My name is Vince Slaughter, thirty six years old from New York, and I work in the veterinary field, and this is my COVID experience. Last April, I had become ill. I thought that I had like a sinus infection or something. I tried to wait it out until I just started coughing up blood constantly. I went to the hospital and sure enough, I was COVID positive, and I also had pneumonia that I'd gotten through COVID. So I was admitted and I was in that hospital for a month and
I really didn't improve. But at the end of that month, that hospital they were becoming overcrowded with COVID patients. They kind of rushed me out, even though I told them that I didn't feel like I was any better or ready to go, but they discharged me. And two days after they discharged me, not only was I still coughing up blood, but when I moved around, I felt like I was going to black out. I would just lose
all my energy that was just exhausted. So I went back to the hospital and I was only there for about a day and they transferred me to a larger, far more competent hospital. And two things were found out
at that hospital. The first being that I had an abnormal blood clot in one of my lungs that effectively killed off one third of my lung The other being that since I was fighting COVID pneumonia and I was compromised from the damage to my lung, ME, who was a at the time, a thirty five year old athlete, was in clinical heart failure. The virus had attacked my heart aggressively and I was in heart failure. That's what was going on. I was taken to ICU and a
number of things were done. There was a tube placed in my back that was constantly pumping out all sorts of gunk from my lungs. I had neck congelos placed on both sides of my neck. I had some sort of port put in my chest. I was barely conscious a lot. I was hallucinating as well. Things got really bad and they had to install balloon pump in my leg to keep my heart beating. The only solution was that I needed a heart transplant. They found a donor
and that's what happened. I had to have a heart transplant. I was in the hospital for over three months, just shy four months actually, and I've had to go back several times since just because my immune system is compromised now due to the transplant. When I was healthy enough after the transplant to be weighed, I went from going into the hospital as a two hundred and ten pound combat athlete to being one hundred and fifty three pounds. Life's been hard since. I can honestly say, it's ruined
my life. People tell me, oh, you're so lucky you survived, but you know what, like, I don't feel lucky. I don't feel lucky.
I work as a case investigator on the COVID response in Georgia. My role includes calling people who have tested positive to gather data about their symptoms and medical history, collect their close contacts for contact tracing, give guidance for isolation, and connect the cases to resources. I've spoken to hundreds of people who have had COVID, most of whom who have had mild to moderate cases, and many of whom
have had severe cases, some later died. The emotional toll can be a lot to bear, and the work never stops. In the current surge, we cannot even begin to reach everyone who is sick, and the most we can do is hope that they are okay. The story I want to share happened shortly before Christmas. My team was focusing on school aged children in an effort to control transmission
in schools before they return from break. I spoke to a mother whose two children had tested positive and she was quite sick herself.
She was very.
Helpful in giving me information about her children and very attentive to the the guidance I gave her. Towards the end of the call, she revealed her husband had tested positive first and was now in the hospital on a ventilator. I offered my condolences and told her I would connect her to available resources to help pay his medical bills. She replied, thank you for your help. I just hope he doesn't die on Christmas. I don't want our kids
to associate his death with Christmas. I have dealt with death and grieving loved ones.
For months now.
It was all a part of the training, and the mortality rates have become background noise to my daily life. But this woman's story hit me in the pit of my stomach. I took a few minutes to gather my thoughts and then moved on to the next case. I found out a week later that this father passed away the day after Christmas. I knew the hospital he was in was using tablets on tripods to allow people to
say goodbye to their loved ones. The image in my mind of this woman and her children saying goodbye for the last time on a screen turns my stomach. I am angry, I am heartbroken, and I am so tired. The only hope that I have is that the vaccine will be able to win the war that those of us working in public health have been fighting for almost a year.
Hello. My name is John and I'm a paramedic in northeast Texas. I have worked for eight years in a small community approximately an hour and a half east of Dallas. I staff a duel medic and ice you on twelve hour rotating shifts. Many of the patients in our community are older. They reside in rural farming areas. We also have a large Latin American population in our community due to a sizeable manufacturing industry. We began to see an influx of cases in late March at one of the
industrial plants in town. Due to many cultural as well as socio economic reasons, The virus spread like wildfire, faster than we expected and faster than we were prepared for. By mid May, our town of less than thirty thousand had more than eight hundred and fifty cases and made regional as well as national headlines. We had no more ICU bed or ventilators. Our dispatch was completely unprepared, and we had no system in place to properly warn crews
of probable cases. In April, my partner and I were sent to a house for a simple anxiety attack. That's all the information that we had. Upon entering the home, the patient was found sitting in the floor, gasping for breath, and a tinged hue of blue around her lips let us know she was in severe respiratory distress. She began to plead in one word sentences for help. The patient was using a nebulized breathing treatment, which we know to
be contra indicated in COVID patients. The haze of the expired vapor of that breathing treatment surrounded my partner and I. Blindsided by these severe symptoms. My partner and I were caught with our metaphorical pants around her angles. We were wearing none of the appropriate PPE. We had gloves and surgical masks.
That's it.
The patient's oxygen saturation was fifty percent. The decision was made to innovate her despite her lack of PPE. That same patient died and our ICU two days later due to complications of the novel coronavirus. Three days after the incident, I began running fever. I had body aches, a cough. I was more tired than I've been in my entire life. Ostensibly I contracted that very disease that was ravaging our community. However, I'm thirty years old, I'm physically fit, and I have
no pre existing conditions. Due to the lack of the testing nationally, I was denied a test. Needless to say, I recovered. I've been back on the front line since returning fourteen days after my initial symptoms. I believe mts and paramedics have a unique perspective as well as a
unique challenge during this pandemic. Hospitals, clinics, and other health care facilities have some amount of control over their environments, entering into patients' homes and interacting with these patients in public, many times without full knowledge of what the circumstances are. We are many times at the mercy of our environment. We have had to adapt and overcome the ever changing
variables as they occurred during this pandemic. I have been lucky to work alongside many wonderful employees, and I have exceptional leadership where our work, including a chief who has been an immense help through it all. He's helped us with all the challenges that we face, giving us the resources that we need, as well as helping us with the physical and mental toll that this has taken on us. Obviously,
my story is not unique. Nearly half a million MS personnel in this country have endured the same hardships for months. Some have even lost their lives doing so. Now, with the rates increasing in and the hospitals working at the cusp of full capacity, we continue to work and continue to adapt day after day to this pandemic.
Thank you so much to everyone who provided their first hand account for this episode, and thanks to everyone who has sent in a first hand account or filled out the form. We really appreciate it.
Yeah, thank you so much for sharing your stories with us.
Hi, I'm Aaron Welsh.
And I'm Erin Allman Updike and this.
Is this podcast will Kill You.
Yeah, welcome to a long awaited another update episode in our Anatomy of a Pandemic series, where we cover all things COVID nineteen.
Yeah, this is Aaron. This is our fifteenth episode.
I honest, we can't believe that we've made this many episodes. That's so many episodes.
It's a lot, it's a lot, but.
There's so much to cover when it comes to this pandemic, and so we just feel like we really have to cover it all.
Yeah.
I mean, we've learned so much in terms of virology or epidemiology, but we've also learned as this pandemic has gone on, just how much we still don't know or how much our knowledge about this virus, or about this pandemic, or about the disease that the virus causes, how much all of these things have changed from our earlier understandings.
Exactly, which brings us to the focus of this particular episode. This week, we're addressing all of the new things that we've learned about the disease caused by the stars COVID two virus, that is, COVID nineteen. We'll touch on things like what is long COVID or how long does immunity actually last? Or what is the impact of infection on pregnant people?
But before we get to that and so many other questions about COVID nineteen, we have some very important business to take care of. Yeah, we do, Aaron. It is quarantin any time, It's quarantin any time. What are we drinking this week?
We're, of course drinking Quarantiny fifteen, so creatively named.
Quarantini fifteen has vodka, It has grapefruit juice, It has some Maraschino liqueur and a little splash of grenadine. And we will post the full recipe for this quarantini as well as the non alcoholic Lasybrita on our website this podcast will Kill You dot com, as well as on all of our social media channels.
Any other business Aaron, that we have to discuss.
There's the usual.
You know.
We have a bookshop dot org affiliate account, We have a good Reads list. You can find those things on our website, where you can also find transcripts, alcohol free episodes and merch, oh merch. Yeah, and we also are still soliciting first hand accounts for this COVID nineteen series. And so if you would like to submit yours, please head to our website where you can find a link at the top of the page as well.
All right, let's get to the meat of this episode, shall we.
Let's do it.
We were fortunate enough to chat with not just one, but two awesome people today who answered our many, very long list of questions about all the things that we've learned about COVID nineteen in this past year.
We were joined by doctor Critika Capali, infectious diseases physician and assistant professor at the Medical University of South Carolina and whom you may have heard on a previous episode in this series, as well as doctor Jason KINDRICHUK, Assistant Professor and Canada Research Chair in Molecular Pathogenesis and Emerging Viruses at the University of Manitoba.
We recorded this interview on March sixteenth, so keep that in mind. If you hear any numbers, things may have changed. And we'll let them introduce themselves right after this break.
I'm Jason Kinderchuck, I'm a PhD.
I have an Assistant professor in Canada Research Chair in the Molecular Pathogenesis of Emerging Viruses at the University of Manitoba. In the Department of Medical Microbiology. Most of my work focuses on both the pathogenesis as well as the transmission and circulation of emerging viruses, including ebola and coronaviruses.
And I'm Kritica Capoli.
I'm an infectious disease It's phys position and assistant pro foster in the Division of Infectious Diseases at the Medical University of South Carolina, and my area of research and interest is in emerging infections and biosecurity. I am interested in looking at the clinical care and pathogenesis of emerging infections and understanding how we can better prepare for outbreaks and pandemics.
And I was doing that before commentavirus Hite awesome.
Thank you so very much for taking the time to chat with us today. We're very excited to hear what you have to say about all of our many questions. So let's dive in. So in our Virology Update episode, which we released a few months ago, we talked about how this virus is transmitted, but how much does the infectious dose or the amount of virus that a person is exposed to, how much does that play a role in whether they will get the disease or how severe the disease might be.
Yeah, so this is such a good question, right, And I think really we're maybe getting a better glimpse into what this looks like in particular when we think about this idea of infectious dot So certainly, I think we're still somewhat of an infancy in understanding what is the specific amount of virus that you need to be exposed to to get infected. There's been some modeling studies that have suggested it's a bit higher than SARS, but a little lower than MERS, so somewhere in the kind of
the hundred particle range. But a lot of that is somewhat subjective, right, So we're saying, okay, that that is the number you need. But there's also this aspect of exposure time, and I think that's become maybe a little bit more prominent the past few months. We've talked about these super spreader events, We've talked about things like people
being in closed settings. That it's not just a function of the amount of virus that somebody is exposed to it at one moment in time or that static moment in time, as much as it may be about the accumulation over a specific period of time, and I think
that's really important. I think we're we're getting to gain a better understanding of the fact that listen, a few of people that are in in closed settings and they are you know, uh, you know, subject to poor ventilation, and you have somebody that is releasing virus, even if they're releasing virus at a low rate, you probably are going to have people that are going to be continually
exposed and you have that overall accumulation. So I think that that is is starting to give the syndication of the fact that we have to think about this not as just a static number, but also a function of the situation as well as a gain the person themselves and whether or not there are biological consequences that allow them to to basically take up more virus or are more vulnerable or susceptible to virus than others.
That makes sense.
So, speaking a bit more about viral shedding by in fact people, how soon after being exposed does someone become infectious and how does that infectivity change over the course of a person's infection.
Yeah, this has been a kind of a long standing question, right is you know, when somebody's exposed, how long does it take for them to start shedding virus, and I think again, we're getting a much better picture. You know, doctor Moode Sebek has done some really great work, I think in providing good kind of contextual data looking at you know, overall infectiousness and periods of infectiousness for COVID
nineteen and in for shedding and stars COVD two. And I think again, we look back at this idea that the majority of people within five to six days post contact or post infection or are likely going to start to have symptoms. In some cases that may trail out
a little bit longer to twelve days. But if we look at that and we take that average, we take that, say that five to six days when people are usually showing symptoms, well we know that now it looks like that infectious period when you can actually recover it affectious virus from that person tends to be about two days prior to symptom onset and then somewhere in the neighborhood of up to about ten days.
Post symptom onset. So that starts to give us a picture that.
Even within you know, the span of a day three or day four post exposure, that you would potentially have somebody that is starting to be able to release virus. And then I think, again, when we look at all the clinical data that's kind of been a crude over time, what we're getting, I think a good perspective of is the fact that people are are likely most infectious in that you know that kind of one day to two days just prior to symptom onset to about five days post symptom onset.
Okay, gotcha. And so because you know, we know that the amount of virus shed changes throughout clinical disease, how much does it change, you know, sort of looking at a different sort of snapshot, how much does it change across different severity of disease? So are people who are severely infected, are they shedding more virus? Are they more contagious than those who are asymptomatic?
Yeah, Again, I think we're starting to get a better picture of what this looks like, right, And I think in particular, when we think about this idea of asymptomatic patients versus those that are pre symptomatic versus those that are symptomatic, certainly, you know, some of the household contact data suggested that people that are asymptomatically infected seem to have a much lower secondary attack rate than what people
that are symptomatic or pre symptomatic do. So that sorts of suggest that people that have you know, basically mild or asymptomatic infections likely are going to lead to lower numbers of infections based on the amount of virus that they release as compared to people that have more moderate or more severe symptoms. But there's also kind of a converse to that when we think about this idea of
people that are severely ill. I certainly know that that people that are severely ill may have a longer period at which they're able to release infectious virus, But the likelihood is also that those severe disease cases are probably
also going to be hospitalized or receiving care. So the likelihood is that those people that are severely ill, even though they're releasing a lot of virus, are probably not going to be, you know, in a position where they're going to be exposing a lot of additional people in public.
So again, I think we get back to this phase of saying that somewhere, you know, kind of in between, you know, people that are mild to moderately ill and kind of looking at the viral loads from the data that we have in that kind of primary infectious period, it probably still follows that, you know, somewhere again in that zero to five day range that people that are moderately ill or mildly ill probably are going to have the greatest ability to release virus during that period.
That makes sense. So overall, we're now like a full year into this or even longer, and we've got a much better picture of the spectrum of disease that SARS covid two can actually cause, like you mentioned already, from
asymptomatic infections to very severe or even fatal outcomes. So could you walk us through a little bit this spectrum of disease in terms of symptoms or clinical observations, first talking about like how many people really are asymptomatic, and then what a mild infection looks like and what moderate or severe cases are like, Like what proportion of cases are we talking about that are very severe versus mild versus completely asymptomatic.
Sure, so, as you mentioned, we have a much greater understanding of the clinical syndrome that we see now, and I think that you know there are very various definitions out there for patients who are infected, and you know, some of these criterias may overlap or vary across the different guidelines that we see, but for the most part, you know, when we talk about patients are asymptomatic or pre symptomatic, these are people who test positive for socoby
two via the nucleic acid amplification test or amagen test, but they have no symptoms consistent with COVID nineteen. And then the next step up that we would consider patients who have mild disease, and these are people who have you know, various signs and symptoms of COVID nineteen.
So these are the very non specific symptoms.
So patients who could have fever, cough, headaches, muscle aches, nausea, vomiting, diarrhea, and then loss of taste or smell, which has become one of the characteristics that we see with this viral disease. But typically these people don't have any shortness of breath,
they don't have any abnormal chest imaging. And then the next stage of disease that we tend to see are people of moderate disease, and these are people who have some lower respiratory disease on their critical assessments imaging, and they may have a little bit of hypoxia or low
oxygen saturation on broom air. The next severity of disease would be what we call severe illness, and these are people who have an oxygen saturation less than ninety four percent on room air, and they might be breathing pretty fast, so they're breathing greater than thirty breaths per minute, and they have pretty significant longonful trips. And then the most severe illness is going to be what we call critical illness,
and these are people who have respiratory failure. These are the people who are intubated and have multiple organs involved.
With their starchcobe too.
And I think, you know, we're still getting a idea of the number of people that are asymptomatic presymptomatic versus those who go on to develop critical illness. You know, last reports are estimate that about thirty percent of people have asymptomatic pre symptomatic infection. However, you know, we are still learning more about this disease than what percentage of the people have asymptomatic disease versus go on to develop moderate to severe and critical illness.
Yeah, so the symptoms, like you mentioned, there's this huge spectrum of disease, and you know, how much do these symptoms or the general course of disease, how much does that vary from person to person, Like how predictable is this virus.
Well, there's lots of things that go into determining how a person is going to respond to getting this disease, right, So we know that underlying co morbidity play.
A huge hole.
People are who have things like cardiovascular disease, chronic lung disease, diabetes, if they're obese, if they have chronic kidney disease, those types of things, you're going to put them at higher risk to having a more severe disease. Additionally, we know that if you're older, that's going to put you at higher risk. So some of the data from the sea showed that if you're eighty five years or older compared to someone that's five to seventeen.
Years old, you have an eighty times higher.
Risk of being hospitalized and over seven thousand times more likely to die. So it's you know, significantly higher given your age compared to someone who's younger. So there's so many different modifying factors that you have to look at when you're looking at how a person's going to react compared to another person.
So kind of along those lines, while a lot of people who become infected will have their symptoms resolve within a relatively short period of time, it seems that others are experiencing much longer term issues with lung performance or even kind of a fogginess. Can you talk about some of these lingering effects of infection and how frequently they seem to occur.
Yeah, that's a really great question, and it's another aspect of COVID nineteen that we're still learning about. It's what we call long COVID now, and it's really not known why some people's recovery is prolonged.
You know, it's not sure if it's related to.
Persistent byrnia due to a weaker absent antibody response, if
it's related to some other inflammatory or immune reaction. So we're still learning about it, but a lot of what we're seeing our long term respiratory, musculo skeletal, and neuropsychiatric sequalae in some of these patients, and it's occurring in about ten percent of people who've had COVID nineteen and many of these patients recover spontaneously, but it takes a long period of time with holistic support, rest, symptomatic treatment,
and gradual increase in activity. And you know, these patients will require some focused assessment, you know, So if they're having prolonged shortness of breath, really trying to do some focused assessment on their respiratory functions, so looking at things like pulmonary function testing, more focused imagings, pulmonary rehab. If they're having neurological symptoms, maybe doing some for their brain imaging,
neuropsychiatric testing. And again, like I said, holistic support, a lot of focus is now going into trying to understand why these things are happening and how we can better support these patients.
Gotcha, Yeah, So how much has our estimate of the case fatality rate changed over the course of this pandemic and how much of that is due to you know, better testing ability or is it also you know, being able to actually treat some of these cases or provide supportive care. So can you talk a little bit about sort of this case fatality rate and what goes into it?
Sure, So I think this is something that we're also beginning to get a better understanding of I think it's really important to understand the difference between the infection fatality ratio, which estimates the proportion of debts among all infected individuals, and the case fatality ratio, which estimates the portion of
deat some monk identified confirm cases. So to measure an infection fatality ratio accurately, we need to know the complete picture of the number of infections and that's caused by a disease, and so in the early stages of a pandemic, most estimates of fatality ratios are based only on the cases detected, and so it can be underestimated. And so I think as we've gone along, we're identifying more and
more cases and through better testing and better surveillance methods. However, I still think, you know, we have to continue to do more testing, and because there may be asymptomatic cases out there that we haven't been detecting and testing for, we still have some work to do to further identify them.
So I think we're doing a better job, I think we still have some work to do for that.
And so you kind of talked a little bit already about how we know that there are some people who are at higher risk than others, even though we know that no one is entirely safe from this virus. Can you talk a little bit more about some of those risk factors that seem to be associated with severe infections? And I've heard things like is there any link between blood type and risk of infection?
Things like that, Yeah, you know, from my standpoint, I mean, I think doctor Capaly, you know, kind of touched on some of these, but from kind of a uniquely you know, Canadian aspect. I mean, one of the things that we certainly have been very i think awakened to throughout COVID nineteen was just how much age has played into severe
and fatal disease. Certainly, when you look at at our fatality rates, we have a massive over representation of people that are seniors and people that are above the age of sixty five, in particular of those that are in long term care facilities and in personal care home. So certainly I think we're getting quite the perspective on the
role of age. But then of course we look across different groups, we certainly see that much like with other you know, emerging effects diseases, that there's a disproportioned effect in UH certainly in minority groups, UH, in people that are in lower socioeconomic status.
People that are in underserved communities.
So I think it certainly is open to gain our eyes to the fact of, you know, the differences in how UH effect diseases, you know, really affect different segments
of our population. And then of course we look at the underlying you know, kind of medical complications that are related to this, whether we look at somebody that has cardiovascular disease, or we look at people that you have a a high BMI or who are you know, obese, or those that have diabetes, those that have you know, are you compromised, or positions uh, you know, such as those that have cancer. I think we certainly realize more and more that there is a broad spectrum of people
that are susceptible to to severe disease. And yes, we have an overrepresentation of people that are seniors, but we cannot discount the people that are overrepresented across other groups as well, and I think that's going to continue to expand. I think certainly as we start to go through the data more and more from from across different countries, I think we'll get a better perspective of how that looks.
And again, in particular within minority groups, you know, what the particular risk factors UH may may have have also been within there that we think about this idea of blood groups. I mean, certainly, you know, there was quite a bit of discussion, and there was you know, this
discussion that you know TYPEO was related to less spear disease. Well, there's been some additional data that's come out fairly recently that has said, you know what, there isn't Actually it doesn't There doesn't appear to be a link between this. So I think we're still trying to figure out what all the data says. Certainly there are standouts that we know are related to more severe disease and worse outcomes.
But I think it's the you know, these kind of more finite symptoms and finite biological factors that we still have to spend some time trying to understand a little bit more deeply.
Yeah, and so what do we know even though it's sort of even though there might be a lot more to uncover as the pandemic goes on and as the data are analyzed and so on. But at this point, what do we know about pregnancy and infection with COVID nineteen. Are there risks and do the risks vary depending on when during pregnancy somebody may be exposed or infected.
So that's a really wonderful question. You know, the full impact of infection with stars COVID two in pregnancy is still being learned and being understood. We know that pregnant women with coronavirus disease are increased risk for severe illness and they may be at risk for preterm birth. There
are definitely some surveillance systems out there. One of them is the CDC has a Surveillance for Emerging Threats to Mothers and Babies network that has been collecting data looking at a pregnant women who have COVID nineteen to see what happens to women who are infected and their babies.
You know, one of the things that have been discussed is that you know, if women who are pregnant are hospitalized for COVID nineteen, they should be definitely monitored closely and be at a facility where they can.
Have the highest level of care.
We know that they should be given a multi specialty approach to care with maternal fetal medicine ID PALMARY critical care. Also, the most recent NIH fidelines also recommend that, you know, any of the therapies that we would use and non pregnant women should be also given to pregnant women to help treat them appropriately. So you know, in terms of any of the other data, you know that data is
still being collected and being looked at. But other than the pregnancy data that shows that they might be at risk for full preterm birth, we're still learning about.
It makes sense, so we know that it appears that people who recover from COVID nineteen do have at least some immunity to the virus that lasts for at least a few months. Do we know any more about the duration or kind of the nature of immunity and the risk of reinfection, especially in light of the new variants that we're seeing.
Yeah, I think we're starting to get some perspective on that, right and certainly doctor Florian Kramer and others.
Have have really led the charge in trying.
To take a look at what this looks like. But we have to I think, first of all, we have to maintain some perspective that you know, we're fourteen months, you know, roughly fifteen months I guess now posts SARS CoV two emergence. So our understanding of long term immunity is pretty limited. When we think about even those first cases from China that you know that ended up in the hospital and then recovered, you know, the data is longer term, but it's I wouldn't necessarily call it long term.
So I think, you know, we're still certainly an infancy and understanding that. But right now, it looks like for the most majority cases that we see, there's at least you know, good memory within the immune system out to around eight months post infection. So certainly in regards to antibodies directed against the virus, it looks like those are
maintained for longer periods of time. It looks as well, like T cell responses that that other aspect of our immune system, our longer term immune system and our and our immune memory also is maintained for you know, all boards of six months or longer. So I think it gives us a picture that, yes, there certainly is some aspect of immunity that that appears to be carried long term.
The difficulty in this is try and understand how that relates to susceptibility to subsequent infection, and whether or not we see any sort of immune waning, and of course how that looks across the population. Is it the same in seniors as it is in somebody that is in a middle aged group versus somebody that is, you know, nineteen or younger. And I think we're, you know, game
what We're trying to see what that looks like. And that's been one of the drives to try and promote vaccination because at the very least we understand that people that are getting exposed to vaccine, that are getting exposed to a constant amount of viral anagen or a constant amount of the particular gene that we're using, that they will get a robust response that's maintained certainly with the variants.
That's added a new variable for us. Right when we look at data coming out of out of Brazil, in particular the data that came out of Matos Brazil, there has been a lot of question about, you know, what was the potential for reinfection with the P one variant of that was first identified there or with Wistar's CoV two in general, and does some of the kind of high burden we've seen of disease in subsequent waves within
that area. Does that suggest that there is immune waning after a certain period of time and that's why we have seen such high amounts of infection even though there seemed to be a high serial prevalence within the population. That would suggest that a lot of people have been infected early. And I think we don't specifically know yet, and that's what makes it difficult.
Certainly.
I think, you know, we're probably looking at you know, reinfections that again or not, they're more the exception not the norm at this point for regarding the data that we've seen. But we're also at a point of saying we don't really want to test that hypothesis. So if we can try and cut transmission and we can get people vaccinated, the likelihood is that we're probably going to see lower numbers of new variants that are going to merge because there will be no ability for the variants
to merge if transmission is cut. And we suddenly reduce any concerns about that question.
M Yeah, fingers crossed that that the immunity will Yeah, So throughout this pandemic, how has treatment for people with COVID nineteen changed. Are we any better at treating people with severe cases now than we were, you know, a year ago, or eight months ago, even six months ago.
Yeah, So I think that's another really interesting question. So I think a couple of things have happened. One, I think we are better at treating patients, and I think we have a couple of therapeutics that help. So let me tackle the first part of that question first. So, I think that in terms of how to support patients who have critical disease, we've gotten better at managing them.
When we first sorted seeing these patients who had significant disease that were intubated, we had a difficult time managing them. And I think throughout the course of this pandemic, our really wonderful critical care doctors have really gotten used to being able to manage them.
Right.
So we have intubation protocols, we have chemical ventilation protocols, we have protocols for proning these patients, which I think has really helped in how we manage them. And the support of care and managing these patients have really become protocolized, which has helped in terms of.
Improving the care for these patients. Concominantly, we definitely have.
Information for how to treat these patients. So, you know, we have a couple of therapeutics that may help, right, So, we have form decipear that has been the only therapeutic that has been approved by the FDA for the treatment of COVID nineteen that is recommended to be used in hospitalization of a patient. We have dexithi zone, which was found to improve survival in hospitalized patients requiring oxygen and having the greatest effecting patients who are ventilated.
So those two therapeutics are.
Pretty much routinely given now to patients who are hospitalized. So I think it is a combination of things. On top of that, you know, we have when patients are hospitalized with severe COVID, it's not uncommon that we find them to have super employed bacterial infections, so making sure we appropriately manage those infections as well. So I do think it is a combination of things that have happened
over a period of time, you know. But that being said, you know, these patients still become critically ill and can be very difficult to manage, and they have numerous complications throughout the course of their hospitalization, and so we still have a long way to go in trying to figure out how to more effectively treat this disease.
Yeah, that makes total sense. So a lot of kind of the very positive news that everyone's talking about with COVID nineteen has really focused on these new vaccines that we have. So, speaking of these vaccines, what do we know at this point about these different vaccine candidates in terms of their effectiveness against new variants that have emerged, And what does it really mean if these vaccines are in fact slightly less effective again some variants than they are against others.
Yeah, such a great question. Right.
So, you know, we're in this period of I think, kind of the intense optimism because the vaccines. Not only have you had a single vaccine that has looked amazingly well, we've had multiple vaccines developed within the span of you know, twelve months or just around twelve months that all seem highly efficacious, and that certainly has I think, kind of renewed the sense of optimism. But we have this new variable with variants that have emerged and ones that will
potentially subsequently emerge. You know, our understanding of how the vaccines behave in regards to the variants, is still you kind of growing right, So we have we have some inference at least from looking at antibodies from those that have been vaccinated that would suggest, you know, that most of the vaccines seem to have decent neutralizing activities of the anybodies that they generate still seem to be able
to neutralize the different variants. The B one three five one variant that that was first identified in South Africa certainly has created some issues. It has been the one I think that that everybody has been quite focused on in regards to this idea of anybody escape. But you know, I think we have to also look at what we're seeing in terms of real world data right now. So Oxford, as for Zenica, their data at least with the one
seventeen or one one seven looks quite promising. They still have you know, I think it was what seventy five percent fac rate, And as well, we're seeing real world data coming out of the UK where administration of Oxford's vaccine has really made a massive reduction in or led to mass production in transmission in cases. So I think you can make the argument that even in an area where B one one seven is is circulating. We're actually seeing a great benefit at the population level of the
Oxford vaccine. Same thing for Pfizer that gained real world data from the UK also would suggest that that we're seeing, you know, really good effectiveness within the population. Maderna, I think there's some data certainly to suggest that that in regards to anybodies that there are still is neutralizing anybody that is there, But we don't know the efficacy yet
in the population. And Novavax, you know, and Johnson and Johnson certainly when we look at B one three five to one, they have had lower reported efficacies against that variant. But again I think we have to, you know, kind of move ourselves back a step and say, okay, when we think about the variants, what have we seen in
regards to transmission in the community. Certainly B one one seven has been a concern because the increased transmissibility has led to a broad distribution and overtaking of circulating strains B one three five to one. We haven't necessarily seen that. Certainly in South Africa it has been an issue in an ongoing issue. Here in Canada, we've had cases, but we certainly haven't seen the explosiveness that we've seen with
B one one seven. So I think again with the vaccines, the more that we can get these vaccines out, all of which seem that at least so far have some capacity to reduce transmission to some extent, that will help us with control of these variants. And I think that's the important factor, is if we want to try and push back the experience, if we get people vaccinated, we're going to reduce transmission, and that really, to me at least is one of the most critical factors at this point.
M M.
Yeah.
So one of the early concerns about the vaccines was that they may not prevent asymptomatic infections. So maybe if you were even still fully vaccinated, you may not get the disease, but you could still spread the virus to other people. But you know, it's a few months now since these vaccines have been implemented widely. What do the latest studies show about that?
Yeah, the data I think is suggesting that, certainly for Oxford is as well as a leave for Pfizer, that they have been able to show that there's been at least some evidence for reduced transmission. Just looking at at, you know, the amount of virus within the nasal passage within people that have been vaccinated and subsequently had been exposed.
So I think it's kind of a good news storm, right, but also at the same time it should, you know, kind of not maybe becomes that much of a surprise that if we have vaccines that ultimately are able to protect against severe and fail disease, so you know, they take that severe disease down to something that is more moderate or even in some cases down to a very very vile disease, that period of infectiousness is probably going
to be fairly limited. And I think that that also probably plays at least some component into this, And so I think it's it's important for us to understand that, you know, there are the vaccines. While initially I think we were all hopeful that they would just at the very least cover severe disease and protect us from that, now we're going to more data to suggest that in fact, they likely reduce transmission and hopefully that that will impact
and lower rates of asymptomatic transmission. And I think again in the real world settings where the larger vaccination campaigns have occurred, we're seeing that play out. Certainly we're seeing transmission rates and cases dropping substantially, very very quickly, and I think that's very reassuring.
Absolutely, that's what I wanted to hear.
Yeah, so as the light at the end of the tunnel gets closer and closer, even though it sometimes doesn't feel that way. What is something that you hope we take away from this pandemic, either at a personal level or you know, as a society.
I think on a personal level, one of the things I will take away has been my appreciation for the amazing collaborations and friendships I've made across the country and across the world because of this pandemic. I've made friends with people that I probably never would have made friends or collaborations with because of this disease, and I think that that has really been an amazing opportunity for me.
So I think that's something that I will cherish. And I think also really speaks to the power of science when things get really bad, you know, seeing how the world comes together, and I find that to be very humbling and very special. From a societal perspective, I really really hope that people will take away the importance of investing in preparedness, investing in the global health security agenda.
We have a very short attention span, and when things happen, we get up in arms and say we're going to do something, but then as soon as it's done, we forget. And I really think that if this pandemic has shown us anything, it's that we do need to invest in preparedness. We need to invest in strengthening healthcare systems, we need to invest in surveillance. And this can't be a one
time thing. It's something we need to do longitudinally. And I really hope that as a society we can put our differences aside and recognize the importance of doing that.
So that when.
The next infectious disease's outbreak comes along, and it will, that we will be prepared and we will be ready, and that we recognize that this is a global threat, not a threat that affects certain people, certain races, or certain ethnicities, that this is something that affects all of us.
Yeah, and you know, I think I would compliment a lot of what said doctor Pauly said. I mean, certainly from a personal standpoint, I much like herself what it was involved in in the Bowle epidemic in West Africa. You know, there's an aspect of it that I think for both of us and all those that I know that that were involved in in that outbreak as well as other outbreaks.
It certainly it changes you.
It changes your perception and your viewpoint on infection diseases, but it doesn't necessarily impact your family and the people around you, And that certainly is something very different. I mean for me with you know, with a young family, with a you know, a two and a half year old at home. This was one of those kind of first instances where there was the question of what is going to happen, you know, what is the world to war going to look like as we go through the pandemic.
But but doctor Capouli said.
It very well that there was this immediate response with with people across the globe that certainly I would have never been in contact with had it not been for COVID, and I think it really energized all of us and certainly made us feel as if there is a global community that is working together at a moment's notice to try and come up with novel answers and novel techniques and diagnostics and vaccines. And therapeutics to fight back against
infection diseases. So there's that aspect that I think a
personal standpoint has changed me from a broader perspective. As much as I'm an optimist, there's a pessimistic side because I look at COVID nineteen and I think, is this going to be the thing that finally changes global perspectives on how we deal with emerging in effects diseases or is this going to be the same as post stars and post two thousand and nine pandemic flu and post ebola, Where yes, our attention span is opened for a few months or a couple of years, but then the interest
drops off outside of the research community and more so within governments in funding communities, And that's concerned for me. I think we have to appreciate that when we look at emerging affects diseases, these diseases disproportionately affect low and middle income regions of the world and emerge in those regions.
Our preparedness and our ability to deal with these as a global community is going to be reliant on ensuring that we have basically the safety nets and the early warning systems, not only in our own countries, but more so within those regions where we know these diseases are going to emerge from. To increase our preparedness, and we have to be prepared to work with locals within those areas.
So I hope that this will change things. I hope that there are enough younger voices in the generations around me and the generations below me that have been invigorated by this and want to instill change so that there is actual change post COVID.
Thank you so much, doctor Kupali and doctor Kindrichuck for taking the time out of your schedule to talk with us. That was an amazing conversation.
Oh my gosh, so much information. It was incredible. We covered so much ground.
We really did. So let's, as always go over the five most important take home points that we learned, shall we.
Let's do it all right?
Number one, Well, there are still some unanswered questions as per usue about what the infectious of virus might be in this case. One thing that has become clear is that exposure time is a really important indicator of risk, So not just how close you might be standing to somebody, but also how long are you in contact with people and in what context, like are you indoors versus outdoors. Do you have good air circulation versus very poor circulation,
all those sorts of things. We also know that the majority of people will start to show symptoms about five to six days after infection, but they're contagious to others starting about two days before symptoms appear, and this infectious period lasts for at least ten days, So that means that as early as three to four days after exposure is when somebody could begin shedding virus even before knowing
that they're sick. And I think that really highlights why and how masks, which we know are so important, have become such a big component of risk mitigation in this pandemic, since they are what's preventing us from exposing others even early during infection when we don't know that we're sick.
And while some data suggests that people who are asymptomatic or in that kind of pre symptomatic phase might be less contagious than someone who is symptomatic or like severely ill, if behaviorally those people are walking around interacting with more people, then they might be actively infecting more people than people who are severely ill, even though those are the ones shedding more virus because they end up hospitalized with their infection.
Yeah, and number two, speaking of asymptomatic versus pre symptomatic, this is a conversation that has gone on throughout the course of this pandemic, and truthfully, we still don't have a perfect handle on what proportion of cases are truly asymptomatic versus those who test positive without symptoms but then go on to develop symptoms a few days later, which
is what we would call pre symptomatic. Overall, about thirty percent of people that test positive fits somewhere in this category, so they are testing positive for SARS COVID two without having any active symptoms. We just don't know exactly how
many of those go on to develop symptoms. And speaking of symptoms, we know a lot more now about what exactly they look like, and there is a huge range of symptoms from pretty mild and nonspecific, aside from like a loss of taste and smell, which is one of the few kinds of like hallmark symptoms of COVID to critical disease involving multi organ failure. And while age is a major risk factor for disease severity, it certainly isn't
the only one. And we've seen even young and otherwise healthy people become severely ill and die from COVID.
Yeah, number three long COVID. So this is a phenomenon that we've recognized now that this pandemic has been going on for over a year, and it's causing persistent, in some cases, pretty debilitating symptoms long after someone was initially infected with the sarskov two virus, and in some cases symptoms are reappearing even after someone seems to have recovered completely.
It seems like about ten percent of people, and I have actually heard even higher estimates on some other news sources, are experiencing things like neurologic problems, which can range from brain fog to severe psychiatric changes or muscle weakness or persistent lung and breathing problems, really long term effects, and this is it's a lot more common than I realized, Aaron, Yeah,
for sure. Yeah, And people who are experiencing this can take a very long time and need quite a lot of support and symptomatic treatment to actually get to a point of full recovery. At this point today, we still don't know exactly what the cause of this is, whether it represents like a persistent viroemia, so someone still has virus infecting them, or whether it's some kind of immune inflammatory reaction. We're still trying to understand why and exactly how this is happening.
Yeah. Number four. There is kind of good news though, in that immunity does seem to last for some time at least, but just due to the nature of this being a brand new virus emerging for the first time, like just over a year ago, we still don't have long term data on this, and when it comes to new variants and their ability to evade our immune responses and reinfect those who have already had COVID. While this is definitely something that's concerning, we do have ways to
prevent it. So cutting down and slowing transmission as much as possible is going to ensure we don't test the limits of immunity, and this will also help prevent new variants from emerging, since less transmission means less opportunity for viral mutation.
Number five. Finally, the best news of all is that we have multiple highly effective vaccines, which is truly incredible.
It really is.
Yeah. In the US as of today, which is March twenty fifth three vaccines are already licensed and being distributed. Several more are being used across the globe, and while some of these vaccines do seem to be slightly less effective against some of these newly emerging variants, it also seems as though these vaccines not only prevent against disease but also have the capacity to reduce transmission, which is thrilling. This is still an ongoing area of research, but the
data are really promising. It seems as though some of these vaccines might be helping to reduce infection, not just disease from infection, and even in the cases where they might be a little less effective at preventing infection, the role that these vaccines play in reducing disease severity and shortening a course of illness likely plays at least some role in reducing the likelihood of transmission. Since we know that infectiousness seems to vary with the course and severity
of disease. This is really really great news because, like we've mentioned several times throughout this series, reducing transmission and spread of the virus reduces the likelihood of new variants emerging, not to mention less people getting sick and dying. It has been a very very long year full of so much heartbreak and unbelievably depressing news, and we have spent a lot of time in many of these COVID episodes
kind of really focused on all the bad news. So it's really nice to be able to end this episode with some real, actual light that seems visible in this dark tunnel that we're all in.
I know, the light at the end of the tunnel does still seem far away, but it does.
I feel like it's getting closer though, I hope.
So maybe it's just that good news takes longer to sink in than the bad news.
Yeah.
Well, this was such a great interview. Thank you again so much to doctor Capoli and doctor KINDRICHUK for taking time out of their schedules to chat with us.
Yeah, thank you so much. And thank you again to the providers of our first hand accounts and to everyone who has sent in your stories. We really appreciate it.
Yes, and thank you to Bloodmobile for providing the music for this episode and all of our episodes.
And thank you to the Exactly Right Network, of whom we're very proud to be a part.
And finally, thank you to you listeners for listening, We really appreciate it. You allow us to keep doing this thing that we love to do, and so we are forever eternally grateful.
Yeah. Yeah, we would never be able to make even our regular series, let alone this COVID nineteen bonus series if it wasn't for you all listening, So thank you.
Yeah. Well, until next time, wash your hands, you filthy animals.
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