still pretty solid. Second issue is variants.
If we suddenly appear to have a variant out there that can evade the protection of the vaccines, but that's not the case. The Delta variant, which is the most common one, is combated by the vaccine. So if we get a new variant or if our protection starts to wane, then boosters likely will be necessary. But not yet.
Sometime in the future, maybe, but at the moment, rather than giving a third dose to so many people, there's so many folks who haven't had the first dose. Those are our neighbors and friends we have to bring in to be vaccinated. That's where the issue is.
Talbot: Yeah, I agree completely. And to your point, we talked about the parent and the son, the daughter, virus. We don't want the grandson or granddaughter virus to come along that wants to top Delta. And what does that look like?
You know, we're hearing about a Lambda that's out there that's just come out, and not sure I know about that. I'm scared to look. But the reality is in the world population, as the virus continues to circulate and with unvaccinated individuals, that's the opportunity. There's that chance.
And the scenario that none of us, none of us, no one wants to go back to where we were last spring in any sense. No one wants people to have harm and die. But that's a scenario, is if we get a strain that says, uh-oh, now look what's happened. Now we've had this. We're giving the virus the opportunity the longer we let it circulate.
Schaffner: So here's a subset of that, because we discussed that off camera, namely immunocompromised patients.
We know they don't respond optimally to the vaccine, lots of different kinds of immunocompromised. We don't know about how they all respond. And there are a lot of those patients and their doctors who have been asking, can we give those folks an extra dose just to be on the safe side?
So a couple of things about that. The CDC does not make recommendations, the Advisory Committee on Immunization Practices, on the basis of a good idea, a hunch, or it probably will work. They need data, evidence-based medicine, so when they go out and make a recommendation, they can tell you pretty much what to expect, how well, if it will work, and what's on the safety side.
So if you get a third dose, where's the problem? The data are scant, let's say, so at the moment, the CDC's Advisory Committee on Immunization Practices is examining this question, but not likely to make a recommendation.
Talbot: Yeah. Good point. I think the last question, and we hit on this a little bit, but let's follow that back up, is many, many folks watching the video have kids under 12. They are not eligible for vaccination. Do you have, reading the tea leaves, do we have any insight as to when a vaccine for kids under 12 will become available?
Schaffner: Well, think about this. There are parents all over the country that have volunteered their children. Come on, you're going to participate in these studies. So the studies are underway at the present time. We think that these studies will come to a conclusion well into the fall, late fall, early winter, and we'll have more information about children younger than 12, and whether they ought to get vaccinated, and if there are any special recommendations there.
But at the moment, 12 and older, we're not vaccinating those children nearly to the extent that we need to. The vaccine's in the refrigerator. As one of my friends said, vaccines never prevented disease, vaccination prevents disease. It's got to go in the arm, and 12 and older, we need to get those children vaccinated.
Talbot: We've got the supplies. And when you open a vial, you've got multiple doses to use. And right now we open a bottle and can use a couple, but there's some that often go to waste. And so in the scheme of the world clamoring for vaccines, you just, it hurts to give up a vaccine like that. So I agree with you completely.
Well, Bill, it's been great to talk with you. Maybe this topic has not been as cheerful, with things getting a little bit worse now, but my hope is we'll meet again and we'll have a more cheerful conversation maybe on something not even COVID.
But in all seriousness, it's always good to hear your perspectives, and thank you for advising us and advising the world on COVID. We really appreciate it.
Schaffner: Always good to be with you, Tom. And let's think low COVID in the future.
Talbot: Low COVID. Get vaccinated.