Dr. Michael Koren:
0:00
Welcome to the MedEvidence podcast.
Announcer:
0:02
This episode is a rebroadcast from a live MedEvidence presentation.
Dr. Michael Koren:
0:07
So, Eric, I'm super jazzed today, and the reason I'm jazzed is because you bring a really cool perspective to this conversation. Dr. Schramm has been a family medicine physician for what? 25 years A long time, that's right, 25 years, a long time.
Dr. Eric Schramm:
0:25
Yeah, a long time, a long time.
Dr. Michael Koren:
0:26
And one of the key things that you have to do with your patients who come in is help them craft their strategy for how to deal with the traditional cold and flu season, which, quite frankly, is a little bit different in Florida than other parts of the country, but that's part of the discussion equation, although the products come in as if we are part of the rest of the country and there's a debate about that whether or not Florida is indeed part of the rest of the country but you've dealt with this for years and years and years, and so you need to craft a strategy with your patients and help them understand why this is so important, particularly in high-risk patients, and that's part of it, and so, when we were brainstorming this, we thought that a good way to help people understand this is to make an analogy between preparing for the cold and flu season and preparing for hurricanes.
Dr. Michael Koren:
1:21
Obviously, in Florida, we're really good at preparing for hurricanes, and we want to be just as good as preparing for the cold and flu season, and you're the perfect person to do this, not only because of your experience, but you also have a clinical trial background, so you can help people understand again what we know, what we don't know, how we're going to figure out the stuff that we don't know, and the practical steps to protect ourselves, how we're going to figure out the stuff that we don't know and the practical steps to protect ourselves.
Dr. Eric Schramm:
1:47
Right exactly, and I'm a long-term Florida resident, so I've seen a lot of hurricanes and, at the end of the day, it's really about preparation there, you go.
Dr. Michael Koren:
1:54
So again, the metaphor that we're going to use today is comparing preparing for the cold and flu season with preparing for hurricane season, and I think there's a lot of analogs between the two, would you agree? I totally agree for that. Okay. So we have a saying here for those of you that have come before, that there is no free lunch. You aren't able to enjoy our sandwiches, but you have to work for it. So the way we work for it is by answering some questions, where we get to know what you guys know about a different topic and also we have some fun together. So here let's start with the first audience question which of these viral villains might cause you to evacuate your home this season? You see the metaphor in there, right? Is it number one, that rascally respiratory syncytial virus, otherwise known as RSV? Is it the cantankerous COVID virus? Is it number C, the infamous influenza virus? Is it choice D, the bubonic plague? Or is it choice E, all but answer D, okay, so I think I hear a rousing agreement that it's all but answer D, which is correct. So one of the complexities of what we do nowadays when we prepare for cold and flu season, it's not just about the flu. It's about three major viruses, all of which can do very serious damage, especially in high-risk people. Okay, so I think we have a second question.
Dr. Michael Koren:
3:31
So here we go, and this is really going to get into the core of what we're going to discuss today. Which strategy do you use to protect you and your family? Do you throw caution to the wind? Is that how you deal with hurricanes and the flu season? Do you go to the doctor when you get sick, but otherwise you don't worry about it? Do you get vaccinated for common winter flu viruses? Do you wash hands and wear masks around sick people? Do you get vaccinated, avoid high-risk contacts and exposures and find out about treatment options when you get sick? Or number F next question, please. So hopefully everybody in this audience will choose answer E, but you can see where we're going with this. So, eric, I'm going to hand it off to you at this point. So tell us a little bit about just epidemiology. What's been going on in the last few years with cold and flu, particularly vis-a-vis COVID?
Dr. Eric Schramm:
4:32
Sure, and this is one of my favorite slides, which talks about mortality in the United States and, of course, at the top of this is heart disease. A lot of people think that the number one cause of death in the United States is cancer. It's not, it's heart disease, and so we spent a lot of time in the primary care office, the cardiologist office, helping people to understand their risks for heart disease and try to mitigate that risk. If you look at and what's interesting is since COVID, which was in late 2019, one of the things to look at on there in terms of the mortality is you're looking at numbers that put that into the number three space and remain quite high over the next several years there.
Dr. Eric Schramm:
5:21
And so, and if you look below that, if you look at the numbers for influenza and pneumonia, you're going to see this is varying in the 40,000 to 50,000 deaths a year and, honestly, that's usually pretty consistent. You're going to see that that's pretty consistent from year to year, so there's a little bit of variance in that, but people do die from getting the flu. Now those people are going to get not just the flu, they're going to get sick, they're going to get pneumonia, they get a lower respiratory tract infection, they're going to end up in the hospital and these are the vulnerable people. So who's vulnerable? Well, if you're an older patient, if you have certain medical conditions, if you're not vaccinated, you would be a vulnerable patient. So it's quite interesting in what that slide will tell you. In the first, in 2020, with some of the highest mortality, the difference there is that we did not have a vaccine. So in that kind of that first year of COVID, we had the alpha variants. We had look down to 2022 and into 2023, you see a big drop in mortality.
Dr. Eric Schramm:
6:51
And so you're going to say well, how did that happen? Well, we came to understand how to vaccinate and get people protected for COVID and we understood a lot more about treating COVID. So there's a lot that goes on into that slide, but kind of in a nutshell, that's what we take out of what happened with COVID.
Dr. Michael Koren:
7:12
Yeah, it's fascinating. The other thing that's fascinating is that influenza and pneumonia deaths went down between 2020 and 2023. So that tells you that some of the things we were doing in terms of wearing masks and washing hands and greater awareness and being careful and avoiding harms paid off not only for COVID, but for other viruses. Yeah, that's true, and I guess this makes that point in a different way.
Dr. Eric Schramm:
7:40
Well, I think this is a really great slide. Graphically, you see, the COVID-19 death rate popped into number three right there, and then this dramatic drop off. I was like, wow, that's what a success story in terms of what medicine and vaccine technology was able to do in a very short period. It was phenomenal. Short period was phenomenal. It really was a game changer for being able to, you know, giving guidance to these patients. We're talking about protecting patients and you know this is why that conversation is really going to start with vaccines.
Dr. Michael Koren:
8:16
Yeah, and the neat part is that the risk factors for people are identifiable and actually treatable now, and we'll get into that. Okay, so avoiding catastrophic effects from viruses may not differ conceptually from avoiding catastrophic effects from a hurricane. Okay, now we haven't lost our minds. It may sound like a little bit of a stretch, but let's make this case Right I think in medicine we always think like analogies and like models.
Dr. Eric Schramm:
8:52
Yeah, yeah, thinking about how, um, in looking at a step process and trying to imagine that, can we know there are going to be certain times of the year and this is a great slide rsv, covid, flu, right, these are the big three. Um, we know, or at least have a pretty good idea, when to expect them. So we know and we know how to make prepare in advance for that. So we do a lot of what we do in vaccine research is a lot of surveillance. We're looking to see and understand what the previous strains were, what the current strains are likely to be, so that when these guys show up on the door you know we're not going to be caught flat-footed, we're not going to be caught off guard.
Dr. Michael Koren:
9:33
Right. So you know hurricanes nowadays we get a lot of preparation because of satellite imaging etc. But there's still unpredictability. When it gets at our doorstep you never know exactly which way it's going to turn or the nuance that may turn it from category one to category five. And in the flu and vaccine and virus world we don't know which of the pathogens is going to necessarily hit us and there could be overlap. So we do know that when there's a spike in viral cases in a community, that ER testing will show there's more flu cases or there's more RSV cases or more COVID cases. But there still could be a mixture of those things and the treatment is actually different for the different viruses. That's right, that's exactly right. So there is some again commonalities and some things that are different. So there is some again commonalities and some things that are different. So why don't you talk about our three-step method to minimize risk that's based on this concept of protecting yourself from harm.
Dr. Eric Schramm:
10:32
Well, I already said it, advanced preparation, right, you have to know and understand, and wearing masks and you know, just kind of awareness, and then being prepared to minimizing consequences, which may relate to thinking about how we treat COVID or how we're going to treat the flu, and we can talk about RSV.
Dr. Michael Koren:
11:06
So we're going to break it down in great detail now. So go ahead. So on one side of the slide, you're going to see what you do for hurricane preparation, and then, on the other side of the slide, you're going to see what you do to get ready for the viral season.
Dr. Eric Schramm:
11:19
Right. So kind of getting back to hurricane prep. Home insurance, flood insurance that's becoming property drainage, this kind of thing Very challenging now in Florida with all the insurances, problems with the rates going up, viral season get your vaccines and again, this is very timely. Ok, so we'll talk a little more about viral season, but historically we're talking anywhere, say, between September and April. So kind of like what happens during hurricane season.
Dr. Eric Schramm:
11:56
Get your immune system in top form. And a lot of times in the office patients will come in and say, well, how do I keep a good immune system? What can I do to stay healthy? And I'll say, okay, we talk about how do you sleep? Are you getting enough sleep? Because your sleep is an incredible, by the way, one of the most important things in keeping your immune system and keeping your metabolism robust. It's critical we manage stress. I mean it's hard to find somebody who isn't stressed these days and stress has a chronic, chronic stress weakens your immune system. And manage that. Nutrition is huge. If you try to eat a healthier, avoiding processed foods, you have an antioxidant-rich diet, avoiding obvious toxins, then you're going to have a healthier immune system. And exercise is important and it keeps us healthy and keeps us from cardiovascular, it keeps us fit and it keeps us healthy from that standpoint. So this is a very important point that I try to make for patients in the office.
Dr. Michael Koren:
13:05
Yeah, and I'm going to ask the audience a rhetorical question, which is Hurricane Sharon is announced and it's about to come in and we know it's going to hit us within the next five days. Can you get home insurance? Then Can you get flood insurance? Then Can you get your property drainage dealt with then? No, so all those things have to be done well in advance, and so the timing is really really important. Same thing for the cold and flu season. Absolutely Right, okay, so we're talking about the CDC recommendations now for advanced prep. Go ahead.
Dr. Eric Schramm:
13:40
Cool, all right. So these are. The guidelines are always constantly being revised and so for this 24, 25 season, they have made some adjustments on this. And if you look at the talk about the flu vaccine, this is the first year in a long time that instead of the four or quadrivalent vaccine, we're going to do a trivalent vaccine, and we can talk about a little bit of why that's the case. They're only recommending that they need to cover three, but there are different, distinct versions of the flu that come out. There's usually when we're vaccinating. We're talking about either between A and B strains, and we have this year H1N1, which has been around a long time and right now is the major player in causing flu illnesses. They recently updated this H3N2. So they are making subtle changes in the vaccine composition based on the genetic expression of the. These are really just surface proteins. You know, when COVID, we knew and heard a lot about spike protein like, oh, that's spike protein, it's rascally spike protein, but and flu has two different genes that code for these proteins, and so from what we knew last year, they were able to predict that H3N2 will be the appropriate strain for the A strain and then the B.
Dr. Eric Schramm:
15:14
Victoria has been the case that this has been pretty consistent. They are recommending for people six months and older, young little kids six months, up to four, five years are going to get two shots. But this is available September and October, best times to get vaccinated. This is always a question when do I get my vaccine, when should I think about it? I'm an advocate to have this. Consider September, october, versus waiting till November, december. I think you want to have this on board and we'll look at some graphs, some charts. They'll tell you why that might be a good idea.
Dr. Eric Schramm:
15:53
I'll talk about the RSV vaccine. Right now there's there are there's Three manufacturers that are producing an RSV vaccine and at some point we'll talk a little bit about why RSV is important in this. But certainly the preponderance of morbidity and mortality occurring in adults typically older. So 60, 65, 75. And these are the groups that which they're recommending vaccinations. If you're 75 and older, you want to get the RSV vaccine. If you're 60 to 74, increased risk for severe RSV. And you're gonna say, well, what is that? And I'll say, well, if you've got heart disease, lung disease, diabetes, smoke, smoking, you have a chronic kidney or liver disease.
Dr. Eric Schramm:
16:43
If you, if you're immune compromised or if your doctor deems that your health in general is such that you would benefit from getting that vaccine, then absolutely, and there's, like I said, there are three manufacturers. They do allow for pregnant women in their third trimester to get that because they can know that you can have, you can create passive immunity to little babies through the mother. So they do have a recommendation for that and they actually do have for infants. They can give them monoclonal antibodies if they're going to deliver during the RSV season. If they're going to deliver during the RSV season, the COVID-19 vaccine okay.
Dr. Eric Schramm:
17:27
So now the recommendation everybody six months and older, regardless of when your last COVID vaccine was, even if you got the booster in the spring this last spring, you want to get the newly formulated COVID-19 vaccine Right now. The platform for this is the two manufacturers that are producing the messenger RNA version of this vaccine. Pfizer and Moderna are offering this. There is the Novavax is offering the non-messenger RNA, the more traditional. It's a cell-based vaccine as well. So you get a choice of different vaccines and we can talk about the platform strategies a little bit if you want to say more about that.
Dr. Michael Koren:
18:19
So yeah, that's kind of what they said, so we've seen it in the slide that those are going to be available. We have choices in terms of the type of vaccine. Absolutely, yep, absolutely, yeah, okay, so I think you covered this about the three manufacturers for RSV, and again, different manufacturers use different technologies to get to the same point of protecting people against the virus. Right, and keep in mind that RSV is something that virtually all of us have been infected by at some point in our lives, and so all of these vaccines kind of boost our immunity.
Dr. Eric Schramm:
18:52
Right. Everybody by age two has gotten sick or exposed. And the mortality the reason to consider these vaccines, because mortality from RSV is typically anywhere from 6,000 to 10,000 patients a year so it's important for that patient population to get vaccinated.
Dr. Michael Koren:
19:14
And again, having a discussion about which of these vaccines is best for you is definitely something you should have with an individual physician, right, okay, so that was the first step preparation. Now that storm is right at your doorstep. Now what do you do? So in the hurricane situation? You make sure you're filled up with gas and water. You would move your patio furniture indoors, you would potentially board up windows or put your shutters down and, if it's really nasty, you might evacuate.
Dr. Michael Koren:
19:41
Sandbags and shutters are the things to consider, and the analogy to that for cold and flu season is wear a mask during the peak of the cold and flu season, isolate from the public, wash your hands like crazy, use hand sanitizer and have test kits available for when you might be getting the sniffles in the very, very early stages, to try to figure out which of the viruses you have, or get involved in a study or have some relationship so that, if you're getting sick, someone can figure out which virus you have and they get you on the right track, depending on which virus. That is Right. So you want to comment on that. How do I know what virus hit?
Dr. Eric Schramm:
20:23
me. Well, you know, the other day I was looking to see what kind of tests are available and so you can go on Amazon, you can go to Walmart. They're offering home test kits now to test for flu A, flu B and COVID. It's like a trivalent test, not an RSV test. We don't have that, but at least not for a home test. So, yeah, these tests are available so you might find like right now I don't know that Walmart has it, but I think as it gets closer to the season they'll probably like to see that, so it's worthwhile at home. Reasons to have to know what you've got is because you have treatment. So if you're, you know if you're infected with COVID. They do have an oral antiviral which is Paxlovid, which I call it Paxlovid because that's what it was called when they first came out. Now everybody's like Paxlovid and I'm like okay well.
Dr. Eric Schramm:
21:24
Paxlovid, whatever you want to call it, and knowing the timing is important.
Dr. Michael Koren:
21:30
And that's, by the way, two antivirals in the same pill.
Dr. Eric Schramm:
21:33
Yeah, it's a two-in-one deal kind of deal, and same way with the flu virus.
Dr. Michael Koren:
21:38
I should amend that the packages come where you take the two pills separately, but you're getting in the same pack. It's not the same. That's right, it's a convenient pack.
Dr. Eric Schramm:
21:46
If you've ever taken Paxloid, you know how that's packaged. But and it's same thing true for Tamiflu, which is your treatment for influenza, which is, you know, been around for a long, long time. But the keys to that are really getting you know, getting the treatment on early, Because if you can get it in within 48 hours you're going to have a much better outcome than if you're waiting three days, four days or beyond. And so you know, this is why this, for a long time in the office, was challenging. Patients would come in, they'd be sick for days and we'd run an office test oh, you got the flu, but you're outside the window. Or if you're doing a rapid COVID test and you're five days out, then you're probably not going to be a candidate for anything like that.
Dr. Eric Schramm:
22:30
So early detection can guide an early treatment and you get a better response out of that. And the cool, the interesting, I think, is cool about the way the antivirals work. They're really not dependent on, even though the different strains may be mutating, right. So all the different COVID strains out there or the different flu strains, the way that those antivirals work, are not contingent on the mutation. So it means it's durable. So this is another reason to you know, test and treat early for it.
Dr. Michael Koren:
23:03
Yeah, and we always like to share some good news along the way. It can get a little depressing when we just share bad news, so you alluded to this before that there's going to be a trivalent rather than a quadrivalent, and you just want to give us a brief reason why the news is good, right?
Dr. Eric Schramm:
23:19
So after 2020, about the time that the Delta variant came out for COVID, we just basically stopped seeing the B Yamagata strain of influenza and it was very interesting. So they kept looking and like it's just not there, it's not there, it's not there, it's not there. To finally, they came to determination that they're calling the virus extinct. Yeah, there you go.
Dr. Eric Schramm:
23:46
I don't know. I'm a little skeptical that it's totally gone away.
Dr. Michael Koren:
23:49
We'll take our little victories.
Dr. Eric Schramm:
23:50
But out of that. You know so it was. They said well, look, we really don't need to have this particular strain as a backup in the vaccine, which makes it a little better for people in terms of whether people may making the vaccine and it's less likely that if you're still trying to maintain a active flu B strain, that if it escapes and becomes a problem. So so this is interesting. It really it looked at as a. We call it a victory because all the things that we were doing for COVID, the social distancing and the hand washing and all of these precautions, seem to have made this virus disappear. And this particular B strain of virus has a fairly narrow. It's kind of it's mostly just going to be seen in humans and a few other mammals, but it doesn't have a big reservoir like some of the other viruses where they can go and emerge from all kinds of crazy places.
Dr. Michael Koren:
24:48
So this is great, a nice little victory for medical science. Yep, all right. So getting back to our metaphor minimizing the consequence of the perfect storm. I think you talked about this a little bit, but just again to drive home that thought process of the analogy is if the hurricane comes through, what are you going to do? You're going to get a roofer to make repairs, you're going to get somebody to help you with the fallen branches and you're going to remove standing water. And for the viral season, you're going to get treatment as quickly as possible. You mentioned the treatments already, but you also need to have a mechanism in place to know that you in fact have one of these viruses and not something else. That's right. You pretty much covered all this, all right. So let's get back to some audience questions.
Dr. Michael Koren:
25:33
Which of the historical remedies for the flu have been proven effective in a clinical trial? Again, this, again, the concept is what has been scientifically proven to work. And there's a little background to this particular slide. You see an old-fashioned picture of two women, and what are they wearing around their neck? They're actually wearing onions. And so back during the Spanish flu 100 years ago it really hit us hard in 1918, people thought that wearing onions would be beneficial and apparently that was being done quite commonly. The other thing, by the way, that was done back then was to take the newest wonder drug, which was aspirin. Aspirin was a brand new wonder drug back in 1918. Unfortunately, they didn't know the right dose, so people were actually taking toxic doses of aspirin back during the 1918 flu pandemic. Which gets the point that it's not only the right medicines, but the right medicines at the right doses at the right time that make a difference. So, with that thought process, which of the following remedies has been proven effective in a clinical trial, a research study?
Dr. Michael Koren:
26:54
A the onion necklace. B a glass of whiskey that helps me sometimes. Why not? C hydrogen peroxide in the ear canal. D mom's chicken soup I don't know about my mom. Or E none of the above. Anybody want to go with the onion necklace? No, we have one brave person, okay, sign her up for the onion necklace. How about a glass of whiskey? Got a couple people? Okay, we got shut down for the whiskey study, unfortunately so that's not currently enrolling patients. How about the hydrogen peroxide in the ear canal? Anybody want to go with that Mom's chicken soup Of?
Dr. Michael Koren:
27:45
course got to vote for that.
Dr. Michael Koren:
27:47
Or none of the above, which is the actual answer. Okay, so let's talk about long COVID, that's actually really something that a lot of people are dealing with now.
Dr. Eric Schramm:
28:01
Oh gosh, yeah so. So the definition, of long COVID, according to the CDC, are symptoms or condition persisting greater than three months after your initial COVID infection. And so, and some people will say, well, is it? Does it relate to having a real severe case of COVID or could it be related to having a more milder case of COVID? It turns out that that may not necessarily predict so, some people knowing they had a bad case, others not, but it is significant 400 million affected globally.
Dr. Eric Schramm:
28:37
You know, again, post-acute and long-term health issues that have occurred due to the SARS-CoV infection. We'll look at some graphs that'll talk about Delta and the we'll go back to it in one second, sure, and it talks about the before, kind of the before and after pre-Delta and pre-Delta and then after with Omicron. And we'll talk about and look at vaccines before vaccine infection and after vaccine and how those infections played out. And the bullet point on the bottom risk of long COVID increases with severity of acute infection and multiple COVID infections. So yeah, you brought up the next slide.
Dr. Eric Schramm:
29:28
Next slide and some number of people might see that to relate to some of these signs and symptoms, for people would have long COVID fatigue. This is right, you hear this all every day fatigue, brain fog, post-exertional malaise, that's a good term for that tiredness or fatigue interfering with your daily life, I think. I think a lot of that is just people kind of, they just don't have much. They'll get out to do something, exercise and then they're just kind of wiped out. And this can be mentally too . You'll engage in some mental activity but then feel like gosh, you're just completely kind of mentally wiped out with that. And that's fairly common. You see, probably some of the from a cardiovascular standpoint shortness of breath, diminished exercise tolerance.
Dr. Michael Koren:
30:16
Autonomic dysfunction. Autonomic dysfunction which means people get dizzy easily when they change their position and just a sense of just things are not right. Their heart rate suddenly accelerates when it didn't do that before. A number of things from the cardiovascular point of view that I see plenty of patients.
Dr. Eric Schramm:
30:34
Yeah, and neurological. I was talking to one of our neurologists this week and I said hey, we're doing a talk on long COVID. What are you seeing? And pretty much right there headaches, dizziness, anxiety, sleep issues, all of those things. And ongoing can be a real problem. Digestive issues not uncommon Joint muscle pain, those are not uncommon either. So you see a lot of musculoskeletal complaints that come out of that and I mean and others, chronic fatigue syndrome is pretty common, says people are just tired all the time and, like you said, there might be other to have to look at long-term disease illnesses like autoantibody diseases, connective tissue diseases and things like that.
Dr. Eric Schramm:
31:25
So we're probably going to figure this out.
Dr. Michael Koren:
31:27
This is so interesting because when people first were describing this syndrome of just not getting well quickly most viruses you kind of recover after a couple of weeks. And then we had these people with COVID that were still feeling poorly two, three, four months down the road and there was a lot of skepticism at first in the medical community, but now there's a firm belief that this is a real thing. Sure Right, that was part of the, and this is the graph you're alluding to.
Dr. Eric Schramm:
31:51
Right. So really the important thing for looking at the top line on that what it looks like in terms of that kind of that Delta era unvaccinated, remember, from Delta came in at a time when we were really vulnerable because we really had no vaccine out for that and so that's just when it started, like january 2021, I think right 20 through so delta.
Dr. Michael Koren:
32:18
December 2020 january 2021 right right.
Dr. Eric Schramm:
32:22
So we had this was this kind of area, area era or time when we were really behind the eight ball and again, very high mortality.
Dr. Eric Schramm:
32:30
You know, this is what got everybody's attention. And then, kind of the next line looks at Omicron and you're going to say, oh yeah, omicron, omicron's been around for about three years now, has been around for about three years now and what we saw in Omicron was okay. Well, there was a drop in mortality which we saw in one of our first slides though it's a more infectious virus, but we saw this drop in mortality. And again, people, the unvaccinated, are still high up there. Then if you look at the vaccinated Delta area, this is where it really gets interesting to see that that line, that curve, is really starting to bend down. And then you know, if you look at the vaccinated Omicron patients compared to the unvaccinated up in the Delta, you know that's a big drop. I mean that's more than 50%. So it comes back to understanding that your best bet in terms of avoiding all that concern for long COVID is get vaccinated. It is definitely something we can do.
Dr. Michael Koren:
33:37
So what percentage speaking, a good segue. What percentage of US adults have been vaccinated with the updated COVID-19 vaccine in the last 12 months? Let's see Is it A 75.5%? I see a lot of head shaking there. Is it B, 55.5%? Is it C, 22.5%? Is it D 4.5%, or is it E? Are you looking at me? So who says A, b, c? You guys are good, d Okay, and the answer is actually C. So we've got some work to do, and this is just something on the seasonality, I guess, of these different viruses.
Dr. Eric Schramm:
34:33
One of my favorite slides, okay, and kind of what I like about this slide and it's interesting. You know, science people always like things that. Look, you know those squiggly line graphs and lines, charts and things A couple things to get out of that. A couple of things to get out of that slide. And we're looking at COVID, influenza and RSV, right, the big three, the perfect storm, right. So in the influenza, in the RSV lines here you do see pretty consistent seasonality. Remember, I said you're looking at a window typically from September through April, okay, and now some years you might get a little more flu than RSV, and then it just kind of goes quiet, right. And then until the next season comes through and you can kind of see this kind of another bump, right and okay, that's the RSV and the flu bump. And then same thing kind of quiets down.
Dr. Eric Schramm:
35:29
Now that kind of tannish line in there that isn't necessarily following a predictable pattern. That's COVID, right. And this is why this is really interesting, because is there a little bump in seasonality in that? First, yeah, you get a little bit in 22, uh, late 2022, and it kind of calms down but doesn't go away. And then in July of 23, summer of 23, you see a big bump, okay, wow, everything else is quiet. But then you see this big bump in COVID in the summertime, okay, and then it kind of goes down, but not very much, and you see it starting to go up again.
Dr. Eric Schramm:
36:10
It's, you know, it's cold. It hits that next cold and flu season and it goes up again like your flu and your RSV, and then it goes down a little bit. But look so the latest date on that August 3rd so this is this month and look at the spike in COVID. All right, you're like gosh, look at that. Everything else is really quiet. So one thing to get out of that is COVID does not fear the heat, right. It doesn't warm weather, no problem, right. So this is really becomes. This is one why reason can be really hard if you're trying to anticipate what the needs for people with vaccines might be and what to expect, because right now we're having a big outbreak and everything else is quiet. And so the other question to point about that was to understand well, why are we getting such a big outbreak right now? Why are we so vulnerable in this and actually kind of the last slide is what I think provides that answer, because you know, 22% of the population is vaccinated, re-vaccinated yeah, or re-vaccinated, then you're.
Dr. Eric Schramm:
37:22
You know we are a vulnerable population. And to remember that, you know COVID is different than RSV and flu in the sense it's ability to mutate. And so Omicron variant right now is, if you compare it to the original, it's a lot like, it's in the kind of same family as Omicron, but it's like your. You know You've got some genes that are similar.
Dr. Eric Schramm:
37:48
But to look at, if you do viral surveillance, looking at COVID, you see it's constantly changing. I mean, the viruses have only two really purposes to exist and reproduce and to evade your immune system. That's all they want to do. And so when you see what COVID is so tricky, because it's constantly doing that, it isn't just having like, well, this is our four-month season to rearrange our genetics and shuffle things around. It's constantly doing it, it's doing it all the time. So you know, looking at the way we're going to recommend the CDC has said to the vaccine, people said, look, here's the latest, latest COVID variant. You really need to be targeting your vaccine at that variant. But to recall, you know, last spring they recommended boosters for patients 65 and older. And so to look at six months and say, okay, well, six months, what's the main circulating strain going to be and is the vaccine going to? How effective this current vaccine is going to be?
Dr. Michael Koren:
38:51
And that's the beauty of the messenger RNA technology is that the lead time is relatively short. You can create a new vaccine within weeks.
Dr. Eric Schramm:
38:59
All right. Historically, with the chicken egg vaccines, which most of the traditional flu vaccines, you know that's a six-month process from the time that you conceive it to the time you process it and get it out to the market, and you know that was never going to work with COVID. So it was a huge advance in technology to be able to come up with a platform that was nimble, right so to be able to look at and I won't say real time, because we don't have that capacity, but to really work in a very expeditious fashion to be able to adapt to what we're seeing in terms of the types of viral strains that we're seeing out there.
Dr. Michael Koren:
39:44
So we're clinical trialists. This is what we do day to day. So quick comments on the things that are happening as we speak that people in the audience can sign up for as we speak.
Dr. Eric Schramm:
39:54
That's right and this is and I think, somebody who's already talked about being in the experience of being in clinical trials we are always looking for the influenza and COVID vaccines. We are actually, and have been involved. This is a very interesting discussion because we have been involved in a combination vaccine study to combine COVID and flu, because it makes sense, and using the messenger RNA platform, using that technology. So, because a lot of times people would have a question about well, is it okay to get my COVID shot the same day I get my flu shot? Should I wait a couple of weeks? What about that RSV shot? Should I wait and wait and wait? I don't like to wait.
Dr. Eric Schramm:
40:40
I'm a primary care doctor, you know, because when people wait they get busy and they forget and then if you're waiting for that perfect time to get your vaccine, you may realize well, gee, I just got sick or there's no perfect time, but just don't delay it so you can get these vaccines together. Right, you can get these vaccines together, but we've got we're doing a great study on comparing the messenger RNA vaccine versus licensed flu vaccine. So chicken egg technology versus the messenger RNA, that's a great one. Oral vaccines for COVID versus the mRNA approved vaccine.
Dr. Michael Koren:
41:21
That's pretty cool, just taking a pill instead of having getting a shot, so that's pretty cool.
Dr. Eric Schramm:
41:25
Yeah, yeah, We've got I'm involved in the RSV human metanumavirus. What's human metanumavirus? Why do we care about that? That's the fourth leading cause of hospitalizations for the suffer respiratory. So COVID flu, RSV, human metanumavirus, and so there's a reason that combining RSV with a human metanumavirus vaccine really does make sense. 60 and older is the patient population we're looking for. Norovirus vaccine versus placebo. 18 years and older, that's a little bit different disease element, but these are some of the ones that we're doing.
Dr. Michael Koren:
42:07
I think we're doing number three just because it's fun to say human metanumavirus.
Dr. Eric Schramm:
42:10
I had to practice that a lot All right, that's right.
Dr. Michael Koren:
42:14
So key takeaway points
Dr. Eric Schramm:
42:19
Do I have to keep saying this? People get vaccinated. Right, prepare, get vaccinated. You know I'm a clinical trialist and worked with Dr. Koren for a long time now and you know clinical research and I know for some people who've not had experiences in clinical research, you're thinking gosh, what's going to be happening? Are they going to treat me like a guinea pig? What's you know? How is this going to work out? And to understand that when you go to a clinical research office, you're dealing with the excellent staff, highly trained physicians with background in research, you're treated well, you're treated with respect. It's a nice experience.
Dr. Michael Koren:
43:06
Right. So for those of you that haven't had the experience, we invite you to try it out, see if you like it. And my favorite statistic to share is that when you ask people who have not done a clinical trial whether or not they're interested, only 40% say yes, . But if you ask somebody that's done a clinical trial and you say, would you do a second one, between 97 and 99 people, 99% of people say yes. So think about that. What product or service can you think about where there's a bit of skepticism before you're introduced to it, but once you are introduced to it, you almost uniformly support it. So I think that's pretty cool.
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43:43
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