Oh, opinions expressed in this podcast by participants are solely their opinions and do not reflect the opinion of bio Virgin or its affiliates. The participant's opinions are based upon information. They consider reliable, but neither bio verge or its affiliates warrants, its completeness or accuracy, and it should not be relied on as such, nothing contained in an accompanying. This podcast shall be construed as an offer to sell a solicitation of an offer, to buy or a recommendation to purchase any security by bio verge, its portfolio companies or any third party past performance is not indicative of future results. You're listening to the bio verge podcast. Nail today. We've got Eric Topo for listeners, not familiar with Eric. Who is he? 

Neil Littman (Host)·01:12

Eric is a physician scientist author and professor Eric was voted the number one most influential physician leader in the U S by modern healthcare. He's published over 1200 peer reviewed articles. He has three best-selling books. For those of you who are interested in the convergence of technology being applied to the healthcare vertical, they are both fantastic reads deep medicine, and the patient will see you now. He is also the founder and director of translational medicine at Scripps research. 

Danny Levine (Producer)·01:47

Yeah, in 2009, I got to write a profile of him for the journal of life sciences. And, he had this vision that he brought to Scripps of not only integrating, genomics into the clinic, but marrying it to technology to understand the relationship between genotype and phenotype. It's, it's not an outrageous thing to hear today, but this was over a dozen years ago. How much of an advocate has he been for that kind of vision of new medicine? 

Neil Littman (Host)·02:23

Oh, I think he's been a huge advocate for that for bringing technological innovation to the healthcare domain. And, and I think he's really, I've been a big fan of Eric's for many years now, right. He, he really is a, a thought leader when it comes to applying a lot of these digital health, technologies and digital health solutions to, different problems in healthcare. He does a lot in the cardiovascular space. So, I think if you take a look at a lot of his publications, if you take a look at his books, right, he talks a lot about the future of health and how things like artificial intelligence and machine learning can be applied to healthcare. 

Neil Littman (Host)·03:04

I think he really is a thought leader in the space and, today's conversation, isn't so much going to be about the digital health front, that many of us have now have known Eric and has worked for many years. We're going to focus really on the Delta Verint and COVID, but he really is a thought leader. He's established himself again as a, a real thought leader in these times of the pandemic. I think, his Twitter feed and a lot of articles, he writes his op ed pieces. I think he really does a public service and helping to sort fact from fiction, in the face of this global pandemic. And, I hope to actually get into the convergence of the digital health and technology aspect of what he's done and how he's applying that to COVID these days, 

Danny Levine (Producer)·03:50

His Twitter feed has been really a reality check on COVID. What are you hoping to hear from him today? 

Neil Littman (Host)·03:58

Yeah, I mean, I, I'm really hoping to get a good understanding of the Delta variant where we are today in terms of the third wave of the pandemic. I mean, I think most of us we're hoping that once the vaccines would roll out, right, the pandemic would largely dissipate and we would move on and get back to our normal daily lives. Right. That has not happened. That is because of the Delta variance. I really want to talk to Eric about this idea of, breakthrough infections, what that means, what we, what our failures are as a society in terms of being able to control the virus, right? The lack of, enough people getting vaccinated, what we can do to help encourage people to get vaccinated, and how our response needs to change to the virus based on the virus itself changing. 

Danny Levine (Producer)·04:53

Well, if you're all set, 

Neil Littman (Host)·04:55

I am all set to any, let's do it. Eric. I'm incredibly excited to welcome you to the show today. Believe it or not. Before I started the podcast, I sat down and came up with a wishlist of guests for the show. You were literally my number one guest or my wishlist. So huge. Thank you for joining me today. I'm glad to have a chance to talk with me as well. So, COVID aside, which we're going to get into momentarily. I've admired your thought leadership with respect to how technological innovations can be applied to help solve fundamental problems in healthcare in particular, your books, deep medicine, and the patient will see you now are both must reads for people interested in the topic and will really both inspirations for me, as I thought about what I would have to do with my career. 

Neil Littman (Host)·05:41

Ultimately it helped shape a lot of what I'm doing today at bio. That said your thought leadership when it comes to COVID in particular, I think has been instrumental in helping many of us sort back from fiction in the face of the global pandemic. Without further ado today, we're going to be discussing, the COVID-19 pandemic, specifically the Delta variant, how our response must evolve along with the virus. Eric, to help set the stage for our listeners. Could you first talk about some of the biological attributes that make the Delta variant such a form of double adversary? 

Dr. Eric Topol (Guest)·06:19

Sure. Neil, well, you certainly characterize it. Well, formidable adversary is a good way to think of it. If we hadn't had Delta, they hadn't evolved to this strain. We'd be really in very good shape, in the U S and throughout many parts of the world. Unfortunately, this, evolve to a point where very different from the prior major variant alpha beta JAMA, this one took some detours in terms of its spike protein and internal domains. It's really been a tough one because it's so incredibly hyper transmissible, hyper contagious. It also does do some evasion of our immune response, including as we'll discuss the vaccine induced immunity response. 

Dr. Eric Topol (Guest)·07:05

Because of that, we're going through what may wind up being the worst wave in the U S and which is remarkable because it's at a time when we have plenty of vaccines, and we're already, a hospitalization rates over 85,000, which our peak was wanting to 25,000. I don't think anyone would have envisioned we'd be at this point and still a ways to go to get past the Delta way. That in itself gives you an impression of how tough this virus is and how it's overwhelmed the, immunity wall that we have, which is a combination of both people who are vaccinated, as well as people who've had COVID previously. They have some natural immunity, but, Delta has just blown through all that. 

Neil Littman (Host)·07:53

And, and I want to get to the notion of breakthrough infections here momentarily. Just while we're on the changes in the biology, could you maybe just spend a minute or two and talk about the transmissibility of the Delta variant compared to the original strain of SARS cov two? My understanding is that the are not of Delta significantly higher than the original strain, which is leading to the increased transmissibility of the virus. 

Dr. Eric Topol (Guest)·08:18

Yeah. I mean, if you want to look at it from the, are not, you it's in the six to eight, whereas the original was one to two, but if you look at it from what is the viral load in people, a really important study that came out of China, very rigorous study showed that it was more than a thousand fold viral load in people who have a Delta infections compared with the original, ancestral strain. So that's actually, it was, 1204. It's a huge increase, magnitudes, orders of magnitude more, and that viral load accounts for how easily it's spread, how it's doing things that the previous versions of the virus really didn't do, including the ability to, engender infections and people who were vaccinated. 

Dr. Eric Topol (Guest)·09:11

It's this load of the virus, its ability to attach to the cells and our upper airway, and get in and hijack these cells and make, enormous amounts of virus quickly. That that's really the big deal here. 

Neil Littman (Host)·09:26

If you compare it to other viruses, right, just for a benchmark comparison, right. I, I I've read it. The, the are not of where the Delta is much more infectious than the flu or common cold, or even MERS or SARS. Are there other viruses that the Delta is comparable to out there that folks may be more familiar with? 

Dr. Eric Topol (Guest)·09:48

Well, I mean, the one that the CDC had compared it to is chickenpox, which is one of the most, infectious pathogens we've ever seen, obviously not nearly as dangerous with spectral lethality and, hospitalizations, but it isn't as contagious as chicken pox. I think that's pretty clear. That's in the 10 to 12 level of our not, but it's up there, it's way up there, it's it many would consider it to be as high infectious respiratory virus, as has been seen, but it's definitely in a Strava that is a deep concern and getting our apps around it. That is it isn't just vaccines. We have to basically pull out every tool in the kit in order to defend against. 

Neil Littman (Host)·10:43

Not, Eric, you had mentioned this , not surprisingly there's a strong desire people have now to return to the pre COVID lives. No. As you mentioned, right, that was largely supposed to happen once the vaccines were rolled out, that was obviously prior to the emergence of the Delta variant. We're now thirdly, in the next wave of the pandemic, I've heard this wave, being referred to as a pandemic of the unvaccinated, which at best doesn't seem entirely accurate and at worst is potentially dangerously misleading. Could you, could you maybe talk about your thoughts there and then in particular, this notion of breakthrough infections and then what that means, 

Dr. Eric Topol (Guest)·11:23

Right? It isn't unfortunately a pandemic of just the unvaccinated. Plenty of those who've been vaccinated, particularly if they're more than six months out, like the original healthcare workforce and nursing homes and people of advanced age, those are the first people to get vaccinated. They're now quite vulnerable because they could get infections with Delta. That wasn't the case before Delta arrived. So, no, it's a pandemic of both the vaccinated largely, that's the vast majority, but it also includes the vaccinated. That is the unfortunate sense that people, oh, I I've been fully Vaxxed. I'm protected. That's no longer true. You still can get infected. It's unlikely. You'd wind up in the hospital. That's still possible unlikely, but getting an infection isn't good because multiple things you could get long COVID from that. 

Dr. Eric Topol (Guest)·12:20

You could transmit it to others, either unwittingly, because it's, before you develop symptoms, you can get some pretty rough symptoms. In fact, even to the point where you have to go to a place to get intravenous monoclonal antibody infusions to inactivate the virus. I mean, so it isn't trivial. This is not just a positive PCR test. These are infections that get people sick. Fortunately, not for the vaccinated people, not the ones that, are usually, accounting for such need for hospitalization. That's a good thing, but, being sick with COVID, most people who've ever had, it will know that is not a good thing. It can be a pretty rough illness to ride through. The fact that you got vaccinated and you thought you're going to get to pre COVID life. This happens, obviously that diminishes the confidence, in the vaccine. 

Dr. Eric Topol (Guest)·13:16

That's just because, the fact that boosters really are needed, and hopefully will be a durable solution to the problem. 

Neil Littman (Host)·13:26

I want to jump into that point in a minute, cause I think that's going to be critical, but obviously there's a lot that we know about the Delta variant and, you discussed in your op-ed or article in the guardian, right. America's flying blind when it comes to the Delta variant there's seems to be even more that we don't know. It was specifically, you talk about the lack of data around breakthrough infections, and how that's giving Americans a false sense of security. Can you explain about your op-ed piece and what you mean by that? 

Dr. Eric Topol (Guest)·13:55

Right. Well, you mentioned it Neil, and you're saying that pandemic of the un-vaccinated that doesn't acknowledge that the vaccinated people have some risks and this false sense of confidence and security, we need to put out the awareness that just because you're vaccinated doesn't mean you won't get an infection at this point and wearing masks, particularly, quality, tight fitting mask, distancing, and elation, avoiding crowds. All these different features are very important just as they were before vaccination they're complimentary or additive. The reason why this is misleading is by not acknowledging the risks in the vaccinated, we're getting more people, getting Delta infections who are vaccinated because they just don't have that public awareness. We need to get that out there. The other part of it that you touched on is we don't have the data for the United States. 

Dr. Eric Topol (Guest)·14:50

We have to rely data from other countries because our ability to gather the data and post it, basically doesn't exist here at the national level, 

Neil Littman (Host)·15:01

Which is somewhat mind boggling at this stage of the pandemic. I want to just touch upon a really important point that you mentioned in terms of yes, vaccinate people can still come down with an infection. I think there's a kind of a misunderstanding about this idea of sterilizing immunity, right? And sterilizing immunity doesn't happen with the current set of vaccines. Could you maybe explain why that's the case and talk about where we are today in terms of the vaccines that we have versus, intra-nasal vaccines that could potentially produce the sterilizing immunity. I, I know there are much earlier in development these days, 

Dr. Eric Topol (Guest)·15:38

Right? Well, that's a really important concept to develop. Sterilization immunity, through shots wasn't expected, because you're basically really going after the blood, immune response, the mucosal immunity that is in the upper airway, particularly nasal mucosa to get that sterilization immunity that realize, especially one particular class of immunoglobulins IGA and the shots don't get us, sustain high levels of IGA protecting our nasal mucosa and upper airway barrier. That was the unexpected thing that happened with the MRN vaccines. When they came out as 95%, protective against symptomatic infections, the primary end point of the trials, they say, whoa, this is better than expected. Indeed until Delta, there was pretty good evidence of not perfect, but close to the kind of mucosal immunity we would want. 

Dr. Eric Topol (Guest)·16:44

That is, there were very few breakthroughs meaning that, the nasal mucosa was holding up and, people were holding, the vaccines were protecting them 1% or less breakthroughs, but what happened with Delta is basically it pierced through the issue of this problem. We now don't have sterilization to me, like we had, it's probably down to, half of what we had, which was, unexpectedly high and worked sterilization probably is the wrong word. Cause that's a binary yes or no, but we have half as much mucosal immunity that is our barrier for entry of the virus is about half as good as it was for MRI. As when we started this, vaccination, phase, it's all because of Delta. And, it's because of the waning of antibodies. Our blood, response immune response is also not as sharp as it was. 

Dr. Eric Topol (Guest)·17:43

When you're only one month or four months out from your vaccine second dose. So that's where we stand. We, we got, an unexpected bonus factor, for mucosal immunity, but it basically only got us through pre Delta and it isn't holding up well in the Delta variant way. 

Neil Littman (Host)·18:05

So, Eric, I think this is actually a nice segue back to an earlier point you made about the booster shot. So, so there's a growing consensus that, a third booster shot or for Mr. And a vaccines in particular, right. Could be very effective. About six months after the initial vaccinations, they could confer increased immunity by increasing neutralizing antibody levels. I think Israel has been doing this already, and I think they've had some great effects to that. What are your thoughts about rolling that out in the U S. 

Dr. Eric Topol (Guest)·18:33

Right? Well, we're mainly learning from the Israelis because they've now given over a million boosters, to people, and, their data. Of course we're the first to show this very diminished vaccine effectiveness against infections, not so much, of course, a drop in hospitalizations, her desk, but against infections, including symptomatic infections from what was well over 90% to levels of about 40%, there were major dropdown. Now what they're showing in the most recent data in recent days is that they're restoring the vaccine effectiveness to that 90% or so level with the boosters quickly, which is what you'd anticipate, because they basically just activate our memory and very quickly get high levels, a blitz of neutralizing antibodies directed against the spike protein. 

Dr. Eric Topol (Guest)·19:24

The Israeli data are supportive of boosters, but I think what we have to acknowledge is, this isn't going to change all of a sudden, if we start using boosters, it's not going to change the face of the U S Delta wave. It basically is going to protect the fully vaccinated who are now six months out or more from getting infections, which is important. I mean, that's a good thing. It'll prevent some transmission illnesses, long COVID, but, we're not going to see a whole lot in the way of reduction of hospitalizations from breakthroughs, because they're very few to start with. It will be helpful, and it will help in some respect to break the transmission chain, but it's nothing like getting more people vaccinated. That's what we really need. That's the bang for the vaccines is in the primary vaccination, not in the boosters. 

Neil Littman (Host)·20:18

And, and I want to talk about some strategies that can be utilized to encourage more people to get vaccinated in a minute. The other question that comes to mind is, will we in the U S really be safe until more people worldwide are vaccinated, right. Especially given that areas and the populations that aren't vaccinated across the globe will be a hotbed for potential future variants that may averge. How do we think about balancing, boosters in the U S with really more broadly distributing the vaccine worldwide? 

Dr. Eric Topol (Guest)·20:51

Yeah, that's a really, critical dilemma. We need both, right now the U S is the main driver of codeword for the world. I mean, there's more cases that are being generated and spreading here than anywhere else. We are the number one culprit right now, and states like Florida, Louisiana, and Mississippi are the leading in the world cases per capita of any country, your state, which is just incredible, who would have thought this was possible. We have done, absolutely unfortunately, a horrible, execution of getting that very high level of vaccination. We needed even Israel, one of the highest, UK other countries, they've had trouble, obviously with Delta. That's how tough it is. So, we would've gotten away with it. We did with the alpha variant, but this one has just changed the dynamics. 

Dr. Eric Topol (Guest)·21:50

Now we need, 90% plus people who either have full immunization or prior COVID or some type of, immunity. Now the global situation is another compartment, if you will, because if we don't get containment globally, even if we ultimately do get this in the U S then we still could get, circulating serious functional variants coming back to haunt us. That's why it's so vital that we get both of these done. 

Dr. Eric Topol (Guest)·22:23

In fact, perhaps you could say the global mission is far more important because there's such a vast majority of the human population who hasn't had any vaccine yet, but you have to also understand the interests that there is a lot of vaccine nationalism and people want to get the most protection as possible because no one wants no one who's reasonable wants to get, go through a COVID infection, because you don't know the unpredictability, how sick you might get, no matter how young and healthy you are because of the risk of long COVID the risk of deterioration. These are the fine line balances that are very delicate, very tricky. And obviously, it depends on your perspective. If you're a place it's got the vaccines and you want to try to help your citizen rate. Okay. 

Dr. Eric Topol (Guest)·23:13

If you're looking at it from a global perspective, it's very different. 

Neil Littman (Host)·23:18

Yeah. There's, again, a lot to dive into there. One of the things that you had mentioned before was this idea of lack of surveillance, lack of data being shared from, local state, federal levels. I mean, w w w in the face of growing hospitalizations, what should the response be at the individual local state and federal level, in the face of this terrifying Delta barrier that we're seeing? 

Dr. Eric Topol (Guest)·23:47

Yeah. I think the problem Neil is by not having the data in this country, it's actually quite a pathetic situation because, this is a decision that's very important, will affect, tens of millions of people, hundreds of millions, of people in this country potentially. We don't have our data, we're w that is, there's some counties around the country that have data on vaccinated, unvaccinated, hospitalizations, and, age and time from vaccination, which vaccine, that kind of stuff. We have nothing at the national level where we have just an extraordinary opportunity. We've got 85, 80 6,000 people in the hospital right now with COVID. That's the diminimous data we should have from every single patient who's in the hospital today, because that would help guide us as to who needs to get boosters, whether for sure we do need to go ahead. 

Dr. Eric Topol (Guest)·24:44

And, what are the risk factors? Because one of the issues here, which is quite prominent is that other countries that you use the eight to 12 spacing of the MRNs vaccine, eight to 12 weeks like Canada, UK, many places use eight to 12 weeks, partly because they had a vaccine shortage. Partly also backed up by the immune response would be superior by spacing longer. The accelerated spacing with three weeks of Pfizer, four weeks of Madonna that was used in the us and Israel, Qatar, and many other countries that may have set this problem up in many respects. We need to know that, we, that data is, still the countries that had the longer spacing, the vaccine effectiveness for MRA is holding up much better. That's just another issue about not having the data. And it's really unfortunate. 

Neil Littman (Host)·25:45

Yeah. Another unfortunate, compounding factor, I think, and this relates back to the data, right. I think, Eric, since the beginning, you've been a strong proponent of rapid antigen based testing, but why has rolling out this rapid antigen based testing been such a failure in the U S why have we been so slow to adopt this? 

Dr. Eric Topol (Guest)·26:06

Yeah. You can add that to the failure list. All right. That's like way up close to the top. I mean, this is one of those essential parts of the toolkit, are you infectious or not? Right. That is so critical because the answer can be had quickly accurately, and it can be used. For example, as you well know, one of the big issues right now is going back to school. How do we do that safely? And people are debating about the mask and the distancing in the schools and that thing. Where are the Don rapid antigen tests that should be in every home where each child and each teacher and each staff person bus driver each day of school has the test. 

Dr. Eric Topol (Guest)·26:52

If we did that, like as being done routinely in Denmark, Netherlands, Austria, Germany, and a long list of countries that have safely opened schools, we'd keep the infectious people at home until they were no longer infectious. We're not talking here about a PCR test, which picks up any virus, remnants, very few copies of the virus we're talking about. Are you infectious? And with Delta, that's what we really need to know. These tests are, can be very inexpensive. They should be supplied by the government. They should be in every household, particularly those that have children who we want to get back to school. The fact that there's know, mom is the word. There's no plan on this. It's really extraordinary. 

Neil Littman (Host)·27:40

It's really extraordinary. And somewhat mind-boggling. Eric, I want to go back to a point that you made, because I think a lot of the criticism around the rapid antigen based tests is that they're not as accurate as PCR, which while true, what entirely misses the point. 

Dr. Eric Topol (Guest)·27:56

Can you explain the, that's a 10 standard PCR is unhelpful for telling us if a person is infectious, actually with PCR, if it's done properly, there's a thing called cycle threshold, CT. When that's low, that does correspond to the level of infectiousness, but nobody gets that data, right? So what you're basically it's reported out as PCR positive or negative. Well, if you're positive, you can have a very high CT and B no chance you're infectious, really. To compare it to that is absurd. The rapid antigen test stand on their own merit, the good ones. Now I have to say there are some that are not worth their use, but there are many that are highly accurate that are very, quick and can be very inexpensive. 

Dr. Eric Topol (Guest)·28:48

They're not, I mean, the only ones out there practically in the U S or, Binaca that are $12 each, there's a Tupac for 23, 20 $4. That's ridiculous. You can't do that every day in a wide scale, in a school, but there are tests out there that could be done, with equal or better results at the cost of a dollar and in less time, like five minutes instead of 15 minutes. So we haven't made that a priority. Basically, I think, is that the country leadership was banking on the vaccination program being the kind of end game and just didn't think about what other things that should be part of this. Here we are well into the Delta wave, and there's no sign that the, availability of tests, rapid antigen test is going to be made, to, the Americans in the near future. 

Dr. Eric Topol (Guest)·29:45

And that's really a problem. 

Neil Littman (Host)·29:48

Eric, I want to circle back to this notion of long-term health effects that you had talked about. You've been involved in some studies that are looking at long-term health effects for people who have had the virus. Can you talk about long COVID what it means, who is likely the most susceptible to it? 

Dr. Eric Topol (Guest)·30:08

Yeah, there's a lot of misconceptions about long covert. People still think that you gotta have a really severe illness and then you'll get potentially the issue of chronic, symptoms and some being debilitated. We don't know the true incidence of it. It's somewhere north of 10% and could be as high as 25, 30%. But I don't think it's that high. The point here is that those 10% who get COVID, and they're usually young, healthy people who had mild to moderate cases, not having to go to the hospital. I have colleagues with this and they are healthy athletic types who now still can't many months later, even a year later, still can't even, resume their prior activity. Some can't even walk more than a few blocks without getting breathless. I mean, it's just a very potentially very debilitating condition and we have no real effective treatments. 

Dr. Eric Topol (Guest)·31:09

We don't even understand truly the biologic basis we've got theories. The only thing we have to do is prevent it, and we're not doing that right now, obviously with a Delta wave in the United States. So long COVID is a big deal. It's mostly in young people because that's where most of the cases are, who are relatively healthy. And, they may get over the illness pretty fast for a matter of days. It comes back to haunt them on a long-term basis. And we don't even know the duration. Some people it clears up in a matter of months, some people it goes on and still going on now a year and a half plus later. It is it, we do not want any more long COVID. We have millions of people with long COVID. 

Dr. Eric Topol (Guest)·31:52

We have long COVID clinics now that have popped up all throughout the United States multidisciplinary clinics. This is a very big underestimated public health problem. That is, in part, because of the denial of it being an issue. On the other hand, in sharp contrast, the serious problems that the people with it are having. 

Neil Littman (Host)·32:17

Eric, you've been involved in this study that used wearable devices to detect longterm changes from COVID. Can you talk about what that study showed? 

Dr. Eric Topol (Guest)·32:28

Yes, that was called it is called detect there's about 40,000 Americans participating. All they have to do is sign up through the app, the tech study and, their smartwatch, any type of smartwatch or a Fitbit or any fitness band that they're have on, passively just their data, centrally de-identify. We know, for example, the heart rate is a really great signal when your heart rate goes up above your resting normal heart rate, and it stays there. That's a very good sign that you could have an infection if there's no other explanation. We have a pretty good signal, actually quite good, for what COVID, looks like through things like heart rate and activity steps, sleep when those data are available through a fitness band. 

Dr. Eric Topol (Guest)·33:23

Also now we've published not only that signal for COVID detection, but also now the fact that for people who have long COVID, they have this heart rate that stays up and just doesn't go back for many weeks months. We're also seeing people when they're vaccinated their response. This passive collection of physiologic data is extremely helpful, and may help identify those who are at risk for long COVID. It certainly, is, would be useful if we took it broadly, adopted it, throughout the country. When we get a containment, we only had nearly getting contained at once, and that was just before Delta hit. That's when you can start to monitor where a new hotspots new outbreaks are just beginning where there's any confluence of people, any, group of people at any part of the country that are showing lighting up for potential COVID signal. 

Dr. Eric Topol (Guest)·34:24

As long as there's not some other infectious illness out there like flu, it's a pretty good way to nail down our risk zone and get in there and stop the outbreak in its tracks. So, we're not using this either, Neil, this is yet another tool we developed here. We released it within the first couple of weeks of the pandemic in the U S in March of 2020. It was adopted in Germany. It's used in hundreds of thousands of people in Germany and also in other countries, but in our own country, we can't get, a much broader participation. We obviously can inform people when we see their signal that they may have COVID. That's, I think a very useful thing for people, because these are low level differences in heart rate that a lot of people would not be able to detect on their own. 

Neil Littman (Host)·35:14

Well, it certainly seems like more people would want to use this type of technology, right? It is available. I think that, I mean, that leads to my next question is what role can digital health technologies play in really improving surveillance, potentially in finding new outbreaks? I mean, these technologies can be applied pretty broadly. I think, in the face of the pandemic. 

Dr. Eric Topol (Guest)·35:36

Absolutely. You know, that's. 

Neil Littman (Host)·35:38

What we're missing here is there's no real, articulated goal to have all the different layers of data, that includes this digital sensor data from the wrist, which is rich wastewater surveillance, mobility, data, genomic surveillance, the data that we've already discussed with respect to, the need for partitioning in the Delta wave. What's going on with the people who are vaccinated, getting sick. No, no less the on vaccine, all this data real time, which is then getting processed, crunched analyzed and getting fed back to the public. So they know where they live. What does that, what the hell is going on, which they don't right now, largely. So there's it's so unfortunate. We're not doing this because it's all out there. I mean, we're not doing genomics sequencing as we should, but that should be out there. 

Neil Littman (Host)·36:37

The sensor, we have 80 million Americans who have a smart watch or a fitness band or some kind that would emit this data. We could tell in one little zip code, one neighborhood where something is potentially is brewing, but we're not doing it. That's of course, one layer of data. There are so many layers that we are missing. Yeah. I mean, it's, it seems like there needs to be some campaigns to encourage more people to utilize the technologies that they're already wearing on their wrist. 

Neil Littman (Host)·37:09

I, I do want to circle back to the idea of how do we, what do you think is the right approach to encouraging more unvaccinated people in this country to go out and get their shots and get vaccinated, right? For example, should we be requiring proof of vaccination to use public transportation, to fly, to dine and doors, to go to sporting events or concerts, or, participate in large public gatherings? I mean, how do we encourage people to garden get vaccinated? 

Dr. Eric Topol (Guest)·37:41

Well, we have to stop, the encourage and go to what you just said in you, Canada and other places I've already done it. You want to go on a plane, the train, public transportation, you have to have proof of vaccination, or you have to have some other, excuse, from a physician about why you can't get vaccinated. We're not taking a hard stance on this and it shows, the FDA approval, which should have been done by early June. And now we're well into August. That's held us back because that would have led to, we've seen a lot of mandates, but those mandates would have come much earlier from companies from municipalities, from universities, high schools, health systems, the military, a long list. We're only part into that. They will, they will increase markedly at the moment, the full approval of FDA. 

Dr. Eric Topol (Guest)·38:41

That's another thing we could do. Another thing is that the misinformation campaign has not been, there's no been no counter offensive to it, and that's serious stuff. The anti-vaxxer, completely fabricated, BS that's out there that is being fed to tens of millions of people every day. Just making stuff up that isn't true, that is manipulating the, various, vaccine adverse events reporting data that the CDC puts out. Unfortunately, all sorts of things are being done to take down the truth about vaccines. We're not doing anything that's worthy, meaningful as antidote for that poison. 

Neil Littman (Host)·39:29

Yeah. I think that's a huge part of the problem and, Eric, that's where I think your Twitter feed is so incredibly helpful is to cut through all of the noise out there and the misleading information. It really acts as a source of truth for what is actually going on. I, I want to just talk about, COVID over the longer term. I mean, D do you think COVID will always be with us similar to the flu where we will need annual vaccinations or boosters, basically, for, I guess the foreseeable future or forever, 

Dr. Eric Topol (Guest)·40:08

It's hard to know about, I mean, it won't be endemic. Yeah. There'll be out there, for many years, not in perpetuity. Yeah. But, if we're, if it's contained, if it has such low levels and most people are either vaccinated or have some prior, infection immunity, it can stay contained, especially if we do the thing as we've been discussing. If we start using the tools in the kit that we haven't even used yet, but, I don't know that it's going to require frequent booster shots yet. I mean, it's possible that the one booster could take us years out, and that would be great. We had thought that was going to be the case before Delta came along and it might have, because we saw signs that the immune response natural meaning was quite durable. 

Dr. Eric Topol (Guest)·41:02

We also started seeing signs that the vaccine immunity, both the antibody and the T-cell response was quite durable. Delta broke through that, but now at the booster and activated memory and these, the whole bridging to a different time, maybe we won't meet these boosters every six months. That's, I'm optimistic. I'm hoping that's going to be the case, but we just don't know until we get there. We didn't know that Delta was going to cause this leakiness of the vaccine for infection. Thank goodness. It didn't do that for hospitalizations and deaths. So, I think the answer to your question is still unknown. But, if you look early next year in 2022, we'll know the answer about whether the six month booster thing will be, something we're going to have to look. 

Dr. Eric Topol (Guest)·41:55

One other point on that is we're not putting enough effort into the pan coronavirus vaccine, the cyber co virus, family, to take them all down so that whatever Greek letter variant that comes along, we can squash it. We are not putting in the resources and our priority to that, and of course the nasal vaccines that you touched on, which would get us to the mucosal immunity. These other things that we're not doing giving prior, and we should be doing now so that when we get containment, we can keep it and not have to go through any more waves we've had enough. Right. We've had more than enough. 

Dr. Eric Topol (Guest)·42:32

So, we're not doing that kind of advanced planning, which, I wish were really going after the pink Krone virus vaccine, because I am confident that we will get there, but we get there faster if we're making an all out effort. 

Neil Littman (Host)·42:47

Yeah. I think that's a really critical point because I, there's little reason to think that Delta Veron is going to be the last burn we're going to see. Hopefully there won't be future ones quite as transmissible as the Delta variant, but it seems like it's probably only a matter of time until new ones emerged. Okay. 

Dr. Eric Topol (Guest)·43:03

Yeah. That may be true. I tell you, this is one tough barrier to, I do. I mean, it's taken over the world here, fast. In order for it to overtake compete with Delta, it's going to have to be, and you started with formidable, it's going to be an, it really is with a capital F this is going to be hyper formidable. Right. It may happen, but we, again, the hope is that, have we reached a peak level of transmissibility, maybe not, and we sure can't count on it, but, that just for all that we have, because this one is hellish. Right. 

Neil Littman (Host)·43:44

Absolutely. Sure. I think that brings me to my next point. Well, how do you, or how should, people who are vaccinated, think about, wearing a mask these days about the social distancing strategy, in the wave of Delta, is this something that needs to be re implemented? a lot of people have, what did it go back to pre COVID days? There's not as much mask wearing, there's not as much social distinct thing. That something that we need to re-engage in, even if you are vaccinated at this point in time? 

Dr. Eric Topol (Guest)·44:17

Yes, definitely. This is that Swiss cheese model. It's been popularized by the virologists in Mackay. We got to use every level of protection. So it isn't just a cloth mask. We need, tight fitting high quality mask, ideally, either can 90 fours, which are cheaper or N 95, again, that would be smart for the government to send those out to every household. Also we need the distancing, the ventilation, avoiding the crowds, all the things that we did prior to COVID some of us did, we got to gear up again, because to get through Delta, it's gonna require, pulling out all the stops to do, to minimize the hit, which you already places like Florida, Louisiana, Mississippi has been profound, but it certainly could get to many other corners of this country, but we're not getting that. 

Dr. Eric Topol (Guest)·45:18

A part of it circles back to our earlier conversation because people haven't vaccinated who are the more likely ones to wear masks and follow the best practices there. A lot of them are got a false sense of confidence. We've got to get them, on the same page that they've got to gear up, that it's not just vaccines now to protect it's everything. 

Neil Littman (Host)·45:42

Eric, I, I think we could probably talk for another week straight about this topic. I, I do want to be cognizant of your time and wrap up other than your Twitter feed. Do you have, resources that you would recommend for people who want to separate fact from fiction when it comes to the pandemic and the Delta variant? 

Dr. Eric Topol (Guest)·46:01

Well, I mean, there are a lot of great people on Twitter who, I become friends with and I rely upon, it could be immunologists like Akiko, it was Saki or Shane Kreidie or Florian Krammer, or it could be, virologists, like Angie, whereas mucin, there's so many my colleague, Christian Anderson who had to get off Twitter because he got so much abuse through social media, which is obviously a downside. I, I know who the experts are. I know who the, for the most part, and, I rely on them. There are certainly some great epidemiologists out there. Natalie Dean is one of my favorites anyway. So, the people in Israel like Aaron Siegel, I rely upon, very extensively. I have a group of people who, are kind of my network that I know these folks. 

Dr. Eric Topol (Guest)·47:01

I, it's not just through Twitter, I've gotten to know them through other forums interviews, or, in person getting to know them, friendships, whatever. That's, helpful because, you can try to read all the literature and all the preprints, but their stuff is happening so fast out there. There's on the ground perspective that is, of course, oftentimes different. And also, obviously I network with the folks who are the, our principal, public officials quite a bit too. So, overall, we have a cognizant D out there, they can be found most of them on Twitter. So it isn't like a one source. I mean, there's many. And, I think we're lucky because it gives us a pulse, as long as you stick with people you can trust. You know, I think it's extraordinarily helpful. 

Neil Littman (Host)·47:55

I agree. I agree. And you're finding those people. You can trust. This is half the battle, especially in light of all the misinformation out there. Eric, I do want to wrap up and say a huge, thank you for joining me on the show today and a really great in-depth conversation. So thank you so much. 

Dr. Eric Topol (Guest)·48:09

Thank you, Neil. I really enjoyed it too, 

Danny Levine (Producer)·48:14

On there. What did you think? 

Neil Littman (Host)·48:16

I thought that was an amazing conversation. I'm incredibly grateful to Eric to join me on the show today. I think, we started at the basic biology and what makes the Delta variant so much more transmissible and, and infectious than the original strain, right? You heard Eric and I talk about it as a formidable adversary, and I think that's so true. So, starting with the biology, how the, our knots differ, why it's so much more transmissible. Then, I think he really helped dispel a lot of this false sense of security that if you're vaccinated, you are protected. That is just not true. When it comes to this Delta variant, you can actually still spread the virus. You may not be hospitalized. 

Neil Littman (Host)·49:04

You may not be at risk of dying unless you have significant comorbidities, but, you may still get mild to moderate, disease and who knows what that really means for the longterm. You heard us talk quite a bit about this idea of long COVID what that means, how that tends to affect, largely younger and healthier people as well. I think we have this false sense of security because we want to get back to normal, but we're just not there yet as a society, 

Danny Levine (Producer)·49:33

The discussion about long COVID I found particularly concerning, it seems it's an issue that continues to be neglected. Why do you think that is? 

Neil Littman (Host)·49:42

I think that's true. I think there's, just a lot of, misinformation about there. I think there's a lot of just misunderstanding about what long COVID is. I just, I think it's a subject that needs further investigation as well. Right. We, we don't exactly know who is affected by long COVID, why they're necessarily affected. I think it's an area that needs a lot more study. You heard Eric talk about some of the studies that he's done in terms of incorporating wearables, in terms of, long-term changes that have resulted from COVID. I think there's a lot more research to be done, but I think this idea of long COVID needs to be a of greater discussion. I don't think it gets enough attention. 

Danny Levine (Producer)·50:32

The data issues he raised are mind boggling, the testing failures you mentioned, and all this, as we're sending kids back to school, w we like to think about how medically advanced we are, but these are startling failures. What do you make of them? 

Neil Littman (Host)·50:48

Yeah, it's pretty scary, Danny. I mean, in many ways I feel like we're in the dark ages, right? I mean, the us was supposed to be, supposed to have one of the greatest health care systems in the world. No, we're supposed to be technological innovators. Yet we see in the face of a pandemic like this, that the systems are broken, right. There is not enough, systems that talk to one another from the local state federal levels, we don't have the infrastructure. We don't have ways to communicate electronically. We don't have ways to even, track the number of infections to measure. Th the, all the data that we need from people who are infected to look at different various to understand who was vaccinated and got the, infection versus who was unvaccinated. 

Neil Littman (Host)·51:37

I mean, it's just a startling failure at such a high level. It is, as you said, it is mind boggling. The other thing that I just can't quite wrap my head around is, this idea of a lack of rapid antigen based testing, right? You heard Eric and I talk about that if we just had that, right. I think we would be getting children back to school in a much more normal fashion, right. They largely would probably not have to socially distance or wear masks if we could roll out this testing, which, should be readily available, a year and a half plus into the pandemic. And it's just not. We, when you combine that with the lack of infrastructure, it's just, it's really, it's just, it's disappointing to say the least. 

Danny Levine (Producer)·52:21

One thing he mentioned was the thinking that the vaccine was going to be an end game. I think, to some extent that might explain the systemic failures we've seen, what's the price we're paying for that. 

Neil Littman (Host)·52:34

Yeah. I mean, I think you see it now with the Delta Veron. I mean, this is now the third wave and the hospitalizations are higher in many areas than they were during the first two waves. Right. So I think it is quite devastating. And, I think a lot of us put a lot of emphasis on the vaccines. I know I certainly did. I was certainly on the opinion when the vaccines rolled out, that's the light at the end of the tunnel will start getting back to normal. And, a lot of us didn't account for the Delta ovarian, cause we didn't know it at the time. I think where we are now paying the price, and I think what we're not doing well enough is adapting in the face of the data that we have. 

Neil Littman (Host)·53:14

Not that we have a lot of the data, but, we're seeing how devastating the Delta variant is. We're really slow to adapt our behavior, which I think is probably the most frustrating part. 

Danny Levine (Producer)·53:26

How hopeful are you that we will arrest this virus and get. 

Neil Littman (Host)·53:31

Well, I, I still remain very hopeful. I mean, I, I think we will, I guess I'm an eternal optimist. I think we will, it's going to take time. It's going to take a lot of effort on everyone's behalf. I, I sent, you heard Eric and I talk about some ways to, help encourage people who are not vaccinated to get vaccinated. I think those types of things, such as requiring proof of vaccination do use public transportation at the fly to dine and doors, right. Go to sporting events or con I think that needs to be implemented immediately. I don't see any reason to wait for that. I think it also falls on all of our shoulders, even people who are vaccinated to be aware that you can still get infected, you can still spread the virus. 

Neil Littman (Host)·54:13

You still need to wear a mask, maintain social distancing, right? We're not out of the woods yet. It does come down to us as individuals. There's a lot that, local state and the federal government could be doing, in the face of the Delta variant, that's just not happening today. 

Danny Levine (Producer)·54:33

Well until next time. 

Neil Littman (Host)·54:35

Thanks Danny. Until next time. 

Danny Levine (Producer)·54:40

Thanks for listening. The bio verge is a product of bio Virginia investment platform, buttons, visionary entrepreneurs with the aim of transforming health viral Berg provides access and enables everyone to invest in highly vetted healthcare startups on the cutting edge of innovation from family offices, registered investment advisors, and non-accredited individuals to learn more, go to bio verge.com. This podcast is produced by the use it for this podcast is provided the Curtis Jonah Levine collect.