Has the U.S. Entered a Fourth Wave?

John Whyte, MD; Eric J. Topol, MD

Disclosures

April 12, 2021

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JOHN WHYTE: Hi, everyone, I'm Dr. John Whyte, chief medical officer at WebMD. You're watching Coronavirus in Context. Have you been hearing about this fourth wave? What do we even mean by that? So to help provide some insights, I've asked one of the best experts out there, my good friend and colleague Dr. Eric Topol. Dr. Topol, thanks for joining me.

ERIC TOPOL: Oh, of course, John, good to be with you again.

JOHN WHYTE: So let's start off and remind our audience, what is a fourth wave? What do we mean by that? And should they be concerned?

ERIC TOPOL: Well, in the US, we've had three waves, progressively worse, with the third one that emerged over the holidays -- Thanksgiving, Christmas, New Year's. That was a monster surge. Hopefully we'll never see the likes of that again. We got cases of a few 100,000-a-day in that. Now, we are presently in the around 60,000-per-day.

But what we're seeing is, in certain regions of the country, particularly Michigan, extending to Minnesota in that part of the country. In the Northeast, New Jersey, New York, and almost the whole Northeast sector. And then starting to see an uptick in Florida and Alaska. So we're seeing this patchwork pattern. Each of those places are seeing increases in cases. And particularly Michigan, with a big jump in hospitalizations.

It's this patchwork could lead -- now that this U.K. variant, B.1.1.7, is the number-one cause of infections in the United States. So we may see, or may not, depending on how this plays out, a pretty substantial -- hopefully nothing like the third, but it could be getting up to 150, 100,000, even up to 200,000. Who knows, right?

JOHN WHYTE: But even with vaccination, you think it could get that high? In terms of -- you and I talked a while back. And I remember you saying, we need to get to 2 million vaccinations a day. And some days we've had 4 [million]. So is it realistic to think that we could be back to where we were before, where we're talking -- literally, remember we're talking hundreds of thousands of cases a day?

ERIC TOPOL: Well, I hope not. And I don't think we will. It's a liability, because we don't -- even though we're doing up to 4.1 million vaccinations a day, a lot of those are second vaccinations, in fact, more than half. So then the question is, you get the most bang out of that first injection -- first vaccine dose -- and that's why, once we saw the B.1.1.7 starting to take hold here, many of us at that point, late January, early February, were advocating, let's just go for broke on first dose and delayed second dose, even though I wasn't in favor of that initially. Unfortunately, that wasn't done.

Another thing we can do right now is just blitz vaccines in Michigan. You know, just get every person we can there, National Guard, retired commissions, whatever. And more vaccines to basically put out the fire. We saw that work in Israel and in the U.K. We haven't done that. So just because you put out lots of vaccinations a day, may not be in the places that need them the most.

The point here is that we don't have enough people yet vaccinated. So we have over 75% of seniors, that's great. But then what you do is, you put the risk -- you shunt it over to younger people. So a lot of people younger than age 75 are nowhere near that level of first-dose vaccinations. That's the problem. So if we see it, it's because we didn't build the wall -- the vaccine wall, enough.

JOHN WHYTE: Now, you always have these great graphics and stats on your Twitter handle. And people should follow you @erictopol. But I want to give you some numbers, because -- I know you know all these numbers -- but a lot of people are saying fourth wave. People are getting concerned about that. Others are saying it's scary information. But you pointed out that 44% of new cases are just in five states.

So how can we truly say this is a fourth wave, which would imply that it's all over the country, where 44%, five states representing 22% of the population? But even more, you're in Southern California, and it was recently announced, 97% drop in new COVID cases since January -- 97% drop. If we look at deaths per day, we're less than 1,000 on average. It's around 700 to 800. I mean, that's what we were 8, 9 months ago.

So is it fair for the media to be calling this a fourth wave? Which some people are just getting confused, tired, and then they're not listening to the rest of the messaging that you just talked about. What we should be doing in those states who are having surges? Because when you look at all the data, when you take it all together, Dr. Topol, in terms of what's happening nationally, what's happening in local areas. And that's what we really care about. What's your assessment of where we are today in terms of the impact of COVID on the country?

ERIC TOPOL: Right, I mean, the good news is we've done really well with vaccinations. So whatever we prevent is an outgrowth of that, because we're not doing well with respect to opening things up. Many states are getting rid of mask mandates, as you know. So the two things we have, the new part is the ammunition we have with vaccination. We've never done well throughout the entire pandemic in the US with respect to tighter masking and mitigation.

Now, I think the short-term is, we don't know if this is going to spread more than those states and regions, as you've alluded to. Most of it, the problem of this uptick, is localized. But we know that it only starts to show up when you get to 60%, 70% dominant U.K. variant. And those places, particularly Michigan, it's in that 70% range. So when it's only 40%, which is a lot of the states, they may not have declared yet.

Now, if you just go fast-forward 4 weeks, 6, 8 weeks, we'll get past this. We will get past it. The vaccine's working exceedingly well against this variant and against basically all the variants we've seen to date. So this is like the last hump, our last challenge. And then we should have enough vaccinations covered enough Americans. So by June, we should be in really good shape with containment of the virus, for the first time ever, in this country, since the pandemic started.

JOHN WHYTE: Let's talk about Texas. The mask mandate removed, but people are still wearing masks. We've seen that. A lot of establishments are requiring it. Only 28% of people have been vaccinated once. Less than 15% of Texans have been fully vaccinated, yet their number of cases and deaths continue to decline. So how do we interpret that data correctly? Because we also don't want people to get the wrong conclusion from it. But we want to be fair.

Do we have enough information to say what's going on? Is it about the density of the population? Is there something else going on? Because some people are looking at it, and being like, hey, I don't have to wear a mask. I don't have to get vaccinated. And that's fine, but then we can look at other states, like Florida, and see where cases are increasing. So how do we interpret that information, Dr. Topol? How do you guide our viewers to looking at that information? Because they see it.

ERIC TOPOL: Yeah, they see it. We see it. But it's just this moment in time. I look at the baseball game in Texas, which was a packed stadium with 50,000 people, making believe we're pre-pandemic, post-pandemic. And I say, well, that's going to be interesting to follow in the next few weeks, what happens with that. So the point being is that it's too early to say that Texas is out of trouble. We may well see that.

And now, we still don't understand heterogeneity. That is, if you look across Europe where this strain B.1.1.7's spread across all of Europe now. Certain countries somehow withstood it, never showed up as a problem. They've basically kept it in check. Now, they've had mostly tighter lockdowns than we've ever -- we never had anything like what has been in Europe.

Then some countries, like the U.K. and Ireland and Portugal and Eastern and Central Europe, really had terrible situations. So in this country, it's possible that certain states, just because of this kind of pattern, the virus this pattern is relying on some local spreading event. And once that takes, we think this is the most likely explanation for Michigan, for example. There's been a lot of -- hundreds of -- small outbreaks. And those have taken off in many different places, particularly southeastern Michigan. If Texas or other states don't get this kind of spread-begets-spread, then maybe they'll be able to ward it off. We just don't know.

JOHN WHYTE: So it speaks to the importance of vaccination. And one question that keeps coming up is, is there one preferred? I've been telling people, get the one that's offered. But you know what, in a couple of weeks, people may have a choice in certain areas of the country in terms of J&J or Pfizer or Moderna. Do you still hold to the belief, take whichever one you can? But what about if all three were offered, they were all available?

ERIC TOPOL: Yeah, well, you know, I'm still waiting for the J&J trial of the two-dose. Because I'd like to know whether the two-dose has the equivalent efficacy of 90-plus percent as the mRNA vaccines. Until that time, there's a drop-off in efficacy with J&J. So you have to weigh, do you want to just get the one dose and not worry about it and have some drop-off in efficacy for mild to moderate infections? Possibly that also is blocking transmission and carriers date, that drop-off. And 20% points is a lot of points of efficacy.

So I'm still keen on the mRNA vaccines. I hold them as the reference standard. And maybe J&J will be as good. But we have to wait for that two-dose trial to come out.

JOHN WHYTE: But in fairness, they were tested when there was more variant around than the other two.

ERIC TOPOL: Well, yes, but if you adjust for that and you look at just the U.S. before we were invaded with the B.1.1.7, it was still 72% versus 95%.

JOHN WHYTE: What do you predict we're going to find out about asymptomatic transmission with these vaccines? We're starting to see some preliminary data in Israel, in the U.K. What's your expectation? Because if we know that for sure, then we could stop wearing masks. If that's true. When do you think we'll know it?

ERIC TOPOL: Well, I mean, we are seeing good data for the mRNA vaccines, where it looks like it's only going to be small single digits, few percent, 5%, maybe less, that have our carrier state. And even less of those could actually spread the virus, that is, they transmit. So one thing is having a carrier with very low viral load in your nasal mucosa. And another is that you have enough viral load, you could actually give it to someone. It looks like the chance of that are really low.

The question, John -- I should call you Dr. Whyte, since you call me -- is we don't know who those masked men and women or unmasked men and women are. So the issue here is if we all had rapid test in our home and we could test post-vaccination and you knew that you weren't one of these people that were a carrier, then we'd be good to go. But we just don't have those tests out there.

JOHN WHYTE: Since I have you, I always like to get your guidance for our viewers. And I know the CDC has made recommendations, but I'm going to ask Dr. Topol's recommendations -- domestic travel. What say you?

ERIC TOPOL: Well, if you're vaccinated, I mean, this is reentry to me. You're vaccinated, you got your two doses, you're 2 weeks post your second dose, as far as I'm concerned, you're good to go.

JOHN WHYTE: Discretionary travel, go where you want, in the United States.

ERIC TOPOL: That would be my view. The CDC's taking a more cautious view of it. But I think, as a courtesy to others, you wear a mask on the trip, because you don't know that you could be an asymptomatic carrier. Low probability, but possible. But yeah, I see -- the world changes, once you get the vaccination over. And we don't do enough with that, Dr. Whyte. We don't give the reward side. We want to get people to stop being hesitant. Well, hell, why don't we give them a reward?

JOHN WHYTE: Indoor dining. What does Dr. Topol say?

ERIC TOPOL: I'm not too keen on that just yet, because while we are sorting out this varying story, it'd be nice to know -- so, for example, for the U.K. variant. The asymptomatic transmission that you talked about, that can lead to higher viral loads. So we just don't know about that. So I'd hold off on indoor dining, which is kind of chief culprit number one -- bars, dining, indoor dining. I'd hold off on that for a few more weeks, until that gets sorted out.

JOHN WHYTE: What about a movie theater? I've been saying, just so you know, I think movie theaters may be better, if they have good ventilation. You're looking forward. You're not talking to anyone. There's no shouting or screaming like a baseball game. And it's time-limited. You're done in 2 hours, and then you leave. What do you say?

ERIC TOPOL: Well, the ventilation is the question. How do you know it has really good ventilation?

JOHN WHYTE: How do I know anywhere? I don't know.

ERIC TOPOL: I want to open the windows everywhere. I don't know any movie theaters that have windows.

JOHN WHYTE: That's because you're in Southern California. That's the standard, to open the windows. But you have some concerns about indoor activities.

ERIC TOPOL: Yeah, I think we still -- B.1.1.7, as it becomes the cause of most infections in this country, we're going to learn more. And maybe in a month from now, we'll be more confident. But right now, that's the iffy zone.

JOHN WHYTE: OK. CDC recently came out with guidance about surfaces. Should people stop worrying about touching an elevator button?

ERIC TOPOL: Yeah, the elevator button and the trash bin in New Zealand, that's been hunted down and there's not a lot to substantiate that. So really, we're talking about aerosol is the main, primary transmission. I think all the effort with the disinfectants and the fomite and all this stuff is misplaced. Not that it can't happen, but the odds are so incredibly low. I mean, just ridiculously low.

JOHN WHYTE: As you said, about the air and respiratory. One final question. Schools are starting reopening. CDC came out with guidance for most districts, depending upon community spread. Three feet, so that allows more kids to be in school. But here's the reality of what's causing some challenges: They say when kids eat, it should still be 6 feet. So that makes it very challenging for some schools. But does that make sense on a scientific basis? If we're talking about elementary school kids, so we already know viral spread is lower. We know that they're less able to communicate, perhaps by the development of the respiratory tract.

So we have 3 feet, yet when they're eating, which by definition is time-limited for kids, is there science to support that, or does that just make it more challenging for districts to have more kids come back to school? And in many private schools, they've been open in many months of the pandemic.

ERIC TOPOL: The problem really is, there's no science for 6 feet, 3 feet, 1 foot -- anything. There's no science. It's very shaky.

JOHN WHYTE: Thank you for acknowledging that, people don't always acknowledge. We don't have as strong data as we'd like.

ERIC TOPOL: It's just crazy. The study that compared to 6 feet to 3 feet has more flaws in it than I could even spend hours describing. So no, the problem --

JOHN WHYTE: Much of the world has used 1 meter, in the metric system -- 3 feet in Canada and elsewhere.

ERIC TOPOL: Yeah, I think the problem is that we don't use the tools we have. If we had the teachers and the kids in and all the ancillary staff vaccinated or we used rapid tests to show they weren't infectious, forget the 6 feet, 3 feet. But we aren't using the things that we know work. And if we had ventilation, which now we're getting out of the colder weather, so that we had every classroom was well-ventilated, windows were open or whatever, these are things we know would work. And then you could have kids sitting next to each other. That's not the problem. The problem is all the other things that we don't do to take precaution.

JOHN WHYTE: So I want to ask you, because we've been able to talk throughout the entire pandemic. Are you hopeful?

ERIC TOPOL: Oh gosh, yes. I mean, I think we're at the last -- we're not at the finish line. But we're getting closer. And it's a marathon that instead of 26 miles, it's like 2,600 miles. And we're kind of like at 2,500. We're getting to the homestretch. And like I say, if we're just get over the main concern, which is this B.1.1.7 strain -- it really is a different virus, in many respects. If we can get over that -- and we will -- I'm confident by towards the end of June, we'd be in very good shape. We may not have absence of COVID, but we'll have it at levels that are suppressed that we've not seen since the beginning of the pandemic. And that's really exciting.

JOHN WHYTE: Well, Dr. Topol, I want to thank you, as always, for providing great insight. I encourage everyone, as I mentioned early on, to follow you on Twitter. You have great graphics, great description of what's going on. And really tease it down for both scientists and nonscientists to see what's going on. So thank for all you're doing to give us good information to keep us safe.

ERIC TOPOL: Oh, thank you, John, you are the same. You're a great resource. And thanks so much for having the chance to have this conversation.

JOHN WHYTE: Well, if you have questions for Dr. Topol or me and you don't want a message him on Twitter or Instagram, you can send them to me at drjohn@webmd.net. Thanks for watching, everyone.

This interview originally appeared on WebMD on April 12, 2021

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