Kyle Allred, MedCram Co-Founder and Producer: Well, I'm thrilled to be here with physician, scientist, author, and professor, Dr. Eric Topol
who has been voted the number one most influential physician leader in the U.S. by Modern Healthcare.
He's published over 1200 peer-reviewed articles, three best-selling books, and he's now the Founder
and Director of Scripps Research Translational Institute. And, Dr. Topol, since the beginning of
the COVID-19 pandemic, you've been a prolific communicator about the science as it comes in,
and you have a large following, but also a very loyal following among scientists, because
they know you're an optimist who's forward- thinking, but you're also willing to
call anyone out at times -- big pharma, the federal government, the FDA. So I want to start with
an article that you wrote in the Guardian a few days ago, titled "America is flying blind when it
comes to the Delta variant." For people who haven't read this article, can you summarize the main ideas?
Dr. Topol: Sure. Well, first, Kyle, thanks very much for your intro, and really good to be with you.
Unfortunately, you know, we're confronting this, really, the worst challenge of the pandemic, delta,
and we are not prepared. We're not tracking the data. So in that piece, I talked about the
people who are in the hospital. There's over 70,000 with COVID right now in America. We have
no idea how many were vaccinated, when they got vaccinated, what vaccine, how old they are, their
co-existing condition. We should have all that data on a daily basis, as just the de minimis for
understanding what's going on with the dynamics of this delta wave, which in places like Florida
and Louisiana and many other places are really is having tremendous devastating effects. Kyle: How does
our surveillance and our testing compare to other countries? I know we're going through this
delta wave in a similar way to the UK and Israel. How does the U.S. stack against those countries?
Dr. Topol: Yeah, well, we have a problem because we're not testing. We're at less than a half of where we were
in the monster third wave, and we were insufficient then. We're less than a fifth of countries like
Israel and the UK that are going through the delta wave, you know, before us, so our testing
is grossly inadequate. So we don't really have a good handle on the denominator of cases out there
and so between the lack of trust, testing, and the lack of use of any rapid home testing,
we we don't have a handle on infectiousness and the kind of critical data
elements that we need to be in control, you know, to be able to have a real,
true assessment. Are vaccines working? How extensive are they working? What can we do to achieve best
practices, to get control and containment of this virus, again, as quickly as possible?
Kyle: Well, you mentioned rapid testing there, and we've had Dr. Michael Mina from the Harvard School
of Public Health on the show before, and he's of course a big advocate for rapid testing, as I know
you are. Why haven't we adopted this yet in the United States? And also could you speak to people
that have heard or read in articles that, you know, rapid testing is just not as accurate as PCR, and
so, therefore, we shouldn't use it? Can you kind of address that question as well? Dr. Topol: Really good point, Kyle.
Michael and I have been united on this front. He's been the the real champion. I think in
in recent times he just gave up, because it was you know hitting the wall, brick wall. The reason why it
hasn't gone forward and where every household hasn't been distributed a big set, an ample set,
of free rapid antigen tests that are so simple and so quick and make the diagnosis of infectiousness.
The issue about the lack of concordance with PCR is is silly, because PCR picks up any virus
remnants, virus copies, whereas what we're looking at with the rapid tests is "do you have enough
virus mass load to be infectious?" It's a totally different principle, and that's the guiding one. So
we could be so much more confident about schools, if we did this every day with each child and
teacher and staff and bus drivers. That's one way we could move forward. Many countries do this
frequently for free, whether it's Germany -- which, by the way, they have as much delta, 97 percent prevalent,
as we do and they haven't had any surge in Germany -- Austria, Denmark, you know. So many countries are
relying, Netherlands, on rapid tests, and we don't have them. I think, to your question, it was because
we had a vaccine-centric strategy that would have worked, and we would have full containment now,
but then came delta. Kyle: What do you think people, a lot of people, don't understand about
infectiousness of, you know, the delta variant, or SARS-CoV-2 in general,
with regard to, you know, this term "breakthrough infections." What does that really mean, and
how realistic is it for people to think that vaccines can create this, like, sterilizing immunity,
where people don't, you know, have any virus in their nose, and aren't able to spread it at all?
Dr. Topol: Your points are really important, Kyle. First of all, this term "breakthrough" is is pretty crazy, because
we knew that, when the vaccines were remarkable in terms of their efficacy from the large trials,
largest trials ever in vaccine history, they were 95 percent. So what do you want to call the five percent?
They were breakthroughs? I mean, they're not perfect, and the problem with delta is that imperfection
has been accentuated, and the reason they're not perfect is they weren't designed, expected to
achieve sterilization mucosal immunity. That would require intranasal vaccine which we haven't, you
know, put the foot on the accelerator to get those out there, and they're still in like
phase one early trials. So this was intended, these vaccines, to get prevention
of severe illness and illness. That was what the end point was: the symptomatic infections.
And they were quite good, better than expected, better than almost any vaccine in history for
that end point. But as you aptly point out, they were not expected to fully prevent spread. But
even though they did that pretty well -- again, until delta came on to the scene, and it's
a much more potent higher load virus with its infections, and that's what we are confronting now.
Kyle: I'm glad you mentioned intranasal vaccines. You wrote a great piece about that, I believe its
in the Scientific American. Could you explain that for people who are new to this concept?
Can you explain some of the advantages of a intranasal vaccine, especially with this virus?
Dr. Topol: Right. So with the shots we get in our bloodstream, we get, you know, IgG antibodies to various parts
of the virus, particularly despite protein. But we don't get long-lasting immunoglobulin A, the type
of antibody that we need in our nose and upper airway. We get some of that, but that's not what
it's directed. It's a blood-specific strategy. The nasal vaccine is for upper airway protection, which
is how this virus gets into us, and there you are going after mucosal immunity, and with this type of
antibody of IgA. So they are very complementary approaches, and had we had effective intranasal
vaccines and were using them widely -- I, by the way, I think they would be even more popular than shots --
we would really hopefully be able to squash the even delta, because that's where we're leaking,
in our nose, in our airway. That's where the spread and these cases
are happening among vaccinated. Obviously, most the vast majority are on the unvaccinated,
but, you know, the ones that are occurring as breakthroughs are people, because they don't have
mucosal immunity. Now, by the way, so they don't have enough neutralizing antibodies in their
blood either, many people. But what they do have is T cells and memory B cells that help protect their
lungs and their body from getting hospitalizations and deaths. So that whole principle is that your
cellular immunity would kick in even though your neutralizing antibodies would fade. That works for
real severe disease, but it didn't really work well for preventing these infections post-vaccination.
Kyle: So, in other words, a nasal, intranasal, vaccine, if one could be developed and
put out to market, could not only prevent, potentially, you know, severe COVID hospitalizations
and death, but also really help curtail the spread of the virus? Dr. Topol: Right, exactly. We had a pretty good
anti-transmission strategy until delta, but if we ever needed another one, whether it's a
universal sarbecovirus vaccine or intranasal or both, this is the time. I mean I wish we'd had
them ready before, but, you know, it's not too late. We don't know what's going to be happening after
delta. I hope we won't ever see anything nearly this bad, but we should be ready.
Kyle: Speaking of being ready and what's next with regard to vaccines, where do you stand on this question
about getting a third dose of say the mRNA vaccines like the Pfizer and Moderna vaccine at
this time in the United States. Do you think we're ready for that? Do you think it should be just for
certain populations of people? Or do you think we should hold off on that and try to develop
something that targets delta variants and maybe some of the other variants that might come along?
Dr. Topol: That's another really good question, and we have this problem of global inequity. And are
we going to start giving boosters to everybody in our hundreds of millions of people or those
vaccines get directed to places that are more desperate that haven't even had the first shot?
The problem is we really need both, and it does look each day increasingly likely
we're gonna need boosters at the least, not just for immunocompromised, but
if you look at people over age 60 in Israel who were the first get vaccines back in January,
they're having, you know, considerably higher breakthrough infection rate. And now that over
600,000 people in Israel over age 60 have gotten boosters of the original vaccine, they're not delta
specific, but they're getting restoration of that really high protection, because it brings up their
neutralizing antibodies. So I have to say, I was very resistant to boosters. Here I thought, "oh no
we don't want to go there, our immunity is redundant, it'll kick in, and, you know, we don't
want to listen to Pfizer and Moderna tell us what we need," but the data in real world data at least
from Israel and now other countries are adopting that it looks like that's where we're headed.
The real question is whom and also when, because we have no plan yet in the United States.
Kyle: One of the graphs that really struck me that you recently posted was about the hospitalizations
in the United States compared to Israel and the UK per capita, and you mentioned that this is
one of the graphs that scares you the most about this current surge in cases. Can you explain that
a little more? Dr. Topol: Right, so as we discussed, Kyle, the testing is so low, it's not a good parameter. But
the hospitalizations, you know, that's the real deal. If people are winding up in the hospital, that's
our best tracking. Fortunately the deaths are still relatively low, so hospitalizations is our
real marker. Now, it's like going in a car from zero to 60 in less than two seconds.
I mean, our rate of rise is scary fast. We've already exceeded seventy thousand, and that was
5x where we were five weeks ago. Now, this is the fastest rate of rise in our pandemic, and
this is in the vaccination era, so that isn't good. The highest we've ever been is 125,000 and we're
pretty substantially on that course. I never envisioned hospitalizations. We get to this level,
and we're not done yet. I mean, since the cases are continuing to accrue,
obviously some of those people are going to wind up in the hospital. It's just a lag.
So without having containment of the virus or seeing any sign of a u-turn, like we've seen in
other countries, hospitalizations are far greater than I would have envisioned with vaccines out
there, even in states that were not -- like, for example Florida is on average of United States --
does it see this happening in Florida, as you know, the worst hospitalizations of the entire pandemic,
right in Florida. That tells you something, and it tells us we're just too darn vulnerable.
Kyle: Two-part question: first of all, how contagious is this delta variant compared to other viruses? And,
two, how has your, kind of, life changed since delta variant with regard to things like mask wearing
or physical distancing? Dr. Topol: Yeah, well it's so hyper- contagious, a super spreader string if there ever
was one, and, you know, it's something that we are not fully appreciating that problem. And I
think it's getting highlighted more and more each day when we watch these hospitalizations go up, and
we know that some percent, whether that's 10 or 15 whatever, is even among the vaccinated, fully
vaccinated. So that just shows you how tough it is, no less looking at countries that are still
dealing with delta waves in Israel, for example, much more vaccinated than we are as a population.
So what I'm doing and what I'm suggesting is, you know, masks, high-quality, tight fit. You know, if you
don't feel like you're breathing as easily, that's probably a good sign your mask is working well.
And distancing. And avoiding indoors. I don't now have a gathering with indoors with vaccinated
people, because I don't know whether they're pre-symptomatic, asymptomatic at this point. We're
in the midst of this, you know, really tough wave, so I'm waiting to get on the other end of it before
getting back to where we were before delta got in here. So all these tools, the Swiss cheese model
of, you know, air quality, filtration, ventilation, avoiding, you know, indoors and crowds and all that
stuff, we got to do that, I think, now to protect ourselves. Kyle: Do you think one thing that's been lost
in those recommendations from the CDC and our government, you know, washing hands, ventilation,
mask wearing, distancing, is just taking care of our own immune systems, as well? Getting adequate sleep,
if you're at a high body mass index now, probably a good time to start thinking about losing weight,
eating healthy foods. You think that some of that's been kind of lost in the messaging?
Dr. Topol: Sure, I mean, you can always suggest that and that would be good whether we're in a pandemic
or not in a pandemic. Unfortunately, you know, I don't know that that's gonna wind up being so
protective right now, because we've got such a tough formidable foe. But, no, absolutely
that, you know, exercising and being in the best shape as possible, sure, it's always
good advice. Kyle: Dr. Topol, thank you so much for your time, really appreciate it, and, again, thank you for
helping communicate to everyone on your social media platforms.
Dr. Topol: You bet, Kyle. Sorry we didn't have more time. Kyle: No problem. Dr. Topol: Take care, talk again. Kyle: Thank you.