Speaker 1: From CurtCo Media. ( singing)
Bill Curtis: This isn't the same rehash discussion of COVID, this is,
Bill Curtis: well, more worth listening to, this is stuff that you
Bill Curtis: need to know. This is Medicine, We're Still Practicing. I'm
Bill Curtis: Bill Curtis. Of course, first, my friend and co- host
Bill Curtis: Zooming in, Dr. Steven Taback, he's a quadruple Board- Certified
Bill Curtis: doctor of Internal Medicine, Pulmonary Disease, Critical Care, and Neurocritical
Bill Curtis: Care, and he continues to fight on the front lines
Bill Curtis: of the COVID battle here in California, for which we
Bill Curtis: are eternally grateful. Steve, how you doing?
Steven Taback: Hey, Bill. Good to see you.
Bill Curtis: And our very special guest, Dr. George Rutherford, he is
Bill Curtis: the internationally lauded Head of Infectious Disease and Global Epidemiology
Bill Curtis: at the UCSF School of Medicine. He is also UCSF's
Bill Curtis: Professor of Pediatrics, and Adjunct Professor, School of Public Health
Bill Curtis: at California Berkeley. I had a chance to print out
Bill Curtis: George's CV. It's 126 pages long, with 221 published papers,
Bill Curtis: and so many important accolades. So I'm going to read
Bill Curtis: the whole thing to you now, only kidding. Dr. Rutherford,
Bill Curtis: although socially distance, thanks so much for joining.
George Rutherford: Real pleasure.
Bill Curtis: So Professor of Epidemiology and Biostatistics, Director at the Prevention
Bill Curtis: and Public Health Group, what do you do?
George Rutherford: Well, I'm an academic, so I teach school, right? I
George Rutherford: do research and I provide advice. The mission of anybody
George Rutherford: in academic, of any academic medical entity is education, research, clinical
George Rutherford: care, and public service. My clinical care is really the
George Rutherford: clinical practice of public health. And I advise the City
George Rutherford: Health Department, San Francisco Department of Public Health, the California
George Rutherford: Department of Public Health, and some of the various health
George Rutherford: departments around the state on approaches to controlling the COVID epidemic.
Bill Curtis: You did mention that your research is partly funded by CDC.
George Rutherford: Yes, that's correct. Yeah.
Bill Curtis: Tell us a bit about that and how that affects
Bill Curtis: your work during these crazy days.
George Rutherford: I've worked with CDC for decades, and most recently I've
George Rutherford: been doing predominantly HIV related work in developing countries as
George Rutherford: part of the Presidential Emergency Plan for AIDS Relief. I
George Rutherford: have a large, competent, very competent research group that basically
George Rutherford: tries to help governments and occasionally universities, but mostly governments
George Rutherford: and CDC missions in developing countries to understand what's going
George Rutherford: on with their HIV epidemics, how things are working, to
George Rutherford: evaluate progress and to discover new ways to try and
George Rutherford: stop the spread of HIV and to try and improve clinical outcomes
George Rutherford: among people who already have HIV.
Bill Curtis: Cases per 1 million population worldwide is running at about 3,
Bill Curtis: 500. Cases per 1 million in the US is running
Bill Curtis: at about 19,300. Did we screw up or do we
Bill Curtis: just have a population that's more difficult to manage?
George Rutherford: Yes and yes. We have sixfold higher numbers of cases than
George Rutherford: we should have, and other countries like India may eventually
George Rutherford: catch up. I think that the US missed a major
George Rutherford: opportunity early on, and that was the problem with not
George Rutherford: having enough tests and having the wrong tests and having
George Rutherford: tests that didn't work and trying to control tests and
George Rutherford: trying to restrict how tests were being used and for
George Rutherford: whom they were being used. I think that there have
George Rutherford: always been a whole myriad of lack of policy leadership,
George Rutherford: which the States have taken over. And I think, first
George Rutherford: of all, the Bay Area in which the six county
George Rutherford: health departments acted in concert to move to a Shelter- in-
George Rutherford: Place ordinance early on, on March 16th, and there's a very
George Rutherford: good reason for March 16th, it was the day before Saint
George Rutherford: Patrick's Day, and then later the state moved in the
George Rutherford: same direction. So I think California has really been a
George Rutherford: leader in this. Now you wouldn't know it from the
George Rutherford: last two months or three months since mid June when
George Rutherford: there's been a huge wave of new infection that's dissipated,
George Rutherford: but I think we still are leaders in this. We
George Rutherford: show data today in the Medicine Grand Rounds at UCSF that
George Rutherford: looked at numbers of deaths for a 100 cases. And in
George Rutherford: New York it's like 10%, in San Francisco it's 0. 87%.
George Rutherford: So it's less than 1% in San Francisco, and the next
George Rutherford: best in a big city, it's something like one and a
George Rutherford: half percent. Did we screw up as a country? Totally.
George Rutherford: Did we screw up regionally in Northern California? I don't
George Rutherford: think so. Did we screw up as a state? Somewhat. I
George Rutherford: think we made the reopening a little too easy. That's
George Rutherford: really hindsight.
Bill Curtis: Well, speaking about hindsight just for a second, I mean,
Bill Curtis: in New York, they've had 445,000 cases and 33, 000 deaths.
Bill Curtis: So they got ahold of this thing long before we
Bill Curtis: did, but we've already exceeded the cases. We're up to 750,
Bill Curtis: 000 cases, almost 80% more than they've had. And we've
Bill Curtis: had 14, 000 deaths, half of what they've had. When
Bill Curtis: you say that we as a country may have screwed
Bill Curtis: up, do we have ahold of this thing now and
Bill Curtis: how much of it is that the population is not
Bill Curtis: wearing masks enough, especially young people who've decided that they're
Bill Curtis: not as susceptible?
George Rutherford: What New York had was bad luck. And they had
George Rutherford: continuous importation from Europe and may have had, who knows,
George Rutherford: thousands of cases imported from Europe, each one of which
George Rutherford: starts a new chain of transmission. We in San Francisco
George Rutherford: we probably had tens coming from Asia. And you know
George Rutherford: the first death here was on February 6th and that
George Rutherford: was diagnosed retrospectively, a woman who'd attended a convention in
George Rutherford: Las Vegas, she was living in Santa Clara County, near
George Rutherford: San Jose, and that convention probably had people from China
George Rutherford: there, or at least in the hotel. And that's probably
George Rutherford: where she got it. If she had come home and
George Rutherford: kind of hit a large crowd event at the wrong
George Rutherford: time with very high levels of virus in her nose
George Rutherford: and throat and spread it around, we could have been
George Rutherford: just as bad off as New York, but we weren't.
George Rutherford: And that's really a question of luck. So New York
George Rutherford: had bad luck, but guess what? We knew this was
George Rutherford: coming since the 31st of December. That's when the Hubei
George Rutherford: Provincial CDC notified the Central Chinese CDC that, " Oh, by
George Rutherford: the way, we may have a little problem here." The
George Rutherford: Central Chinese CDC sent a team to Wuhan on December
George Rutherford: 31st and basically started, began an immediate investigation, started to
George Rutherford: close stuff down and to rein the whole thing in
George Rutherford: under control. That was the starting bell. I mean, there
George Rutherford: was basically two months lost. Now CDC will say, " Well,
George Rutherford: we developed tests, we did this, we did that," yeah,
George Rutherford: that's true, but then the FDA threatened to decertify their
George Rutherford: laboratory that was producing tests, and they produced tests in the
George Rutherford: hundreds, not in the tens of thousands, which was what
George Rutherford: was needed. Thousands of people came from Europe to New
George Rutherford: York and it got spread around, helped by a couple
George Rutherford: of super spreader events where people infect, instead of one
George Rutherford: person, they infect hundreds of people at the same time.
Bill Curtis: Do we actually know who and where that was?
George Rutherford: Yes. It was a lawyer who lived in New Rochelle
George Rutherford: who infected 121 people at his firm and at a synagogue.
Bill Curtis: Wow. You know, if you don't mind me throwing your
Bill Curtis: CV at you, it says that at UCSF, some of
Bill Curtis: your work is in immunizations and bioterrorism.
George Rutherford: Yeah.
Bill Curtis: So let's start with the bioterrorism part. Is there anything
Bill Curtis: here that mirrors that, and have we now convinced the
Bill Curtis: world that we are more susceptible to that issue because
Bill Curtis: of our lifestyle?
George Rutherford: Oh, I mean, Iran had just as big a gigantic
George Rutherford: epidemic as we did, as does China, as does Russia,
George Rutherford: as does India, as does Western Europe. So, I mean,
George Rutherford: we're hardly impervious.
Steven Taback: From a social perspective because we are so rebellious as
Steven Taback: a country. 50% of the population seems to be naysayers
Steven Taback: relative to public health whereas other countries perhaps are a
Steven Taback: little bit more cooperative.
Bill Curtis: Our economy is so important to us and whether or not
Bill Curtis: we're a little uncomfortable because we want people to see
Bill Curtis: our lips, we seem to be lacking discipline.
George Rutherford: We have a hyper individualistic streak as part of the
George Rutherford: national psyche, and it gets continuously promoted. So wearing masks
George Rutherford: is important for three reasons. Okay. Number one, you protect
George Rutherford: yourself from inhaling this virus. So we're talking predominantly droplet transmission
George Rutherford: and we're talking about close contact, and if you have
George Rutherford: a mask on, your chances of becoming infected go way down.
Bill Curtis: Do you have a feel in terms of numbers, to
Bill Curtis: what degree you lower your risks by wearing a mask?
George Rutherford: Probably 60%. It depends on whether you had glasses on
George Rutherford: or not too. If you have glasses on, especially safety
George Rutherford: glasses, you can make it almost negligible. The conjunctivae, the
George Rutherford: lining around the eye, the thing that gets red when
George Rutherford: you get pink eye, is part of the respiratory epithelium and
George Rutherford: communicates with the respiratory epithelium. It's part of the respiratory
George Rutherford: tract and has the same receptors on it that the
George Rutherford: rest of the respiratory tract does. And so, yes, it can
George Rutherford: be a portal of entry, which is why we go
George Rutherford: to these elaborate lengths with face shields and safety glasses
George Rutherford: and stuff.
Bill Curtis: Interesting. You know, we had some shows in one of our sister
Bill Curtis: shows here, Politics: Meet Me in the Middle, where we
Bill Curtis: talked to some university presidents and talked about how they
Bill Curtis: were opening up their schools. And they all did so
Bill Curtis: much work, at least looked like they were doing so
Bill Curtis: much work. Are they talking to you, are they asking
Bill Curtis: you how they should do this or not do this?
George Rutherford: Yeah. I'm on a UC wide committee that basically tries
George Rutherford: to provide advice to the president of the UC System
George Rutherford: on a million things about public health around COVID virus,
George Rutherford: including screening, or how to reopen, how not to reopen,
George Rutherford: what do you do when somebody is sick? How do you
George Rutherford: do contact tracing on campus? All of those kinds of things.
Bill Curtis: What do you tell them?
George Rutherford: First of all, you got to decrease density. You're really talking about one
George Rutherford: person per room. So that cuts the size of the
George Rutherford: enrollment in half.
Bill Curtis: I think you're saying 5, 000 people at risk versus 20, 000
Bill Curtis: people at risk by reducing the size, classes and dorms,
Bill Curtis: et cetera.
George Rutherford: Yeah. Then when there's somebody gets infected, you have pods
George Rutherford: of 10 people. You have to go into quarantine. You know, if you get it
George Rutherford: done right. It's really complicated doing colleges, it's quite complicated
George Rutherford: doing high schools too, because people change classes all the time.
Bill Curtis: You said that we can get away with kindergarten through
Bill Curtis: third grade, basically. You're a pediatrician, and you said younger
Bill Curtis: children are not that susceptible if they're infected and they're
Bill Curtis: not as transmissible generally. Can you explain that?
George Rutherford: Sure. The receptor that you have, receptor's the only word
George Rutherford: I know, the protein on the surface of the cells
George Rutherford: that the virus attaches to, to invade the cell, they're
George Rutherford: less dense. There are fewer of them for surface area
George Rutherford: in younger children than in adolescents and adults. So there
George Rutherford: are fewer susceptible ports of entry, basically. The observation is
George Rutherford: that there're not a lot of pediatric cases diagnosed. We know
George Rutherford: that there are pediatric cases, but they're just not as
George Rutherford: proportionately as many as an older age groups. The other
George Rutherford: thing we know is that children are less likely to
George Rutherford: develop severe complications. Now that doesn't mean they don't develop
George Rutherford: severe complications because they can, and there are pediatric deaths.
George Rutherford: And then in household studies, if the first case in
George Rutherford: the household is a child, there's less transmission than if the first
George Rutherford: case in the household was an adult. So they're direct comparisons.
Bill Curtis: Why is that?
George Rutherford: You know, there's a whole school of thought that says, because they're
George Rutherford: short, I kid you not.
Bill Curtis: The aerosol hits your knees rather than your nose.
George Rutherford: Yeah. Yeah. Yeah. Basically you get coughed on your thighs,
George Rutherford: but that's the observation and that's the physiology behind it.
George Rutherford: The other thing is that the observations that are around
George Rutherford: the world, all the outbreaks have been in middle schools
George Rutherford: and high schools. Yes, there was an outbreak in a
George Rutherford: summer camp in Georgia, but if you read through that
George Rutherford: and look at the timing of that carefully, it looks
George Rutherford: like all the kids were infected by counselors in the
George Rutherford: first three days they were there and rather than transmitting
George Rutherford: it kid to kid.
Bill Curtis: I've got a couple of grandkids, a four and a half
Bill Curtis: year old and roughly a two year old. And believe
Bill Curtis: it or not, while lots of schools are closed in
Bill Curtis: California, theirs is not. How much do I have to
Bill Curtis: worry as grandpa about getting near my kids or my
Bill Curtis: kids' kids or supposed to see my kids for dinner tonight.
Bill Curtis: Should I do it?
George Rutherford: Yeah. What are they going to have?
Steven Taback: I was thinking about (inaudible) , is that a problem?
George Rutherford: No. That sounds pretty good. Their little kids aren't getting much of
George Rutherford: that, so there's more for you.
Steven Taback: How much lower is the risk if I'm willing to
Steven Taback: take some risk that the kids could go to school
Steven Taback: and come home with a transmissible disease that I don't
Steven Taback: want to have?
George Rutherford: There's not a lot of risks. You know, the Swiss have actually issued an edict that
George Rutherford: it's okay for grandchildren to hug their grandparents. There's some
George Rutherford: very interesting kind of legislative things. My favorite was the
George Rutherford: prime minister of New Zealand sent a letter to every
George Rutherford: kid in New Zealand under the age of seven or
George Rutherford: eight or something and said that by decree, she declared
George Rutherford: the Easter Bunny an essential worker.
Bill Curtis: That's taxpayers dollars really well spent.
George Rutherford: No, I mean, in fact, it is probably, you know?
Bill Curtis: We're going to take a quick break. We'll be right back.
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Bill Curtis: We're back with Dr. George Rutherford and Dr. Steven Taback.
Bill Curtis: On a slightly more helpful basis for a minute, up
Bill Curtis: until about a month ago, we would get our groceries
Bill Curtis: either delivered or go to the grocery store and you
Bill Curtis: would have thought we were in a hazmat suit and
Bill Curtis: going into a biohazard when we go to the grocery
Bill Curtis: store. And then I would get home and douse everything,
Bill Curtis: including the apple, in alcohol because I was worried that
Bill Curtis: I was bringing home virus. I've been told that that might
Bill Curtis: be overkill. So can we talk about surface transmission for
Bill Curtis: a minute and what have you guys found out?
George Rutherford: Yeah, that's overkill. Surface transmission or as we say in
George Rutherford: the trade, fomite transmission, where basically a surface has been
George Rutherford: contaminated by somebody sneezing or coughing on it and you
George Rutherford: come along and you get it on your fingers and
George Rutherford: rub it in your eyes or nose, theoretically possible. It
George Rutherford: doesn't appear to be that big a problem epidemiologically. There're
George Rutherford: always sort of more facile explanations than that. Actually the
George Rutherford: amount you need to get enough infectious virus may be
George Rutherford: on the order of a milliliter or so. So what
George Rutherford: I say is, if it's not glistening, it's unlikely to be
George Rutherford: infectious, to have sufficient numbers of viral particles. You know,
George Rutherford: I don't flip out and do crazy stuff and I
George Rutherford: wash my hands after I get out, but I don't
George Rutherford: bother to wash the fruit.
Bill Curtis: You had mentioned that about 60% diminished transmission if you're
Bill Curtis: wearing a mask and another 30% if you're wearing eyewear.
Bill Curtis: Why are we not mandating eyewear as well? Just too
Bill Curtis: big a nut to crack, we can barely get people
Bill Curtis: to mask, so why bother adding the stress of goggles?
George Rutherford: Remember that that's just about protecting you. If you're infectious,
George Rutherford: your mask cuts out 95% of your ability to transmit
George Rutherford: to other people. The third thing is because they cut
George Rutherford: down the number of viral particles that get through. If
George Rutherford: you do get infected, you're going to get infected with
George Rutherford: a lower dose of virus and you're going to have
George Rutherford: less severe disease most likely. You protect yourself from infection
George Rutherford: period, protect others in case you're infected. And if you
George Rutherford: do happen to become infected, you're going to have less
George Rutherford: severe disease.
Bill Curtis: Interesting. Do I have to throw this mask out tomorrow?
George Rutherford: No. You have your own mask, right? You're not sharing it
George Rutherford: with anybody.
Bill Curtis: No.
George Rutherford: Okay.
Steven Taback: Yeah, but you don't want to be touching the front
Steven Taback: of your mask if theoretically you're inhaling potentially a viral particle.
George Rutherford: Yeah. You take it off from the ears, you don't
George Rutherford: pull it off like this.
Steven Taback: What are your thoughts about the Russian vaccine that supposedly
Steven Taback: is ready to be launched?
George Rutherford: Has Putin got it yet?
Steven Taback: I think professional courtesy, I don't think he can actually
Steven Taback: get it.
George Rutherford: Oh, yeah? Okay. The problem with the Russian vaccine, it's
George Rutherford: a human adenovirus vectored vaccine, which means that they've taken
George Rutherford: a piece of viral RNA that codes for the spike
George Rutherford: protein, the thing that sticks off the top of the
George Rutherford: virus, that actually fuses with these receptors we are talking about.
George Rutherford: And once the adenovirus infects humans and the adenovirus RNA
George Rutherford: with this little addition gets inserted into a human genome,
George Rutherford: it will spit out just these pieces of protein. So,
George Rutherford: that's the idea. The problem is, is that they're using
George Rutherford: human adenovirus. One of the concerns is that people have
George Rutherford: immunity to those, adenoviruses cause summer colds and stuff, and whether you
George Rutherford: can actually get an adenovirus infection established in a large
George Rutherford: part of the population that may have had previous experience
George Rutherford: with the viral vector. So that's the issue about the
George Rutherford: Russian vaccine. The AstraZeneca Oxford vaccine uses a chimpanzee adenovirus.
George Rutherford: And so unless you've been working at the circus or
George Rutherford: something, you're probably unlikely to have come in contact with
George Rutherford: a chimpanzee adenovirus.
Steven Taback: It's a good point. Just yesterday from when we recorded
Steven Taback: this program, AstraZeneca actually put their trial on hold, right?
Steven Taback: Because they had an adverse reaction in the United Kingdom.
George Rutherford: Yes.
Steven Taback: So on the one hand, yes, that's a big hiccup
Steven Taback: and makes us all go, " Oh, that's too bad." On
Steven Taback: the other hand, the bravo, it makes me feel better
Steven Taback: like this is a scientific process instead of a political or profit- based.
George Rutherford: Yeah. Yeah. And at least the statement today from the
George Rutherford: CEO so that they weren't getting any profits from this
George Rutherford: vaccine, they were doing it for the good of humanity thing.
Steven Taback: From your vantage point, when are we going to movie
Steven Taback: theaters again? When we'll be back in the baseball stadium?
George Rutherford: Those are two very different things. So talk about outdoors.
George Rutherford: The Kansas City Chiefs are opening the NFL season tonight and they're going to have 10,
George Rutherford: 000 people in the stands. So the answer is if
George Rutherford: you live in Kansas City, Missouri, it's now.
Steven Taback: Yeah. Let me qualify that question, safely.
George Rutherford: Oh, I think it's going to be pretty safe. Whether it's economically feasible to have
George Rutherford: one sixth of the gate in, I don't know.
Steven Taback: How long does it really take before herd immunity or
Steven Taback: combination of herd and or treatment and or vaccine that
Steven Taback: gets you to the place where we can resume everyday life?
George Rutherford: I'll just say, forget about naturally acquired herd immunity. That's
George Rutherford: going to come at much too great a cost in
George Rutherford: terms of mortality. In terms of vaccine immunity, if the
George Rutherford: vaccines work and if we have enough of them, we
George Rutherford: can actually give them starting at the beginning of next
George Rutherford: year. I'd say this time, next year, you could be in
George Rutherford: Dodger Stadium, but there may still be social distancing and they're going to
George Rutherford: want to make sure you're vaccinated before they let you
George Rutherford: in.
Bill Curtis: First of all, I think people don't realize how long
Bill Curtis: it takes to vaccine the public. My understanding is they're
Bill Curtis: talking about, oh, maybe getting 3 million people vaccinated a
Bill Curtis: day, which doesn't that mean that it's going to take us
Bill Curtis: five months to vaccinate the population?
George Rutherford: Let's just start with California. California has 40 million people.
George Rutherford: So Dodger Stadium has 50,000 seats, about, right?
Bill Curtis: Right.
George Rutherford: So, that means you'd have to fill up Dodger Stadium
George Rutherford: 800 times? That's the kind of effort you're talking about.
George Rutherford: We can no longer use jet injector guns, which is
George Rutherford: what they used in the old vaccination campaigns because of
George Rutherford: HIV and Hepatitis C risk. You know, you're going to
George Rutherford: have to give individual doses with needles and syringes. So,
George Rutherford: yeah, you can vaccinate 50,000 people in a day in
George Rutherford: one location, but to do all of California in four
George Rutherford: months, they're all two dose series by the way, so
George Rutherford: you have to give 80 million doses.
Bill Curtis: Everything is a two dose? It's not just some of those?
George Rutherford: No, all the ones that are in advanced stages are
George Rutherford: two dose, in 21 and 28 days apart.
Bill Curtis: There's a rumble going around, especially with millennials, that they
Bill Curtis: don't want to jump into an early vaccine unless they're
Bill Curtis: absolutely forced to. A, they feel like they're super people
Bill Curtis: that they're not really subject to it because they have
Bill Curtis: a stronger immunity. And frankly, there's a lot of doubt
Bill Curtis: about whether these trials are going to be complete and
Bill Curtis: safe. What's your prognosis of us vaccinating our population successfully
Bill Curtis: and getting enough people to participate?
George Rutherford: I think we'll be lucky if we get 50%.
Bill Curtis: Is that enough to kind of push this herd immunity
Bill Curtis: concept?
George Rutherford: No, you'd probably need to vaccinate about 80%. Let me
George Rutherford: give you two factoids. So we go to the sort
George Rutherford: of our latest, greatest public health experiments, San Quentin State
George Rutherford: Prison. San Quentin had a horrendous outbreak of COVID- 19.
George Rutherford: It didn't stop until 70% of the inmates, 70, were
George Rutherford: infected. So I think that's probably pretty close to where
George Rutherford: herd immunity lies. Now is being in prison like being
George Rutherford: in the regular world? Who knows, right? Who knows how
George Rutherford: analogous it is? It might be closer to a cruise
George Rutherford: ship, but the ships got to 85%. So I think
George Rutherford: what we're going to say is that herd immunity lies
George Rutherford: somewhere north of 50 or 60%. If you have a
George Rutherford: vaccine that's 90% effective, which means you have to immunize another
George Rutherford: 10% to get to the 90% effective, and we're trying
George Rutherford: to get to 70% of the population immune, that means
George Rutherford: we have to vaccinate 77% of the population.
Steven Taback: Right. That's a big ask and that's probably not going
Steven Taback: to happen. But what I think we look for is,
Steven Taback: one, to have an option so that there is an
Steven Taback: option for those people who believe in it and want to do
Steven Taback: whatever they can to prevent the illness. And then the
Steven Taback: rest, if they've so chosen in this freedom of choice
Steven Taback: country that we live in, but also the magnitude of
Steven Taback: the illness and the magnitude of the impact on the
Steven Taback: population will still be markedly less. You will have had
Steven Taback: some people who've already had the disease, perhaps are immune,
Steven Taback: those people who have been vaccinated, the severity, the intensity,
Steven Taback: of the epidemiologic disaster that we're experiencing now will be
Steven Taback: mitigated tremendously. Would it not?
George Rutherford: It'll be cut down by the proportion of people who are vaccinated.
Bill Curtis: If the vaccine doesn't work, if it only partially works,
Bill Curtis: is it possible that getting the vaccine gives you a
Bill Curtis: less severe case or is it just a yes or
Bill Curtis: no question about whether you get the disease?
George Rutherford: Well, they're judging it to PCR positive, whether you're actually
George Rutherford: infected with the virus and not so much clinical disease,
George Rutherford: the end points in the trials are about becoming infected,
George Rutherford: not so much about clinical disease, although they will have
George Rutherford: clinical disease end points. The best way to prevent death
George Rutherford: is to prevent illness, the best way to prevent illness
George Rutherford: is to prevent transmission and infection. Can't people opt out?
George Rutherford: Of course, they can opt out unless they work in
George Rutherford: hospitals or going to schools in which case they'll probably
George Rutherford: be forced, but you're going to see people want evidence
George Rutherford: of immunity to get on an airplane, to walk into
George Rutherford: a restaurant, to go to the Dodgers game, to go
George Rutherford: into a theater. You're going to see a lot of
George Rutherford: pushback about people who don't get vaccinated.
Bill Curtis: Is it impossible in this country for government to say, "
Bill Curtis: You guys have to get vaccinated"?
George Rutherford: I don't think would ever happen. I mean, we can do it in
George Rutherford: the military, we can make it a condition of employment
George Rutherford: in hospitals and nursing homes, we can make it a
George Rutherford: condition of attendance in schools, we could potentially make it a condition
George Rutherford: of employment by school. So the University of California system
George Rutherford: is requiring everyone, including the guys who cut the grass,
George Rutherford: to get tested. The idea is that everybody's going to
George Rutherford: have to get vaccinated eventually. We have in fact acquired influenza
George Rutherford: vaccine across all the campuses and for students as well.
Bill Curtis: So speaking about the vaccines, just recently, there was a
Bill Curtis: joint issue of kind of a public pledge, I understand,
Bill Curtis: company Pfizer and J& J talking about they're not going
Bill Curtis: to seek approval for their vaccines until they're really ready
Bill Curtis: and really safe. How do you feel about the process
Bill Curtis: that these companies are going through and what level of
Bill Curtis: confidence do you have?
George Rutherford: Well, that gives me a lot more confidence that they're
George Rutherford: not going to be a rush. There was nine companies, by the
George Rutherford: way, nine CEOs who signed up, and it gives me
George Rutherford: quite a bit of confidence that we're not going to have a rush
George Rutherford: to something that's less than safe.
Steven Taback: Are they really waiting for safety or they're using safety
Steven Taback: as a political ploy because their fear is that there's going to
Steven Taback: be political pressure, not to put them out because of
Steven Taback: a ultra conservative government that we have now with the
Steven Taback: hope of a more liberal, socially conscious and socially aware
Steven Taback: government that may be coming in the future?
George Rutherford: Understand the issue of safety is a complex issue with vaccines
George Rutherford: because you're vaccinating people who have no disease. It's not
George Rutherford: like therapeutic trials like Steve does in the neuro ICU
George Rutherford: where the basic patient population is very sick to start
George Rutherford: with. Here you're vaccinating people without any illness at all.
George Rutherford: So you have to be absolutely positive to the greatest
George Rutherford: extent that you can be, that it's safe. Now, having
George Rutherford: said that rare complications will not show up in the
George Rutherford: trials. And if they do show up in the trials,
George Rutherford: like this case of transverse myelitis in Britain, that's a
George Rutherford: real signal flag that there might really be something there.
Bill Curtis: But sometimes things show up years later.
George Rutherford: Well, correct, because all of a sudden you've moved from a 100,
George Rutherford: 000 people being in three trials to having 4 million
George Rutherford: people who've received the vaccine.
Bill Curtis: Is this going to be a live vaccine or a
Bill Curtis: dead one?
George Rutherford: Well, the adenovirus is live. That's the idea in the
George Rutherford: AstraZeneca vaccine, that they are given the adenovirus and that it
George Rutherford: replicates. The others are just pieces of messenger RNA. They're not
George Rutherford: replication competent, they're just pieces of RNA.
Bill Curtis: Are those generally safer?
George Rutherford: Nobody has any idea. There hasn't been an mRNA vaccine
George Rutherford: before. And by the way, the only adenovirus vectored vaccine
George Rutherford: that's in general use is for Ebola.
Steven Taback: Right. But I think the concept being that you're giving somebody a
Steven Taback: live adenovirus that is fairly common in the community, we've
Steven Taback: been challenged with adenoviruses and we don't have pandemics. And
Steven Taback: the severity of illness doesn't even come close to what
Steven Taback: we're seeing with Corona so that it then is bringing
Steven Taback: on the little piece of Corona with it. And then you're
Steven Taback: basically generating an antibody to the little piece of Corona
Steven Taback: that your body then will become immune to.
George Rutherford: Yeah. Yeah.
Bill Curtis: Interesting. So let me ask both of you doctors, when
Bill Curtis: this vaccine comes out, are you going to take it in
Bill Curtis: the first month? Wait, wait, wait. Don't answer. Answer in
Bill Curtis: 30 second. We'll be right back.
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Bill Curtis: Okay. We're back with Dr. George Rutherford and Dr. Steven
Bill Curtis: Taback. So guys, tell us are you going to take
Bill Curtis: this vaccine in the first month that it comes out?
George Rutherford: I can absolutely guarantee you that I will not. And
George Rutherford: that's because I'm not going to be in one of the groups
George Rutherford: that's supposed to get it. It's going to be given
George Rutherford: for healthcare workers who are actually seeing patients, unlike me,
George Rutherford: who are in ICUs and emergency departments and on the
George Rutherford: hospital wards where they see the sickest patients. That's who's
George Rutherford: going to get it first and that's who should get
George Rutherford: it first.
Steven Taback: I definitely will be taking it. Transverse myelitis be damned,
Steven Taback: I'm going to take my chances and hope for the
Steven Taback: best, because I think I have a better chance with
Steven Taback: a vaccine than if de novo I pick up this
Steven Taback: virus at 60.
Bill Curtis: So other than how long it will take for them
Bill Curtis: to get to you, George, when will you take it?
George Rutherford: When I become eligible for it. I'm 68, I would
George Rutherford: not stand a great chance if I got this.
Bill Curtis: New York's governor, Andrew Cuomo, said that New York City
Bill Curtis: is going to resume indoor dining at the end of
Bill Curtis: September at a 25% capacity. I was wondering, because right
Bill Curtis: now if you go to New York, it's kind of
Bill Curtis: like Paris with a lot of outdoor cafes and it's
Bill Curtis: actually very nice, but come October, they're all going to
Bill Curtis: have to go inside otherwise you're going to have to
Bill Curtis: wear a ski jacket when you're eating. So is that
Bill Curtis: a good idea? Is New York prepared for that? Does
Bill Curtis: New York have a kind of a little bit of
Bill Curtis: a herd immunity because their numbers are certainly impressive given
Bill Curtis: how they started?
George Rutherford: There's some thought that parts of New York may have
George Rutherford: upwards towards 40 or 50% of the population with antibodies.
George Rutherford: Now, I don't know that I truly believe all that.
George Rutherford: I don't know what kinds of antibody tests they ran.
George Rutherford: Antibodies are a little complicated to test for. And we
George Rutherford: don't know whether immunity is transient or not yet. It
George Rutherford: appears if you look at the Coronaviruses that cause common
George Rutherford: colds, that antibodies really are only protective for four or
George Rutherford: five months. I think operating restaurants at 25% capacity is
George Rutherford: probably a fairly low risk thing. I'd want to know
George Rutherford: how the air was handled. You probably want several air
George Rutherford: exchanges per hour, and you want all the air exhausted to the
George Rutherford: outside instead of recycled, which is tough with air conditioning.
Steven Taback: Yeah, because to me this whole concept of reopening restaurants,
Steven Taback: it's human nature, " Oh, we're doing so much better, therefore
Steven Taback: now we're safe." It's sort of kind of denying the
Steven Taback: reality that we haven't done anything for this virus to
Steven Taback: go away, what we've done is we finally did what
Steven Taback: we were supposed to do in terms of social distancing
Steven Taback: and wearing masks. And that's the success. So to throw
Steven Taback: all that, all caution, to the wind, therefore we must
Steven Taback: be safe, let's resume, it's just asking for trouble. It's
Steven Taback: like we haven't done anything, why would you expect a
Steven Taback: different outcome? So it's just very frustrating as a healthcare
Steven Taback: professional to say, " What are you guys doing?"
Bill Curtis: Guys, does this virus care about the weather as it
Bill Curtis: turns out? Does it matter if it's a warm day
Bill Curtis: or if we're in the middle of winter?
George Rutherford: Probably a tiny bit, but not enough to make a difference.
Steven Taback: I have this theory about this coming winter. You tell
Steven Taback: me what you think. I have a feeling we're going
Steven Taback: to have a fairly light winter relative to influenza and
Steven Taback: other respiratory viruses because of all the social distancing and
Steven Taback: masking and whatnot. What do you think?
George Rutherford: You've been peaking. That's exactly what the Australian data say right now today.
Steven Taback: Oh, is that right?
George Rutherford: Yeah.
Steven Taback: Okay. But yeah, that's what I was figuring.
Bill Curtis: Let's talk about more vulnerable. All of us on this
Bill Curtis: discussion, if you were looking for us in the grocery
Bill Curtis: store, you wouldn't find us in the spring chicken section.
Bill Curtis: We're all somewhat more vulnerable than the teenagers, I imagine.
Bill Curtis: If we do get it, has anything changed since March
Bill Curtis: about whether or not we're going to have a bad
Bill Curtis: experience with it?
George Rutherford: Yeah. The mortality in the second wave is a lot
George Rutherford: lower than the mortality in the first wave. And part
George Rutherford: of that, maybe the people are just younger. Part of
George Rutherford: it may be better medical care with remdesivir and judicious
George Rutherford: use of steroids and prone positioning with oxygenation. It's very
George Rutherford: unlikely that there's any kind of configurational change in the
George Rutherford: virus. And in fact, that the data would suggest that
George Rutherford: it's actually gotten more invasive rather than less invasive. But
George Rutherford: what the real difference we think is, is that people
George Rutherford: are wearing masks so they're getting infected with lower doses
George Rutherford: when they do get infected and they're having less severe
George Rutherford: disease.
Bill Curtis: So actually if you start off with a smaller dose,
Bill Curtis: your body has time to create some antibodies and fight
Bill Curtis: the disease, as opposed to it's all going to end
Bill Curtis: up the same at the end of the day and replicate at a
Bill Curtis: certain level and you're just going to get just as sick? So you actually
Bill Curtis: get less sick if you get a smaller dose?
George Rutherford: That's the theory, yeah. I mean, and it's actually been observed
George Rutherford: for influenza.
Steven Taback: Have you heard of any promising new treatments on the
Steven Taback: horizon? Because I figure maybe that would change the game
Steven Taback: here if we're all just waiting for a vaccine, but
Steven Taback: if we can cut the legs off of this thing
Steven Taback: when you get it so that you're not so worried
Steven Taback: about the effects, that would have a major impact. Have
Steven Taback: you heard of anything?
George Rutherford: Yeah. Well, there are two kind of classes. One are
George Rutherford: antiviral drugs of which there are half dozen antivirals in
George Rutherford: trials right now. And some of them are actually being
George Rutherford: tried for prophylaxis and early treatment. So prob one would
George Rutherford: use an antiviral for prophylaxis, we do it for influenza
George Rutherford: now, so if there's an outbreak in a nursing home,
George Rutherford: we'll give everybody influenza antivirals until the end of the
George Rutherford: flu season. So that's the kind of way we do it now.
Bill Curtis: For the rest of, what's an antiviral?
George Rutherford: Like Tamiflu, right? Instead of an antibiotic that kills bacteria
George Rutherford: or an antifungal that kills funguses antivirals kill viruses. The
George Rutherford: other thing that's promising is trying to control the immunologic
George Rutherford: storm that surrounds the progression from upper respiratory infection to
George Rutherford: pneumonia, to bad pneumonia, to acute respiratory distress syndrome, to
George Rutherford: respiratory failure, and death. We've been using steroids like dexamethasone
George Rutherford: for that. There's this very cool thing at UCSF that's
George Rutherford: using nanoparticles to deliver basically receptor blockers. It's kind of
George Rutherford: cool stuff.
Bill Curtis: Let me ask you a question about the steroids for a second, because
Bill Curtis: if something like a decadron is working, it's an antiinflammatory, right?
Bill Curtis: As steroid is an antiinflammatory. So explain to me why
Bill Curtis: apparently ibuprofen is potentially getting an inverse effect and they're
Bill Curtis: not recommending you take that when you feel lousy?
George Rutherford: If children have this, do not give them aspirin under
George Rutherford: any circumstances whatsoever. There's a very, very bad pediatric disease
George Rutherford: called Reye's Syndrome where basically your liver dissolves and that's
George Rutherford: triggered by aspirin during a flu infection.
Steven Taback: But are we seeing that with Corona?
George Rutherford: No. I mean, nobody gives aspirin anymore for anything-
Steven Taback: Right. Okay.
George Rutherford: Except for rheumatoid arthritis.
Bill Curtis: Wait, wait, wait, wait. So when you say, if your kids have
Bill Curtis: this, don't give them aspirin.
George Rutherford: Don't give aspirin to children for any reason at all.
George Rutherford: It's much simpler than that. I can make it much
George Rutherford: simpler. And you don't have to differentiate among other things.
Bill Curtis: Let's talk for a minute and let's assume that we're
Bill Curtis: dealing with both the question of a vaccine and also
Bill Curtis: all the people who are running around who have recovered.
Bill Curtis: What's the current thinking on re- infection right now? I
Bill Curtis: know that we're talking about, oh, there are four cases
Bill Curtis: or something like that that may have gotten reinfected. What's
Bill Curtis: the real deal here? Is this virus mutating enough to
Bill Curtis: make it so that someone who had it and got
Bill Curtis: rid of it four months ago, they're just as susceptible
Bill Curtis: as the rest of us?
George Rutherford: Well, there are four cases, so you're right. They all
George Rutherford: were documented as coming from different viruses, right? So they're
George Rutherford: not identical genetically, virus has changed over time. It took
George Rutherford: about four months between the first and the second infection. In
George Rutherford: three of the infections, people got no symptoms or very
George Rutherford: mild symptoms, in one of them the person got sicker
George Rutherford: than he was the first time, which is concerning. Some
George Rutherford: of us are concerned about a phenomenon called antibody- dependent
George Rutherford: enhancement or ADE. And that's something that goes on with tropical
George Rutherford: disease called dengue fever. The first time you get it,
George Rutherford: it's bad. The second time you get it, it's much
George Rutherford: worse. And so you don't know what you don't know,
George Rutherford: right? We're looking at four cases out of 25 million
George Rutherford: to try and parse out these pearls of wisdom. The
George Rutherford: other way to look at it is there are only
George Rutherford: four cases. And so it's an exceptionally rare phenomenon.
Bill Curtis: Does it mean there are only four cases? There might be a hundred thousand cases and
Bill Curtis: we're only paying attention to four that kind of came
Bill Curtis: to bear?
George Rutherford: Of course not, but we have, that's what's in front
George Rutherford: of us right now.
Steven Taback: But if it was a pervasive problem that would come to the fore.
Steven Taback: You would know that.
George Rutherford: And it may come to the fore next week. I mean, we're
George Rutherford: right sort of at the end of the kind of the four to five
George Rutherford: months. But I agree with you, I think this would
George Rutherford: not be subtle if it started to happen. The other
George Rutherford: good story is that there is this great story, I
George Rutherford: don't know if you've heard this one, Steve, is American
George Rutherford: commercial fishing boat, crew of 122 from Seattle. Everybody got
George Rutherford: screened before they went to sea. Everybody was negative by
George Rutherford: the nasal swabs. They also had blood taken for antibody.
George Rutherford: They go to sea, come back 10 days later, 85%
George Rutherford: attack rate for COVID. They run all the bloods, three
George Rutherford: of the 120 people for whom they had bloods, had
George Rutherford: neutralizing antibody. Could actually measure neutralizing antibodies. What we're trying
George Rutherford: to make happen with the vaccine. None of them got sick.
George Rutherford: Of the other 117, something like 107, got sick. So
George Rutherford: there's this story about neutralizing antibody being protective in the
George Rutherford: face of massive outbreak.
Steven Taback: Wow! That's very... I have not heard that story. That's amazing.
Bill Curtis: So your advice to folks that are over 50, over
Bill Curtis: 60, over 70, where does the real problem start occurring? Is it an
Bill Curtis: age related thing or how does someone know if they
Bill Curtis: just have to stay home for, again, for the next year?
George Rutherford: Well clearly, the older you are, the greater your risk
George Rutherford: is. But as I also said, I just saw some
George Rutherford: data today that which suggests that even among people over
George Rutherford: 80, the mortality rate is decreasing in the second wave,
George Rutherford: as opposed to the first wave. And that may be
George Rutherford: better ICU care, it may be smaller, inoculate because they're
George Rutherford: wearing masks, who knows? But that's the observation. I think
George Rutherford: you have to be very careful if you're over 70.
George Rutherford: If you're over between 60 and 70, it could be a
George Rutherford: little bit more out there. On younger people, the greatest
George Rutherford: risk factor is obesity of a BMI over 30. And then
George Rutherford: there's the usual sort of triad of heart disease, hypertension,
George Rutherford: pulmonary disease, preexisting pulmonary disease, diabetes, smoking, which presumably includes
George Rutherford: vaping although no one's showed that. I guess, that's five.
George Rutherford: That's a pentag. First of all, everybody should be careful.
George Rutherford: You don't want to get this disease. There are a lot
George Rutherford: of long- term consequences we haven't talked about yet. You
George Rutherford: don't want to get this disease at all. And this
George Rutherford: idea that, well, I'll get immuned and then everything will
George Rutherford: be fine, that's nuts. There are a lot of longer
George Rutherford: term problems.
Bill Curtis: Let's talk about that for a minute.
George Rutherford: It's just kind of coming out now in football players that
George Rutherford: they've been screening for infection and it turns out they
George Rutherford: had some sort of anti- myocardial antibody.
Steven Taback: Right.
George Rutherford: So it's (inaudible) against the heart muscle. You know,
George Rutherford: that's not good.
Steven Taback: Yeah. It's a very systemic disease. You look at this
Steven Taback: and we're trying to draw comparisons to 1918 with influenza,
Steven Taback: and I know from our ICU where you have patients
Steven Taback: now with ECMO, their lungs shut down from the virus if
Steven Taback: they're clearly invaded and we shut the lungs down further
Steven Taback: but with ECMO and we're just sort of bypassing the
Steven Taback: lungs. Two months later, they get off of ECMO and
Steven Taback: their lungs seem to come back to full recovery. What
Steven Taback: we're seeing with COVID, obviously ECMO has worked in a
Steven Taback: certain number of cases, but so many of our COVID
Steven Taback: patients that have not done well, their lungs are getting
Steven Taback: totally destroyed by this virus. It's not like there's terrible
Steven Taback: lung injury that then is amenable to cellular repair. It's turning
Steven Taback: to fibrosis, it's turning to scar tissue. And that's happening
Steven Taback: and we're seeing it in myocardium, we're seeing neurologic issues
Steven Taback: that are long- term and persistent of young people who
Steven Taback: otherwise metabolically are improved, but are basically comatose and chronically
Steven Taback: vegetative because of multiple strokes, not to mention the vascular
Steven Taback: abnormalities. I started looking at this, if you watched WarGames, that
Steven Taback: movie when you were a kid like in the 70s,
Steven Taback: when the computer finally realizes and it says, " Peculiar game,"
Steven Taback: the only way to win is not to play because
Steven Taback: they're talking about global thermal nuclear war. That's what this
Steven Taback: is like. The only way to really win this thing
Steven Taback: is don't get sick. Is prevention is everything in this disease.
Bill Curtis: Well, that being said, I have one more question for
Bill Curtis: you, George. And I would like to congratulate you. Something
Bill Curtis: magical just happened. You were put on the ballot for
Bill Curtis: president of this country and everybody voted for you. So
Bill Curtis: you are now in charge. And so a little bit,
Bill Curtis: we'd like to give you our sympathy, but we'd also
Bill Curtis: like to ask you, what are you going to do
Bill Curtis: to help guide us out of this thing from that
Bill Curtis: vantage point?
George Rutherford: Well, first of all, you have to put people in
George Rutherford: charge of the agencies who know what they're doing, who
George Rutherford: aren't political appointees, who actually are... we don't put political
George Rutherford: appointees in charge of the Navy. You know, people who have
George Rutherford: careers in that and then they kind of graduate up.
George Rutherford: It's the same thing for public health. We should be
George Rutherford: putting people in charge of these agencies who know what
George Rutherford: they're doing, who have the experience, who have the training,
George Rutherford: who understand what is... who faced these crises before. That's
George Rutherford: be the first thing I would do. The second thing
George Rutherford: is I think you have to ramp up testing capacity, like crazy.
George Rutherford: And the third, you got to make sure that people get vaccinated
George Rutherford: and you have to set the examples about vaccination. And the other
George Rutherford: thing is, is that we can't have this sort of ostrich-
George Rutherford: like existence with our heads stuck in the sand. You
George Rutherford: know, we have trading partners in Canada and Mexico who
George Rutherford: need vaccine just as much as we do, we have
George Rutherford: to figure out how to get along with everybody else,
George Rutherford: we have to be part of WHO, we have to
George Rutherford: be able to do things like take climate change seriously,
George Rutherford: which actually is probably what underlies this at its deepest
George Rutherford: roots, if you're going to do a root cause analysis.
Bill Curtis: Explain that to us please, George.
George Rutherford: That you have overgrowth of bad populations because of human
George Rutherford: migration and human land use so that people come into
George Rutherford: contact with bats or the animals that come into contact
George Rutherford: with bats. This is what's happened with Ebola. And this
George Rutherford: business it's always bats that get blamed.
Bill Curtis: But it's really humans are the problem, but bats are sort of getting the blame.
George Rutherford: People and bat next time. Yeah. Yeah. And you know, you've
George Rutherford: got to take the climate change stuff seriously. I mean, I'm
George Rutherford: sitting here in Northern California, yesterday the sky was orange,
George Rutherford: and today it's pink, the fires and all that stuff,
George Rutherford: serious stuff. And you know, this is millennial thousand year
George Rutherford: cycles, we're perturbing, and there's a lot of ecological effects
George Rutherford: and ecosystem effects, and bad overgrowth and people coming into
George Rutherford: contact with bats. That's just one of them. And population
George Rutherford: growth obviously adds to it. So those are the things
George Rutherford: I would take seriously. I think you have to take kind of a bigger view
George Rutherford: of this stuff, and meanwhile set good examples, put good
George Rutherford: people in charge, and lead by example.
Bill Curtis: Okay. Well, Dr. George Rutherford and Dr. Steven Taback, thank
Bill Curtis: you for that. We're going to leave that there. And
Bill Curtis: George, if someone wants to follow you, what's the best
Bill Curtis: way for them to do that?
George Rutherford: You know, I do a lot of speaking at UCSF,
George Rutherford: either at Town Halls or at the Medicine Grand Rounds.
Bill Curtis: Okay. Well, Dr. Rutherford, I hope you'll come back and
Bill Curtis: join us again. This has been both entertaining, enlightening, a
Bill Curtis: little scary, but very much appreciated. I'd like to thank
Bill Curtis: our producer, A. J. Mosley, and sound engineer, Michael Kennedy.
Bill Curtis: Our music for Medicine, We're Still Practicing is by Celeste
Bill Curtis: and Eric Dick. If you learned something here like I
Bill Curtis: have, please forward the show to your friends, and yes,
Bill Curtis: even your doctor, because they'll get a lot out of
Bill Curtis: this too. We'll see you next time on Medicine, We're
Bill Curtis: Still Practicing. ( singing)
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