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This video was recorded on 12/8/2020.

Hank and our content manager, Alexis, interviewed Dr. Howard Bauchner, the Editor in Chief of the JAMA network of medical journals. They discussed some of the surprising things that we've learned since the beginning of the pandemic and how we should approach vaccine hesitancy.

JAMA's COVID Content: https://jamanetwork.com/journals/jama/pages/covid-19-interviews

Hosted by: Hank Green and Alexis Dahl

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Sources:
Novel Vaccine Technologies Viewpoint
https://jamanetwork.com/journals/jama/fullarticle/2676502

mRNA vaccines
https://www.bbc.com/news/health-54986208

Corticosteroids
https://www.covid19treatmentguidelines.nih.gov/immune-based-therapy/immunomodulators/corticosteroids/
https://www.covid19treatmentguidelines.nih.gov/therapeutic-management/

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https://www.istockphoto.com/vector/vector-illustration-of-mrna-vaccine-against-coronavirus-gm1259026115-369019996
https://www.istockphoto.com/vector/antibody-and-virus-illustration-health-care-and-medical-infographic-gm992750920-268951280
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https://www.istockphoto.com/vector/seamless-pattern-background-of-coronavirus-icon-gm1212706039-352139050

 (00:00) to (02:00)


[Intro] 

[Hank] 

Hello everybody!

Welcome to a special episode of SciShow - I'm Hank Green. We are always trying to bring you science news, but these days the news comes fast and there is a lot of it in a lot of different shapes and forms.

And it's good to be curious about the world generally, but also at a time when science views(?) is more important than ever, it's good to get a little deeper and get into some more context. So, I'm always excited to be able to talk to people who are at the edge of important science that's going on right now.

And today I am joined by Alexis Dahl our Content Manager and Dr. Howard Bauchner the Editor in Chief of the Journal of the American Medical Association (JAMA).

Hello Dr. Bauchner. It's very good to talk to you, and I imagine that it's been a wild time.

[Dr. Bauchner]
It has, Hank, but first, please call me Howard - I'm perfectly comfortable with that.  

[Hank]
Okay. *laughs*

[Dr. Bauchner]
It has been a wild time - I think since February first we've had almost eleven thousand submissions to JAMA that have been related to the pandemic. They come in different forms - original research reports, research letters, what we call 'A Piece of My Mind' or narrative -

[Hank]
Mmhmm

[Alexis]
Have you slept at all this year?  

*laughter*

[Dr. Bauchner]
It's been a long year, but sadly gratifying from a scientific standpoint because so much interesting information has come into the journal. It's - It's really just a remarkable privilege.

I lead a remarkable group of individuals - you know, Associate Editors who are all in practice in academic medical centers around the United States and then our full time staff, so it's a privilege and an honor.  You know, one of the changes is no travel -  

[Alexis]
Mmhmm.

[Dr. Bauchner]
I usually take quite a few trips each year, and that travel's all gone, so I think I've been able to utilize much of that time to do a lot of reading.

 (02:00) to (04:00)


[Hank]
Yeah. As a journal, do you just expand until(?) unexpansion is necessary, or are you still publishing them roughly the same amount?

[Dr. Bauchner]
No, we've changed a bit about how we publish, so

[Hank]
Yeah

[Dr. Bauchner]
I would say clearly there's been a shift to much more of our content being related to the pandemic.

We've published about 150 more opinion pieces, viewpoints. We've doubled or tripled the number of research letters. And around original investigation, there's been a shift to COVID-19 content.

I think the other major change - the very very major change - is we've done quite a few interviews with prominent scientists around the world. We call them 'Conversations with Dr. Bauchner', and we've doubled the number of podcasts we've done.

So we've tried to change the way in which we communicate.

[Hank]
Yeah. And that's - that's a different vibe for you, I get the sense, and a lot of learning had to happen pretty fast.

[Dr. Bauchner]
Yeah, well we had always been doing podcasts, and we had begun to experiment with these kind of livestream events 

[Hank, Alexis]
Mmhmm.

[Dr. Bauchner]
- that can then be made into a podcast, and they've become quite popular. I've been very fortunate - Tony Fauci and I are colleagues, and Tony's been on the show eight or ten times -

*laughter*

[Hank]
Yeah

[Dr. Bauchner]
And whenever he's on the show, people tend to wake up and listen. He's probably the most important voice in American medicine at this point.

And then, you know, I've been able to interview people who are experts in vaccines, experts in epidemiology. So it's been a broad range of individuals, and people have told  me it's gotten a nice following. People like the style of the interviews.

They're conversations, they're not prerecorded or prerehearsed. It's not meant to be confrontative

[Hank]
Mmph.

[Dr. Bauchner]
or political

[Hank]
Yeah

[Dr. Bauchner]
I do think people have liked the conversations.

[Hank]
So, where could we find those things if we want to listen to some of your livestreams or podcasts?

[Dr. Bauchner]
Well, pretty easy now. If you just go to one of the search boxes - usually Google - just put in 'JAMA network video' and it'll come up. You can come to our website - they're all free...

 (04:00) to (06:00)


[Dr. Bauchner]
...All of our COVID-19 are free on our website or YouTube. Just put in 'JAMA network' and up will come all the videos.

[Hank]
Do you have a sense - and this is going back and deep a bit - do you have a sense of the work that has been done over the last few decades that has led to

[Alexis]
Mmhmm

[Hank]
the development of mRNA vaccines, because this is

[Dr. Bauchner]
Yeah, it's really -

[Hank]
 - I think these are the - you know, this is fairly new stuff.

[Dr. Bauchner]
Yeah, it's a really interesting concept, Hank. So, you know sometimes you are just so lucky who you talk to, so I'll just give you a couple of examples. So, two and a half years ago, Tony Fauci wrote a viewpoint for us about the new vaccine platforms.

[Hank]
Mhmm

[Alexis]
Hmm

[Dr. Bauchner]
This was two and a half years ago. 

[Hank]
Mhmm

[Dr. Bauchner]
And one of the platforms he talked about was mRNA.

*Hank laughs*

[Dr. Bauchner]
Tony was very excited that he thought we could take vaccine development from you know ten years, from five years to three years - I don't think he ever imagined nine or ten months.

*Alexis laughs*

[Dr. Bauchner]
And he wrote about that three or four years ago in JAMA. So, I think there had to be certain basic scientific breakthroughs to allow us to use the platform, and that's occurred over about ten years.

I don't know all the details of the scientific advances, and mRNA has been tried before, but not on this scale or this importance because of the -

[Hank]
Mmhmm

[Dr. Bauchner]
- size of this pandemic. So, I think it's been coming for three or four years and then obviously the pandemic really accelerated the scientific portion of discovery.

[Hank]
Wow. So, mRNA vaccines can just be developed more quickly - like that's one of their main advantages.

[Dr. Bauchner]
Right. You're not manipulating the virus in any - in some regards. Your inducing an immunologic response 

[Hank]
Right.

[Dr. Bauchner]
By allowing the host - the human being - to produce the protein itself, and then the body makes antibodies to it, creates memory cells so that when it sees it again,

[Hank]
Mmhmm.

[Dr. Bauchner]
it protects against infection. So, it's an entirely different approach...

 (06:00) to (08:00)


[Dr. Bauchner]
...to the traditional inactivated virus or the heat-killed virus. 

[Hank]
Right. And so in those situations, you would - you'd heat up the virus until it was dead or mostly dead and then you'd give that to people. Or, you'd put it in some kind of system that isn't the human body to sort of evolve it

[Alexis]
Mmm

[Hank]
to be not as harmful.

[Dr. Bauchner]
Right, so an entirely different approach with the mRNA, DNA, and the viral vector vaccines.

[Hank]
Wow. I mean that's wild. It - you know one of the things I said at the beginning of this is like, you know, now is always a better time to have a pandemic than last year. Because we always know a little bit more than we did the year before.

And, just hearing you talk about that makes me feel like it's even more true than I felt.

[Dr. Bauchner]
Yeah, and there's been some gauge. You know, it's been a very difficult fall. When I talked to so many people over the summer, people were really concerned about the fall, but I don't think anyone predicted or thought we'd have numbers in the 200,000 range in terms of cases a day, and back to over 2,000 deaths.

So, clearly the fall has been far worse than people anticipated. In addition, there hasn't been much circulating flu, so the initial concern would be that you'd have some COVID-19 with flu. This is not related to flu at all.

So, I'd asked - interestingly enough I had asked Tony about a month before Thanksgiving because we talked about Thanksgiving and Christmas, and once again he was prescient in saying 'Can we just get through Thanksgiving, and then I'm willing to come and talk about Christmas', and he couldn't have been more... more right, I think.

You know, there's a 100,000 patients in ICUs. Now, the good news is it's around the country, it's not concentrated in a number of states. But still, the numbers are enormously concerning. More and more medical centers are beginning to close once again for elective procedures.

The other good news is that care has gotten better. We're clear about what to do and what not to do, and so mortality rates for those who are not intubated, not critically ill have come way down, so, so that's encouraging news.

 (08:00) to (10:00)


[Hank]
Has that been something that has been a big part of y'all have been publishing? Has there been a lot of, you know, care and understanding what those systems of care are?

[Dr. Bauchner]
So, there's been a shift of the types of articles that the major journals are publishing. So, early on it was really the epidemiology of the disease - 'How did people get infected? Who got infected? What could we do to prevent people getting infected?'

We published two or three epidemiology papers in February, and the major epidemiology hasn't changed. We know, in general, we know who's at high risk - the elderly with comorbid conditions. That has not changed in nine or ten months.

We also came to understand presymptomatic and asymptomatic spread, and I think that has been without doubt the greatest surprise of the pandemic has been the power of asymptomatic spread, and now people have this term 'presymptomatic spread'.

We had a research letter in February about asymptomatic spread as did a number of other journals, and I think we could have done perhaps a better job of touting what that really meant.

And then through the early portions of the pandemic when many different drugs were tried, some of the antivirals - Remdisivir - people began to experiment with some of the inhibitors of the inflammatory cascade IL-6. There were concerns about potential coagulation abnormalities, so people experimented with anticoagulants.

And surprise, surprise, the one drug for those who were seriously ill that clearly reduces mortality is corticosteroids. And corticosteroids have been used for decades and have been proven to be effective. So, I think there has been some surprise.

The good news is when used for individuals with COVID-19 they don't have many side effects...

 (10:00) to (12:00)


[Dr. Bauchner]
... And they're widely available, and they're inexpensive. And that's -

[Hank]
Right.

[Dr. Bauchner]
- in contrast to some of the other drugs which have not proven to be very effective. 

[Hank]
Right, we also know what the - you know, we know all about steroids. We know what the side effects are -

[Dr. Bauchner]
Correct.

[Hank]
- We know the impacts they have on various different populations because we use them all the time for all kinds of things.

[Dr. Bauchner]
Right.

[Alexis]
Yeah, and with steroids, that's just basically fighting the body's kind of like overzealous response? Is that the goal there?

[Dr. Bauchner]
Well, I think the one thing it, it's interesting  - steroids affect many different portions of the biochemistry physiology of the body. It's kind of a a pleiotropic drug.

[Hank, whispering]
Pleiotropic

[Dr. Bauchner]
And so I think people are a bit surprised that it's worked so well because it's not precise. 

Like, if someone has diabetes, you give them insulin. We know precisely how -

[Alexis]
Mmhmm.

[Dr. Bauchner]
- insulin works. 

[Hank]
Mmmhmm.

[Dr. Bauchner]
Steroids work in a much broader way, and I think it may speak to that this disease has different manifestations, and it may be why single drugs that have a very specific action have not worked as well. so the antivirals haven't worked as well. Certainly hydroxychloroquine didn't work very well. 

And I think it's because the individuals critically ill with COVID-19, his or her body may have many different biological or physiologic manifestations, so you needed a drug that worked more broadly.

[Alexis]
Hmmm.

[Hank]
I have this very weird sense that this disease has just a lot of different surprising effects. You know, we sort of like - there's a lot of coronaviruses out there, and most of them are very similar to one another.

But then we've got like, you know, research showing that there's, you know, neurological effects, there are blood effects, there's -

Like, it seems very broad, and like part of me is worried that we're just doing so much research right now that we're finiding things. Because maybe we're getting false positives here and there, maybe upon more peer review or more data, these effects will be less strong...

Is - or am I just, like... talking out of my butt?

 (12:00) to (14:00)


[Dr. Bauchner]
No, there have been surprises -

[Hank]
Yeah

[Dr. Bauchner]
I just mentioned too, I think the extent of asymptomatic spread has been a very substantial surprise.

[Hank]
Yes.

[Dr. Bauchner]
And then I think the effect of corticosteroids has been a surprise. Now, we've gotten a lot of papers on the so-called 'Long-Haulers'.
And the first time I heard the term, our news section had written a wonderful piece about it. Someone said to me, 'What do you think about Long-Haulers?' and I jokingly said - jokingly said, because I wasn't sure what they were asking, 'Why are we talking about truck drivers?'

[Hank]
Yeah. *laughter*

[Dr. Bauchner]
And then they explained, 'No, we're not talking about truck drivers, we're talking about people who seem to have  long-term effects.'

[Hank]
Mmhmm.

[Dr. Bauchner]
Now, at the moment we have quite a few case series about them, but we don't have denom - we call it 'denominator data'. So, we know we may have a report of fifty people who seem to have long-term effects, but we don't know how many that got infected, so we don't know is that fifty over five hundred, fifty over a thousand, or fifty over fifty thousand.

So we don't really have a sense of it yet.

[Hank]
Right.

[Dr. Bauchner]
People who are in the ICU with Acute Respiratory Distress Syndrome and sepsis, we know they have long-term complications.

[Hank]
Yeah

[Dr. Bauchner]
And so I don't think we yet have a lot of clarity if the side effects that are affecting these individuals are substantially different than those that have affected people in the past -

[Hank]
Right.

[Dr. Bauchner]
- who get admitted to the Intensive Care Unit with serious illness.

[Hank]
Right, that makes sense.

[Alexis]
Yeah.

[Hank]
It's just - that's been like bumping around in there, and I just haven't said it out loud until now and I appreciate you walking it through with me.

[Alexis]
*laughter*

[Hank]
I think that one of the things that we feel weird about studying, or we don't know how to study, but like has become a tremendous health problem is people not trusting the advice of -

[Dr. Bauchner]
Yeah

[Hank]
- doctors, but also just the scientific community in general. It feels to me that vaccine hesitancy and that both in terms of like, just people who are hesitant...

 (14:00) to (16:00)


[Hank]
... and who like, you know aren't really that involved don't think about this all that often - like that group of people is bigger, and so are - but so are the people who are like vehemently, sort of like part of their identity is that they are anti-vaccination.

[Alexis]
Hmm.

[Hank]
Like all that seems to be growing to me. I don't know what to do about it. I know that you were working on it - like working on these conversations, working on - like you have a successful series of videos too that talks about -

[Dr. Bauchner]
Right.

[Hank]
-  Covid-19. And obviously we are working on it as well. But I think that we need to think really hard about how to reach these people.

[Dr. Bauchner]
Well, you know it's a topic that crosses my desk every day

[Hank]
I'm sure

[Dr. Bauchner]
Whether it's research reports, or viewpoints, or people who I talk to.

[Hank]
Mmhmm.

[Alexis]
Hmm.

[Dr. Bauchner]
It's a struggle, I mean it's probably a dozen surveys that I've now seen where it appears as though about fifty percent of the people are comfortable with the idea of being vaccinated, about fifty percent aren't. It's somewhat related to education, political affiliation, race, and ethinicity.

I think those numbers or those percentages may change as different people speak out we have more information.

[Hank]
Mmhmm.

[Dr. Bauchner]
I think it may - people may be influenced by a long winter and being inside.

[Alexis]
Hmm

[Dr. Bauchner]
On the other hand, I do think it's going - it's critically important that we tell the public what we know and what we don't know.

In the data that was released today from Pfizer, where the average follow-up for patients who have been vaccinated for about two months there were no particular serious adverse side effects that showed up in the group that got immunizations versus the group that got placebo.

[Alexis]
Hmm.

[Dr. Bauchner]
That's two months.

[Hank]
Mmhmm.

[Dr. Bauchner]
It's not four months, it's not six months, it's not ten months, it's not twelve months. Now, if you talk to vaccinologists...

 (16:00) to (18:00)


[Dr. Bauchner]
... they will tell you through the history of vaccination, in general, the serious adverse events that will show up, generally show up in the first two or three months. But they're quite rare. And so you need a hundred thousand people vaccinated, or two hundred thousand people vaccinated.

So you may not see it in forty thousand people. And in addition, that's the traditional vaccine. This is the new vaccine. So, we can't be sure of what six months or eight months or ten months or twelve months will bring. 

The early data are very, very encouraging, but I think it's incumbent on the scientific community to really speak honestly -

[Hank]
Mmhmm

[Dr. Bauchner]
- about what we know and don't know. People are incredibly impressed with the robust immunologic response to both of these vaccines, particularly in the younger populations.

[Alexis]
Mmhmm.

[Dr. Bauchner]
The lack of any signal about harm is encouraging.

[Hank]
Mmhmm.

[Dr. Bauchner]
Now, the other thing that people need to remember is every day people die from myocardial infarctions - heart attacks. Every day people have strokes.

So what's going to happen when people begin to vaccinate five or ten or twenty million people - someone's going to get vaccinated on a Monday and have a heart attack on Wednesday - or a stroke on Friday.

[Hank]
Mmhmm.

[Dr. Bauchner]
That's not going to be caused by the vaccine, but simply because heart attacks and strokes occur every day.

When you begin to vaccinate not forty thousand people, but when you begin to vaccinate a hundred thousand people - or a million people or two million people - there will be these events that are associated with getting the vaccine.

But that does not mean that the vaccine has caused that event. And that is incredibly important. And again, this is going to take a great deal of education.

[Alexis]
Mmhmm

[Hank]
Yeah, it's - it's so hard in a world where any event can be a story so easily and so quickly where people are - you know, some people are in bad faith...

 (18:00) to (20:00)


[Hank]
... trying to create those narratives because it's good for their subscription revenue or whatever - or for selling t-shirts or what have you.

But then you have people who absolutely hear that story and are, you know, worried about it.

And I think it's also important to recognize like where we sit is often really easy to sort of lump all anti-vax - where I sit, not where you sit - easy to lump all anti-vaccination people into sort of like a group of unreachable nuts. And that's just not the case.

Like as you just said, like it makes sense when this is very new for some people to be hesitant. And like, in allowing them to have that hesitancy, early on, when we only have two months of data, actually probably is the right thing to do because we've got fifty percent of people who could take it now.

And then over time that hesitancy might like like like when it becomes, you know, less logical to have that hesitancy as it has been taken more by more people, we haven't seen negative impacts, and we see that we can end this pandemic.

Then, without confronting those people and like, like sort of affirming that this is a really us versus them thing -

[Alexis]
Mmhmm

[Hank]
- and they need to be on one side or the other, we can just sort of like invite them in to, you know, become sixty percent of the people who are okay with it, and then seventy, and then you know maybe seventy-five and then that's as far as we get. *laughter*

[Dr. Bauchner]
It was interesting, I was home - I was home for Thanksgiving and my family was talking about vaccines and what we knew and didn't know, and I was listening, I was in the other room because I wanted to just hear their discussion

[Hank]
Mmhmm.

[Dr. Bauchner]
And I could see what issues came up, like how long is the vaccine going to last. We don't know.

[Hank]
Yeah.

[Dr. Bauchner]
Okay?

[Alexis]
Mmhmm.

[Dr. Bauchner]
And that's the honest answer. Early data says you get a great immunologic response - we'll know in six months or a year if it's still lasting. You know, people are guardedly optimistic that it'll be more effective than flu and you won't need the flu vaccine. It's not like you'll need the flu vaccine -

[Hank]
Yeah.

 (20:00) to (22:00)


[Dr. Bauchner]
- every year. You know, they wanted to know what happened to the mRNA after it's injected. Well, the nice thing is after it induces the DNA, it goes away. It doesn't change your genetics at all.

[Hank]
Yeah.

[Dr. Bauchner]
So it was just interesting within my own family to -

[Hank]
Mmhmm

[Dr. Bauchner]
- to hear what the discussions were. And I don't really want to confront people who don't want the vaccine. I want to try to help educate them about what we know and what we don't know.

[Alexis]
Mmhmm, yeah. Hank, you were mentioning the kind of thought of, you know as more and more people take the vaccine, or get it, more people might grow more accepting of it.

[Dr. Bauchner]
I think Hank's right, you know, we're going to see healthcare workers get it first -

[Alexis]
Mmhmm

[Dr. Bauchner]
- that's very clear in the US. We - Their priority's going to be  healthcare workers and the elderly, particularly those in skilled nursing homes, and hopefully it'll go well so that, you know, you'll have seen another five or ten million people get it and there'll be reports about whether or not any adverse events are occurring.

And I think that will be - that will be reassuring to people.

[Alexis]
Yeah. Also, Howard, I love the idea of like, your family's in the other room - like 'What are they saying over there?'

[Dr. Bauchner]
Oh no, I was just listening because I was really - it's important to me - for me to think about what people think the issues are.

Now there are one or two odd things about the vaccines that I think people really need to try to understand. And it goes to some points that many of the people I've spoken to have tried to talk about.

And it's why the need for masking isn't going to go away anytime soon.

[Alexis]
Hmm

[Dr. Bauchner]
So the early reports on both vaccines suggest that they protect against the individual who's being vaccinated getting disease, okay? That's really important.

But if either of you get vaccinated, we know that you'll be protected from disease. But we still don't know if you can give the infection to someone else.

[Alexis]
Hmmm.

[Dr. Bauchner]
That's a different scientific question.

[Hank]
Mmhmm.

[Alexis]
Hmmm.

[Dr. Bauchner]
That is unanswered.




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