COVID-19 Updates

It’s Like a Code Red Hospital Alert

Gregory A. Poland, MD; Halena M. Gazelka, MD
The worst thing we could do is become indifferent to new covid variants. Learn about the Lambda variant and how it’s hurting the one population that used to be safe: children.
8/30/2021
Infectious Disease
GIBLIB

–Mayo Clinic Q&A–

I'm Dr. Halena M. Gazelka. We're recording this podcast on Monday, August the 9th, 2021. The ongoing surge of covid-19 in the United States is prompting action. All 50 states are reporting rising vaccination rates. But there's still work to be done as we race against the Delta variant and try to stop other variants from developing. 

Dr. Greg Poland is here again this week to discuss this with us, give us some updates, and answer plenty of questions from our listeners about vaccination. Welcome, Greg. 

Dr. Greg Poland: Thank you, Helene. A lot has happened in the last week, and I hope we get to talk about it.  

Dr. Halena M. Gazelka: Wonderful. We are so glad to have you again. All of our listeners know that Dr. Greg Poland is an infectious disease expert at Mayo Clinic who specializes in vaccines and virology. Wonderful to have you here; give us strength. 


WHAT’S GOING IN? IS THE COVID OUTBREAK GETTING BETTER OR WORSE?

Dr. Greg Poland: Well, lots happening, as you mentioned, Halena. We're now having over 100,000 cases, new cases of covid a day. Just at the end of June, we were at about 10,000. So this is a tenfold increase. We have about 63,000 in the hospital with covid in the U.S. as of Friday. So those numbers should give you some sense of just the overwhelming surge that's happened. And those are just the ones sick enough to be identified. So you understand just how big this is with the Delta variant. 

Dr. Halena M. Gazelka: Right. And now, Greg, I have seen something in the news yesterday about the lambda variant infecting individuals in the United States. What do we know about that?

 

WHAT IS THE LAMBDA VARIANT, AND WHY IS IT HERE?

Dr. Greg Poland: Yeah, the lambda variant is an interesting one. It's unclear at this point whether this will overtake Delta the way Delta overtook Alpha. But basically, Lambda has a set of mutations that do two things that make it a bad actor. 

One is that it increases viral infectivity just the way Delta does. But it has a second characteristic, a little bit like Delta but worse, where it can evade neutralizing antibodies. So, in other words, you get previously infected with covid, or you get vaccinated with covid, now you get infected with LAMBDA. 

Why do you get infected? Because it can evade those antibodies that you have, whether it's from vaccines or infection. Not 100 percent evasion, but we don't know exactly how much evasion can occur. 

And what this illustrates is what you and I have talked about really over the last year. Frankly, my message today to the public is a term you and I recognize in the hospitals, and that's code red. It is code red in the U.S. and for the globe in regards to these variants. 

And there is immense concern that we are on the verge of developing ever more infective and virulent variants that could escape completely or in large part from previous immunity, whether from infection or vaccines. So I hope our listeners really get that message. It is code red. We need to get everybody vaccinated as quickly as possible. 


WHY LAMBDA IS WORSE THAN THE DELTA VARIANT

The other thing that is really sad for us as health care workers is the number of children and young adults now getting infected. Last week, 72,000 kids were infected with covid. Now, that was not happening with the previous variants, but the viral titers in the infectivity of the Delta variant are so high that even kids who had mostly escaped the ravages of covid are no longer the exception. 

The Ochsner medical system has over 800 kids hospitalized. One of my colleagues down in Houston is saying they're now airlifting babies out of Houston to other hospitals because they are full. This is nothing to play around with. This is a serious variant.

Dr. Halena M. Gazelka: Quite concerning as we're sending kids back to school. 

Dr. Greg Poland: Well, you know, that's another thing. You look at where this is happening. This is happening in the context of kids going back to school, sometimes in states that are trying to outlaw the use of mass, which is just inconceivable. 


LARGE GATHERINGS: KIDS HEAD BACK TO SCHOOL, ADULTS START LIVING AGAIN

If you look at the Netherlands Music Festival Festival that just occurred, they had 20,000 people over 2 days. They're already able to trace over 1,000 infections. 

Look at what happened in the U.S. The Lollapalooza concert in Chicago going on right now, where they think they'll have an estimated 700,000 people get together. And in an environment where, unfortunately, much of America has been misled into thinking that the pandemic is over, and mask mandates and distancing is over, nothing could be further from the truth. 

We are, as we have talked about, in the most dangerous phase of this pandemic to date. 

Dr. Halena M. Gazelka: And vaccination rates are going up. Is that correct? 

Dr. Greg Poland: They finally are a little bit. In fact, if you look at it, 50 percent of Americans are fully vaccinated. And when you look at adults, just adults, 70 percent have gotten at least one dose. 

But think of what that means. We've had these vaccines since December/January, and yet only 70 percent have gotten at least one dose, meaning 30 percent have not even gotten one dose. And it's very unfortunate, getting through to those individuals with credible information and data has proven to be incredibly difficult, if not impossible, in a number of cases. 

 

A POPULATION-WIDE TRAGEDY

Dr. Halena M. Gazelka: I got a text saying that the Minnesota Department of Health is offering one hundred dollars (yeah) for individuals who will go get their first vaccine if –

Dr. Greg Poland: – they have it. I mean, this is desperation. How do you save the public from itself? Some governors this is not my approach, but some governors are saying, well, they're just going to have to pay the people who will die, who cannot get this message and cannot believe it. 

And just take a glimpse at the news. You see article after article of people pleading for the vaccine once they're intubated or dying or are begging their family to tell everybody we were wrong, we were wrong about this. People who were mocking vaccines and masks are now dead of covid. It almost makes you feel beside yourself because you're watching a population-wide tragedy occurring, and yet can't get the message across to people. 

Dr. Halena M. Gazelka: And I think this has been psychologically difficult for some as well. I was talking to some colleagues at a work event, and we were saying how very difficult it is to grapple with the fact that we are just opening things up. 

We had just been told, “Oh, you don't need to necessarily wear a mask.” And now, by opening up, some of those restrictions are probably going to need to be imposed again. And now, it’s certainly advisable to wear masks, as you said.


BURNED-OUT DOCTORS

Dr. Greg Poland: You're right, and I felt very badly about it over this last week. I talked to a number of colleagues around the U.S. who are basically calling it quits. They said, “I've worked 14, 16 hour days for 18 months. I'm risking my life, and the public doesn't care.” 

They're just calling it quits, which will make the problem worse. That's no solution. But they're literally so burned out from overwork and the inability of the public to grasp this simple message. 

Dr. Halena M. Gazelka: Greg, some of our incredibly astute listeners have sent us questions, and there's one that I think has come up over and over, I've heard it in the media as well. 

This person says, “I know several individuals who became ill due to covid during the initial wave, and they are refusing to get vaccinated based on their assumption that they are now immune to all of its variants. Are individuals who have had covid better protected by also being vaccinated, and therefore they are less likely to put others at risk?”


QUESTION: DO I NEED TO GET THE VACCINE IF I’VE ALREADY HAD COVID?

Dr. Greg Poland: Yes, so let me give the punchline and then go through the data. The debate is over. People who have previously been infected do better if they get vaccinated. Now, why? The controversy's first study out was the Cleveland Clinic study for which they've now issued a clarification. 

They looked at health care workers who had previously gotten vaccinated and then followed them. They did not do prospective PCR swabs. So they only know about the people who happened to come back. That's a major limitation of that study. The other thing is that these were younger individuals, the vast majority of whom had asymptomatic or very mild disease and who were employed in the healthcare field, not at all representative of the United States. 


CASE STUDY

And in that study, they did not find any benefit in immunity to vaccinating. Now, again, in this series, we have made it our dedication, our promise to speak very transparently about those data. Those data are in a preprint server. They have not been peer-reviewed. I don't think that study's going to get published without massive underlining of the limitations of that study. Why do they say the conclusion I did? Because we have two better studies. 

One is a small study. When you look at a group again, this tended to be health care workers in Chicago, Illinois. So they looked at people who had been previously infected, those who got a dose or two of vaccine, and those who didn't. 

Their baseline antibody titer was 621. If they had not gotten infected, they never got infected. Their baseline titer was 4. Right after one dose, the people who had gotten just one dose of the vaccine were not infected, their antibody level was 800. If they were previously infected and got one dose, their antibody level was not 800, but 30,000. 

What about after two doses in people who had not gotten infected? Antibody level was 15,000. People who were previously infected, up to 36,600. 


COVID ANSWER:

So these are real-world data that confirm, in my mind, that people who have previously gotten infected do better and have less risk of reinfection if they get immunized. Why would that be? One really simple explanation here. They're getting reinfected with Delta Variant when they got originally infected with the original variant. 

When you get a vaccine after having been infected, you dramatically increase the depth of your immune response such that the amount of immune evasion that occurs from Delta is overcome by those very high antibody levels. That's why they do better.  

Dr. Halena M. Gazelka: This individual has written to ask you: “I've seen some doctors on TV say that the immunity for those who are fully vaccinated is much more robust than for those who've actually been infected with the virus. But I've also heard the converse that doctors say that your immunity is better if you've been infected with covid rather than been vaccinated.”

Dr. Greg Poland: So it's a misunderstanding of terms. The antibody levels are higher in people who were previously infected and got fully vaccinated. The antibody response is, if you will, more focused in people who are fully immunized. What's not clear is do we see the same quality of that antibody in people who were vaccinated after getting infected? I think the answer is going to turn out to be yes, but there's still a little wiggle room or controversy there. 

So what makes this difficult is the variant. If they had gotten infected initially, and that was the only virus circulating, I think they'd be fine. But that's not what's happening. They got infected with another virus. They risk reinfection with virus B, which is much more contagious or infectious and has some amount of evasion in immune response. That's why bumping those antibody levels up in a very focused way with immunization boosts superior immunity.  

Dr. Halena M. Gazelka: But essentially the argument is a moot point, Greg, because any individual who is eligible to be vaccinated should be vaccinated. It doesn't matter if they've had covid. 

Dr. Greg Poland: Absolutely. Absolutely right.  

Dr. Halena M. Gazelka: All right. Our next vaccine question is for those who may be at higher risk, such as the elderly, and they received the Johnson and Johnson vaccine because that's what was available. It now appears that perhaps Moderna and Pfizer vaccines are more effective. Should and can those individuals get one of the Mirinae vaccines, and will there be advice about this coming from the FDA and the CDC? 


IS THE JOHNSON & JOHNSON ONE-SHOT EFFECTIVE AGAINST THE VARIANTS?

Dr. Greg Poland: This is a very fair question. Halena, in the face of the Delta variant, this was not an issue with the previous alpha variant and the original strain, but with the Delta variant, it's apparent that these vaccines are not that good at infection blocking. Now, they block infection about 50, 60 percent of the time. They block disease more in the 90 plus percent, Johnson and Johnson being a single-dose vaccine. 

There's some data out there suggesting that there may be less infection and disease-blocking ability, but this is a little unclear. Again, to be very transparent, no one knows the answer to the question that that listener asked. And, you know, the answer is literally “stay tuned.” A lot of work is going into trying to determine if there are differences between vaccine platforms? 

It's unclear right now. In fact, the only new recommendation I'm aware of is that we're getting close to, in the next days to weeks, recommending a third or booster dose in those who are immunocompromised. So, people who have pretty moderate to severe levels of immunocompromised, we will probably be boosting them. Whether that will then get expanded to the elderly is as yet unclear. 


SHOULDN’T UNVACCINATED PEOPLE BE QUARANTINED? 

Dr. Halena M. Gazelka: Next question: “If vaccinated individuals can spread the virus, even asymptomatically, why don't we have them quarantined? Presumably, if they test positive for covid, and I come into close contact with someone with covid-19, I could carry it and spread it to others. But I don't need to quarantine, I just need to mask fully to protect others around me.”

Dr. Greg Poland: The issue of doing vaccinated and unvaccinated, if infected transmit equally? Well, the guess is no, probably not. But that data, again, is not very clear. Some people have suggested that viral loads or viral titers in those two groups are about the same. Other studies have not suggested that. So it's a little unclear whether somebody who's asymptomatic is transmitting at the same rate that somebody who's symptomatic. I would empirically say no. If I'm coughing or sneezing, I have viral titers high enough that I'm symptomatic. 

What about quarantine? I think obviously, whether you have symptoms or not, and you are known to be PCR positive, then you are duty-bound to isolate yourself from other people so that you don't spread that infection. But I want people to understand this: it is not confusion or just changing recommendations for political purposes. This is the nature of science you and I are comfortable with and live with every day. 

Science changes. An immense number of eyes are on coronavirus, an immense number of people doing research. And so you're seeing this happen at the speed of sound where we're getting lots of different studies, sometimes with discrepant results, which happens in science. But you look at the trend and as the science changes, so should recommendations. And that's a good thing. It's evidence of taking in that science and reshaping policy based on new data. 

And what we're studying is changing. We have gone from the original Wuhan's strain to the alpha variant to the California, Illinois, and other variants to the Delta variant, now to the Lambda, Gamma, and Beta variants. So everything is changing while we're trying to study it. So a very dynamic situation, and everybody's doing their best to shape those findings into recommendations to the public that will keep them safe. 

 

SHOULD WE LET KIDS UNDER 12 WHO ARE UNVACCINATED GO BACK TO SCHOOL?

Dr. Halena M. Gazelka: Next question is back to school is a big issue right now, as we discussed earlier. So what about the kids under 12 who aren't yet vaccinated? Do you have any clue about when they will be eligible? 

Dr. Greg Poland: Yeah, this is a really good question. And, you know, all of us want to see this happen sooner rather than later. But what's happening is that the major studies looking at immunizing children under the age of 12 really got going in June. So, by the time those studies are done, by the time all the quality checks and safety checks are done, and the FDA reviews it, my guess is that it's going to be very late fall, early winter before we see that recommendation.

This is why it's imperative – I am not above begging parents – to please get vaccinated. Please get anybody in your family who's 12 and older vaccinated to protect those younger kids. And those kids, no question, need to be in a mask. 

WE HAVE FAILED EACH OTHER

Dr. Halena M. Gazelka: So I have a follow-up question from a listener on that, Greg. They have children who are old enough to be vaccinated and younger children who have not been vaccinated. They're planning to keep the younger children home and do distance learning until they can be vaccinated. 

They're curious what the risks of allowing the older children who are vaccinated to go to school is in terms of could they be bringing the infection home to their younger siblings. 

Dr. Greg Poland: So the reason I said that we are in a code red situation is, and I don't say this to scare people, but to give them a sense of what's actually happening. I called this. We are in a code red situation, so that means nowhere is safe. There is no safe. Now, all we have is safer

When you look at it that way, you realize even kids that are immunized that are going to be gathered in indoor settings should be masked, not only to protect themselves but those around them. You can never eliminate it but this reduces the risk of then infecting their younger siblings. 

And again, if anybody doesn't believe this, just go and look at data on major medical centers that are experiencing surges here in Tennessee. An 11-month-old baby died. They are airlifting children out of Houston to other hospitals. This is serious. This variant is a bad actor, and we need to take science-based precautions to protect ourselves and one another. You might have seen the headline on the front page of USA Today this past Friday. The headline was, “We Have Failed Each Other.”

AIR TRAVEL IN COVID

Dr. Halena M. Gazelka: Greg, our next question is about air travel. I was actually astounded by how busy the airports seemed to become almost immediately in the summer when the world began to open up again. And our next listeners are wondering, can you give any advice about air travel? What would you say? And they're also wondering about getting together in large groups when you don't know who's been vaccinated in that group. 

Dr. Greg Poland: You know, this is really hard. I feel like I've spoken so much about this to stop for years because people don't want to hear this. They emotionally don't want to hear this, and so they will grasp on to any piece of misinformation that supports what they emotionally want to do. Here's the science. Here are the facts in the middle of the world on fire with this highly contagious variant. My personal recommendation is to limit your travel to only that which is truly essential. Otherwise, you are adding risk to your profile. 

And we not only risk getting infected, but one of the things that are becoming clear is we risk infecting other people, including members of your family. There's one tragic story after another, with a wedding, a birthday get-together, a summer camp, whatever that might be, and the risks of so-called long covid, which are life-altering. So why wouldn't you protect yourself?

I would say no airline travel. I know I'll get in trouble with the airlines by this. But again, transparency is important here. No travel that is not essential. And you're wearing a can 95 mask. That mask stays on sanitizing your hands, you're distancing as much as is practical. And if you develop any symptoms, you're getting tested to find out if you got infected. 

Dr. Halena M. Gazelka: I think I know what you're going to say about this next question. But a family member told me that they were at a wedding this last weekend where there were 400 guests. And this individual has also asked us about getting together in large groups. 

Dr. Greg Poland: I guess a way to do it is to look at the outcome of somebody infected, getting hospitalized, maybe having to be on a ventilator or dying or even surviving it, but developing long covid. Now unwind that would you have said, yep, that was worth it? Or could we have done it outdoors? Could we have done it en masse? Could we have done it socially distanced? 

I think if you went into a wedding of that size and somebody you know, I'm not trying to be crass here, but somebody walked in holding a loaded gun. Everybody would attend to that risk immediately. And yet with something equally as deadly, we want to emotionally ignore it and say, well, I'm vaccinated. Well, I'm young, I'm healthy. Oh, I was previously infected, when the science doesn't support that as something that's going to keep you safe from infection.  

THE FUTURE IN COVID CONCLUSION

Dr. Halena M. Gazelka: Greg, what does the future look like? Are we going to do this masking and social distancing for every variant that comes along? And will we need a new booster for every variant that comes along? 

Dr. Greg Poland: Really, really good questions. Halena, I guess I didn't realize just how much this is affecting me. My wife said these last three days that giving vaccination instructions in my sleep. So, you know, my brain is grinding away on this. This is, again, absolute transparency. None of us can predict the future. So I don't really know the answer to the question.

What we can say is when we look over the last 18 months, we have, with a steady drumbeat, developed more and more worrisome variants. Most of us think more of those variants are going to come. Given that we have so many people ignoring vaccination and masking recommendations, I think it's inevitable. 

But I don't have a way of knowing for sure what we think is going to happen long-term because of the way we dealt with this as a society and a globe is, rather than eliminating this, which we had the opportunity to do and lost, more likely this will become at best something more akin to influenza that will always be with us and that we will have to regularly immunize against. Whether they'll have to be variant-specific is unclear right now. My guess is, like all RNA viruses, it will learn to evade vaccine-induced immunity. So we'll always have to be catching up with the virus with newer and more updated vaccines. That's my guess. 

CONCLUSION

Dr. Halena M. Gazelka: All right. Well, any last words for us today? 

Dr. Greg Poland: Yeah, you know, I did prepare something just briefly that I wanted to say. And that is, in this code red, public emergency, I would urge at least five ways that you can layer one after another to best protect yourself and yet live as normal a life as all of us want.

You know, we're not mean doctors sitting in an ivory tower thinking of ways to make life miserable for people. Quite the contrary. My desire is nobody ever gets admitted to the hospital with covid. No kid ever dies. No mother is ever lost from covid. So how can we do that? 

1) Listen to credible experts, not just people who are celebrities or politicians that you're attracted to, people who know the science. 

2) Get vaccinated. 

3) Wear a proper mask properly. 

4) Please limit your travel to only that which is essential.

5) Avoid crowds. If it's inevitable that you have to be around the crowd, stay to the periphery, wear a proper mask in order to best protect yourself. 

Folks, what you don't see and what we see is tragedy after tragedy, day after day after day. And there's no way for me to adequately transmit this. I help with research at a hospital down in Florida, which is a real hotspot. They went from 12 cases to 150 cases. They're intubating teenagers and putting them on ventilators. And the public has no awareness because, of course, we can't take cameras in there and show people in these families are devastated. 

And yet we keep feeling like we're trying to say the message over and over again, please, please take care of yourselves and prevent getting infected, sick and those around you. And it's doable, it's doable with these simple measures.  

Dr. Halena M. Gazelka: Very sage advice, Greg, thank you. 


To watch the interview, click here.

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