Delta is really a very formidable virus in that it has the capability of transmitting, much more efficiently than the original prototype virus that we had been confronted with early on in the outbreak in the sense of transmissibility. Also, it has the very interesting capability that when you get infected the amount of virus that’s in your nasal pharynx with the Delta variant, compared to the amount of virus that would be in the nasopharynx of the other variants that we had faced previously is up to a thousand times more, which really is the mechanistic explanation of why it so readily transmits. You bring up the point of breakthrough infections. A breakthrough infection is something that is to be expected because no vaccine is 100% protective.

And the vaccine trials that were originally done, that we’re familiar with, for example, with the MRNA showing that they were 94 to 95% protected, that was protective against clinically apparent disease and not necessarily against infection, which for the most part, even if you had a sub clinical infection that didn’t make you symptomatic at all, there was very little chance previously with the other variants that you might transmit the infection, if you were vaccinated and had a breakthrough infection, because the level of virus would be so low in your nasal pharynx, but this virus is so efficient in transmitting that even if you are a vaccinated person and you get an infection, even if you have no symptoms at all or minimal symptoms, you still have the possibility that you may transmit it to someone else, even though you don’t have very many symptoms. So that adds an extra important wrinkle in this, which is the reason for the modification of the CDC guidelines about wearing of masks. Because the transmissibility in an indoor setting, particularly in a place like Florida, that has a high, high level of virus transmission, that the recommendation is to wear a mask if you are an indoor public setting, including in schools, because the transmissibility is such a high level of this virus. It sounds like things change with regard to recommendations. That’s only because the virus itself is changing.

Dr. Zinner: Antibody testing is something we can do but it is not recommended by the CDC to make clinical decisions so we are not using that yet to make clinical decisions.
Dr. Fauci’s response:

Vaccines right now, when you think in terms of protection from serious disease that might lead to a hospitalization or deaths still do very well. But we are seeing data particularly from Israel, which is about, you know, a few weeks to a month or so ahead of us in the dynamics of this outbreak and in the implementation of vaccines, they’re starting to see, even in vaccinated, people with this Delta variant, more and more people, particularly the elderly and those who are in nursing homes and in extended care facilities are having an uptick in some of the hospitalizations. So, for that reason, what has happened is that we are putting together a plan that will likely be implemented sometime in September to make booster shots available by booster. We mean a third shot. If you’ve had a two-shot regimen, essentially for everyone, but particularly concentrating temporarily and getting it rolled out with the people who originally got the shots earlier, the healthcare providers, the elderly, those in nursing homes.
And the reason that plan is being implemented is because we want to stay ahead of the curve. You know, we use that analogy that Wayne Gretzky used to say, you want to skate where the puck is going to be, not where the puck is. So, we’re wanting to anticipate that if in fact, we do see a diminution in protection against hospitalization and or serious illness that could lead to death, that we want to be prepared to give the extra level of protection with a boost to people so that you can increase dramatically their immune response. In fact, in studies that have been done and are continuing to be conducted, we know that a third shot after several months of an interval after your second shot (important because you give the immune system a chance to mature and make it more amenable to getting that extra kick from a boost) that you can increase protection really much, much better. When you think in terms of antibody responses and other measurable immune responses, that’s the rationale for planning and implementing ultimately the capability of giving booster shots to individuals.

Dr. Fauci’s answer:
We would like very much for it to be the same one you had earlier, but there are studies now called mix and match studies, which are trying to determine the safety and actual adequacy of the response, the same, if you use the same or a different one. We’ll get that information pretty soon. But to the extent possible we would like people to stick with what the original vaccine was.

Dr. Del Rio’s answer:
I think that what Dr. Fauci said is what we all are concerned about, immunocompromised individuals. I think it’s absolutely right when we see hospitalized patients who have been vaccinated, we’re seeing people who are transplant recipients. people who have severe immunodeficiency, because for example, they received a disease modifying agent, like a CD four, you know, antibody, something like that. But in general, you know, people like me are not in the hospital. However, I have seen the data showing a decrease in neutralizing antibody response over time in people who have been vaccinated after six to eight months, and we can certainly boost that response, but I’m not sure we have seen data showing that that makes a clinical difference. So, my concern is while we’re giving a third shot to people who already received two shots like me or you, or most of us, we’ll be taking over resources that could be used to give people the first shot.

And what I tell people is the most important booster that I need is for the 93 million Americans that haven’t been vaccinated to be vaccinated, because if we all vaccinated, we can stop transmission of this virus. This is not just about individual protection. This is about community protection. So I am worried that by giving boosters, we may be overcrowding those facilities and those healthcare providers that are needed to provide shots to the people that, that currently are not vaccinated and who are going to be vaccinated because vaccine mandates are going to make people take vaccine sooner or later, as far as with vaccine to take, you know, I hear what Dr. Fauci says, you want to get the one that you are likely to receive, but I have absolutely zero data to support that.

And in fact, the data I should just the opposite from Europe, we have data that you get the Astra Zanaca vaccine followed by a Pfizer vaccine, you actually get a much better immune response. So quite frankly, why not? I mean, why not give me a Johnson and Johnson vaccine, I may get an even better response. The reality is we are navigating right now on a data free zone. And I want to emphasize that to people. We have no data to say the things we’re currently saying.

Dr. Del Rio’s response:
My answer would be that it might be possible, but the reality is if you’re vaccinated and the other person is vaccinated, the possibility of you getting infected and the possibility of you infecting other person is really, really small.
The reality is why I, as a vaccinated person should wear a mask indoors, quite tactically is to protect the non-vaccinated people is to protect all those that have not been vaccinated because they don’t want to, or because they can’t, for example, young children. But really the other vaccinated people are actually fairly well protected. And we need to emphasize that/ We’re getting into a minutia that it’s too, too delicate. We’re really concerned about the little bumps in the car. When the reality is the big accident out there which is the people who are unvaccinated, we need to get people on vaccinated as quickly as we can. That is the key to our strategy to get out of this pandemic.

Dr. Fauci responded:
It gets back to what I just mentioned to you about the Delta variant. The Delta variant is highly, highly transmissible. We’ve seen that in adults, and we’ve seen that in children and the more children that get infected purely from a quantitative standpoint, even though it is true that children have a less of a chance of getting severe disease, than does an adult or someone with an underlying condition. We are seeing more and more children, literally on a quantitative basis requiring hospitalization and getting serious illness. And for that reason, we want to do the following: First, when you think in terms of school, we want to make sure we surround the children by people who are vaccinated, who are eligible to be vaccinated like teachers, personnel, who are involved in the school system. For those children, 12 years old and older, who are eligible to be vaccinated, we want to encourage them very strongly to get vaccinated. For those children who not yet are eligible and the studies are being done to determine if it is safe to do that and the kind of response and what dose they should get. That’s the reason why we want to make sure we get people masked in the school system to protect the children and to allow them to safely get back to an in-person learning because we know of the deleterious effects of keeping children physically out of school, mental health, developmental issues, and others.

Dr. Patel added:
We are in kind of a relatively higher vaccination rate in Washington D.C than in other parts of the country. We’re also kind of flipped into what would be considered by the CDC is high transmission based on our numbers of cases. So most of our schools are opening, have opened or will open in the next week and already, I think you’re seeing a scrambling and a pretty mask kind of friendly environment. We are seeing a lot of concern from teachers, from parents, even from students who are pretty savvy. I think we kind of underestimate how much kids actually understand. And they’re kind of scared when they see what’s playing out on the media about scary numbers and quarantine. So I do think that children, by the way, if anything is back to Carlos’s point of anything COVID has taught me is that if I think I know something I’m totally wrong, so I’m not going to kind of get arrogant enough to say we know everything about Delta variant children, other than the heightened, infectiousness the ability for even toddlers to transmit or have enough of the virus in their nasal passages and respiratory tracks.

And that’s a warning sign. That just means that, you know, we are at a stage where we had higher transmission than when we actually move most schools to virtual learning. So this is our obligation, vaccinating the world and trying to have that be our best line of defense. This is the best line of defense we can get for our children. Anybody watching, listening, if you know somebody who’s not vaccinated, don’t judge them, spend time and try to appeal to the elderly family members in their life, children, grandchildren. And instead of running to think about when you need to get your booster or what date you need to get your booster, think about how you can send a message to all the people that are unvaccinated around you. We also know that we just aren’t reporting data from the hospitals in the states, the way we would like to. So, we could very well see a darker picture with children. And I hope we don’t get there. We can prevent it.

Dr. Nayyar’s response: What I tell my patients and my nine-year old here in south Florida, where numbers are not looking very good: Number one, trying to decide what mask to wear, go to the CDC website. They have very clear guidelines, but the reality when it comes to especially children, the best mask is the mask that kids will wear and the best mask that you as an adult can tolerate. A mask is way better than no mask. Don’t get hung up on it. We don’t want to see the mask around your chin. We don’t want to see it dropping down from your nose. You’ve got to wear it correctly. That is the most important thing.

The second thing is really counseling your children. So I’ll tell you the discussion I had with my daughter before going back to school. I said, the original virus, if it were a superhero, he’d be Clark Kent, right? The Delta variant is Superman. He’s faster. He’s more transmissible flying from nose to nose, right? That’s the nasal pharynx. And that’s what you hear when we talk about this being more transmissible and more contagious. This is why it’s important to wear your mask. And the danger zones when it comes to going back to school is when you’re eating lunch or out in the playground. So counsel your kids on taking their mask off. If they get sweaty, they get acne, do it away from other children, eat lunch, outside, drink outside.

Dr. Nayyar’s response:
As a mom, as a woman of childbearing age, hear it loud and clear, THE VACCINE DOES NOT AFFECT FERTILITY period! End of story. And by not getting vaccinated, you are more likely to get, COVID-19 more likely to end up sick in the ICU, getting hospitalized. Believe me, that will impact your family planning. Way more than thinking about getting vaccinated. Talk to your OB GYN. They are going to tell you the same thing. This is not an issue to be concerned with.

Dr. Patel also responded:
I’ll just add to that, that the CDC recently released some updated guidance and it was based on data, kind of what I’ve called real world evidence from over a 103,000 women who kind of went forward and just submitted data on their vaccination fertility pregnancy status. First of all, with fertility, we also think about miscarriages
There were no differences in terms of vaccinated people having more miscarriages. And in fact, we now know that with COVID infections, there can be a higher risk for preterm labor and some bad outcomes for the mom and baby. With respect to fertility, there have also been across the world, several studies that have been looking at now, if you think about it , we’ve had billions of people receiving vaccines, so we really do have not just the trial data, but growing evidence, no differences and no effect on fertility. There’s a lot of bad rumors that my patients have found on Facebook, WhatsApp about changing their ovarian cells. There’s no proof of that. These are not vaccines that interfere with your DNA. That’s another reason people think it affects fertility. And then I’ll just say for men, we do know again, that COVID can potentially have outcomes on your sperm count and other factors for fertility. So I know many young men have been worried about this as well. They should ask these questions so far, I would say, and I like to get reminded of by some of the vaccine experts, we’ve got one next that if you were going to see some of these outcomes, you would also generally see them in the weeks following vaccination, which is why it was really important for the CDC to conduct their registry and also for other countries to share their data. So hopefully we can dispel a very valid concern amongst men and women.

Dr. Del Rio also responded:
This idea that the vaccines affect fertility is FAKE NEWS, misinformation that has been disseminated by people. And I’ll give you two pieces of information besides everything that has been said. Number one, there’s a paper published in JAMA showing very nicely in men who were vaccinated. There’s absolutely no decrease in this sperm count. You’ll see the same level of smirk, sperm, motility, and numbers of sperm. And number two, I’ll just give you an anecdote as an investigator on the modernists study, while we did not enroll women who were pregnant, some of the participants that we enroll were women of reproductive age, who got pregnant during the study. And I can tell you that more women got pregnant on the vaccine arm than the placebo arm. So maybe the vaccine actually increases your fertility. I don’t think it decreases it.

Dr. Zinner’s response:
We’ve made some decisions at the Miami cancer Institute to follow the CDC guidelines and give boosters to cancer patients under active treatment. And those would be those that we think are immunocompromised, but not to give to those who simply have a history of cancer, particularly if we think that they are in remission and they’re doing well. They may fall under the category that Dr. Del Rio and Dr. Fauci talked about that’s coming up in September, that may be age related and or other disease related. But right now, we’re focusing on patients that are under active cancer treatment.

Dr. Del Rio’s response:
We’re teaching science to the community through television and herd immunity is a very complicated concept. Instead of herd immunity, I like the term community immunity. The level of disease, people who either have suffered a disease, have been infected or have been vaccinated is determined by what we call the RO, the transmission rate of a virus. The original Wuhan strain had an RO of about 2.5, which means that with 2.5 individuals, every one individual infected infects 2.5 individuals. So, in the native population, at the end of 10 cycles of transmission, you have about 9,000 people. The herd immunity is determined by RO. With an RO of 2.5, your herd immunity threshold is about 60%. With the Delta variant, we think that the RO is somewhere around 6. When you get an RO of six, then one individual infects six. And each one infects, six, et cetera, et cetera. At the end of 10 cycles with transmission, you have 30 million people infected. That’s the difference with Delta. What that does to the RO is that now, it’s over 85% , actually closer to 87%. And what that means essentially, in my mind, is that you’re not going to be able to get the herd immunity, because unless you really cover a hundred percent of your population with vaccines, and that is the challenge at this point in time, eradication of this disease is going to be virtually impossible. The best we can hope for is mitigation and decreasing the transmission to a level that is manageable in your hospital, in my hospital, and the mortality rate in a manageable range. So, the reality is at this point in time with Delta, I think herd immunity is, is really a far-reaching concept.

Dr. Patel’s response:
The data hasn’t been peer reviewed. I’ll just say that one of the studies that was released without peer review publication, but it was mentioned by Dr. Fauci and Dr. Willinsky and did make its way through the press, illustrated that when you followed people who got Moderna, as well as people who received Pfizer, kind of in cohorts, meaning they tried to find people who got it in January and see how their effectiveness changed over time, they found that Moderna seemed to decrease its efficacy at a lower rate than Pfizer, or simply put, the headline that was taken away was that Moderna was somehow better than Pfizer. There are many issues to take with that, including the fact that they really did not actually see that both vaccines worked incredibly well in preventing death and hospitalization, kind of a theme you’re going to hear us say over and over, which leads to the conversation of even if there is decreasing efficacy, there is no data to support that one MRNA vaccine is somehow superior to the other. There are also a lot of speculations that maybe Moderna, because it was administered four weeks apart versus Pfizer, which was three weeks apart for its two doses, might’ve been a better combination, but again, but if we can just avoid the minutia and you go back to the question, there is no reason to think that any one of our current three vaccines can’t protect us against what we really want it to do.

They’re both the same technologies. They both approach the immune system the same way, different, different doses per se, but not a change that I would dwell on. And I will say the same thing, the best vaccine kind of like the best mask is the one that you’ll actually get. So don’t just get dose one of anything, make sure you get both. And if that means Johnson and Johnson is a better fit for you, then that’s a great option too.

Dr. Zinner added:
One of the takeaways was that even though there may be some difference in terms of effectiveness over time, there was no difference in hospitalization rates in either one of those two vaccines. That was somehow missed in the press.