Roberto Burioni on Conquering COVID and Charming the Skeptics

; Abraham Verghese, MD; Roberto Burioni, MD, PhD


April 02, 2021

This transcript has been edited for clarity.

Eric J. Topol, MD: Hello. I'm Eric Topol. My co-host, Abraham Verghese, and I are delighted to welcome Professor Roberto Burioni here to talk about the COVID-19 pandemic and his experience dealing with vaccines and antiscience.

This is quite an opportunity. Professor Burioni is a virologist at the San Raffaele University in Milano, Italy, and a serious scientist. But back in 2016, something happened that changed his course. He was on television with two anti-vaxxers — a famous actress and a former DJ — who were taking on vaccines. At the very last moment, he was given a chance to respond on camera. He said, "The earth is round, gasoline is flammable, and vaccines are safe and effective. All the rest are dangerous lies." Those were called "the 13 most beautiful words heard on TV." This prepared Professor Burioni for the COVID-19 pandemic, and he's ready to teach us all about how to deal with these issues. Welcome, Roberto.

Roberto Burioni, MD, PhD: Thank you very much. It's a pleasure to be here with you. And hello to all the podcast's listeners around the world. I believe the problems we are facing with antiscience are gaining a foothold everywhere, and this is very dangerous.

This pandemic has taught us clearly that science is the only thing that can save us. So it's important to trust the science, the pharmaceuticals, and the vaccines. I always say that drugs are a bit like money; you exchange your goods for pieces of paper, and you do this because you trust that these pieces of paper have a value. With these pieces of paper, you can buy what you want. But it's only a matter of trust. It's the same with a vaccine. We can't really know what's inside a vial of vaccine. We have to trust doctors; we have to trust authorities; and we have to trust also the pharmaceutical companies, which are not always careful about communication.

What's really worrying, at least here in Italy, is the skepticism that is now growing about some of the vaccines, in spite of very good data. This should prompt everyone, including authorities and pharmaceutical companies, to think about the way they share information about their good work. They have provided very good vaccines, but here in Italy, there is a perception that some of the vaccines are not as good; they are not safe; they are a second choice. This perception is quite harmful.

Science and Suspicion

Abraham Verghese, MD: Dr Burioni, it is such a pleasure to be talking to you. You strike me as having much in common with my co-host, in the sense that both of you are not at all afraid to speak your minds. You have said that Italy is a country wobbling between science and superstition. I believe that in America it's very similar, except we're not wobbling between science and superstition, but between science and suspicion, fueled by social media. You've spent a lot of time in the United States. Do you have any thoughts about the differences in the anti-vaccine sentiments in the United States compared with Italy, or is it the same phenomenon?

Burioni: I can find a huge difference between Italy and the United States, in favor of the United States. One of the problems we are facing in Italy is that lack of a strong institutional voice. A few days ago, a music teacher died after he got the COVID vaccination, which is unfortunate. But in Italy, each year we have around 50,000 cases of sudden cardiac death. So it is not completely strange that one of these deaths could occur in someone after vaccination. But a judge seized the entire lot from which the vaccine had been administered to the music teacher.

The autopsy demonstrated that this man had cardiac problems; the vaccine had nothing to do with his death. We need those vaccines, and they are probably waiting in storage. They will expire and be completely useless. We don't have a strong institutional voice. We have the Istituto Superiore di Sanità and they are good, but they are not heard. In the modern world, you need to be heard.

The HPV vaccine is an example. Scientific data are absolutely clear that this vaccine is extremely safe and effective in preventing cancer. Everybody is scared about cancer, including myself. So this vaccine is safe and effective, and in Italy, completely free of charge and administered through our national health system. But in spite of all this, more than 50% of parents are refusing this vaccination for their children.

I am an immunologist and a virologist. I spend my life working on human monoclonal antibodies and thinking about vaccines. But should I be working to produce a better vaccine when we have a very good vaccine that 50% of the people are refusing on the basis of superstition and misinformation?

My father is 92. He's a retired pediatrician; he stopped working in the year 2000. In his entire life, he never had a single patient refuse a vaccine. Many people are refusing vaccines now and the bad news is that their choices are not made on the basis of rational reasoning, so it's very difficult to convince them otherwise. It's almost impossible, I would say. They are not so many in number, but they scare other people. I'm a reasonable person, but if I am in a movie theater and somebody screams, "There's a bomb!", I'll run away. I'll take my daughter away from the danger. Scaring people is very easy.

The problem is that our government sometimes wobbles between science and superstition. They have improved, but they are not perfect. A few days ago, in Piemonte, one of the most important Italian regions, they approved the use of hydroxychloroquine for the treatment of COVID-19, which is unbelievable at this point.

Pushing Back on Science Skeptics

Topol: Up until you were in your 50s, you were, as you say, a hardcore academician. You were a virologist, an immunologist, a pioneer of monoclonal antibodies. Then you added another dimension to the arc of your career, long before the pandemic, to take on the anti-science movement and then the anti-vaccine movement. Now you are engrossed in this. Do you encourage others to do this? Is the net effect something you would advocate or do you have regrets?

Burioni: I felt this was a duty. When you are a tenured professor, you're granted a lot of privilege because you're relatively safe in your job. But this also brings responsibilities. You have a responsibility to your patients as a doctor, professor, and citizen to talk about what can be a dangerous threat for your country.

My daughter is 9 years old. In 2015, when she was 4, I realized that at the school she was going to attend, parents were refusing vaccinations.

This was quite dangerous. In some parts of Italy, vaccine coverage was very low, not only for measles, mumps, and rubella but also for polio — not even reaching 80% in some areas, which is unbelievable. This was a real danger. Misinformation was being spread, not by Italians, but by people on social media who could barely speak or write Italian. So I thought, well, I can speak and write Italian and I am more educated than they are. I wondered, why are they so vocal and we are all quiet? So I started to post on Facebook some very simple messages.

I soon realized that the language I needed to use on social media was very different from the language I use with colleagues, students, or patients. All of these people already know and trust me. But social media users don't necessarily trust you. You have to be convincing and use different language. If we are in a group of scientists and you ask me whether autism is caused by vaccination, I would reply that currently we have no proof that vaccines cause autism, which is correct. But if you say this to an uneducated audience, they will say that vaccines cause autism and the scientists don't know it because they don't have enough proof. So we have to be very careful about what we say.

In this case, the form is the substance. Over the years we've seen changes in modes of communication: first the printing press, then the radio, and then television. Now we have social media, which are important in the formation of public opinion. When we discuss infectious disease, public opinion is important because if people don't change their behavior, if they don't get their vaccines, they're going to lose against an infectious disease.

Topol: You certainly have a savviness in speaking to the public, which is something we can all learn from. We need to do this to help crowd out the lies and the false myths that are out there.

An Autocratic Enterprise

Verghese: I'm struck by the title of your second book. You called it The Conspiracy of Dunces: Why Science Cannot Be Democratic. You have a wonderful way with words and you don't pull your punches. You said, "When I define someone as an idiot, it's not an insult. It's a diagnosis I offer for free."

But there is a danger that at times you can actually push people back into their camps and they can become more resistant than ever. Has your strategy evolved over time? Have you learned some lessons on the way?

Burioni: I remain a scientist, so I am guided by numbers. I don't have numbers telling me that my communication approach works. I can see the correlation, but I would never say that it is causation. I used the word "dunces" because in Italian it is "donkey"; we say somebody is "a dancing mule."

Science is not democratic. You can't decide on the dosage of an antibiotic by a poll or an election. Science says that we need a particular dose of amoxicillin.

So in regard to convincing people on social media — and this is my personal opinion — I believe that a small percentage of people will never be convinced. They are completely irrational. And because in science we only have rational arguments, it's impossible to convince them. These people are not numerous; in our most recent elections, they gained about 0.7%-0.8% of votes. But in the places where they are particularly active, vaccination rates have dropped 20% — not less than 1% as we might expect — because they frighten other people.

You can't convince the really hardcore anti-vaxxer, but you can ridicule them. You can show other people how stupid and ignorant they are and how fake their statements are. You have to demonstrate the disconnect. Being blunt with these people will not affect them. The downside of this is that it exposes you publicly. I've received threats and my daughter has received threats. I have police in front of the school my daughter attends. I had to lay low for a period, which was quite unpleasant. When you think about being famous, this is something you don't take into account. If you want to be a professor or a doctor, you just think about being famous with your colleagues for what you're doing, to be known in your own circle. But now I'm known by everyone. It is a bit uncomfortable.

One thing that happened was surprising in a good way. I participate in a popular talk show on Sunday nights on Italian state television. I always give a brief, 6-minute lecture, and it's difficult to say all you want to say in such a short time. One evening, I explained what's in the mRNA vaccine, what is a variant, and how COVID is diagnosed. What was incredible was that the audience numbers peaked when I talked about science. This surprised me, because I had the idea that science is considered boring by the general public. But if you're presenting it in a way they can understand, people like science.

Topol: I've seen you in action. I joined you on one of the shows. It's remarkable how you make the science so appealing, so easy to understand. You charm them with the science, which is really important. In your book Vaccines Are Not an Opinion: Vaccinations Explained to Those Who Really Don't Want to Understand, you make it clear. These are best practices we can learn from here in the United States, because we face similar obstacles.

A Dangerous Moment

Topol: Let's move on to the situation of the pandemic. Italy and the United States were among the worst hit in the world. And now the numbers are going up again in Italy, and they are beginning to do that in the United States as well, perhaps because of the B.1.1.7 variant. What are your views about that and about the vaccination issue in Europe, in general and in Italy specifically?

Burioni: Unfortunately, we are facing a difficult moment. In my hospital last week, 70% of the isolates were the English variant, B.1.1.7. This is a dangerous moment. In the United States, you're vaccinating like there is no tomorrow, and here we are vaccinating at a slower pace because Europe is more bureaucratic.

One afternoon, I volunteered at the vaccination center of my university. I wanted to provide a good example for other academics. And I can tell you that it took me 1 minute to vaccinate each person but 15 minutes for the paperwork. In 1973 we had a cholera outbreak in Naples, and in 1 week they vaccinated more than 1 million people. It was another world. We should do the same now.

One problem is that Europe has not been as effective as the United States, the United Kingdom, and other countries in securing the amount of vaccine that is necessary. We are behind in vaccinations, so we struggle with lockdowns and closures. At this moment, schools are closed.

I believe that the route to saying goodbye to this nightmare we've had for the past year is to vaccinate. It's a miracle that we already have effective, safe vaccines. Absolutely unbelievable; in a year, we actually have more than one vaccine. We should be giving them at a faster pace. Now the government, which was not extremely effective in managing the situation, has changed. They put a very qualified person in charge of vaccination — a general in the army and a well-respected person. Considering that we are in a war, I think he's the most appropriate person to handle this emergency.

Verghese: We have people here in America arguing that in some cities, for example, Los Angeles, we have already achieved herd immunity. Is there any sense that after such a devastating first and second wave in Italy that you have some degree of herd immunity?

Burioni: Unfortunately, the numbers are telling us that even in the places where we were hit in the worst way, only 7%-15% of the population was infected, which is far from what's needed to have herd immunity, assuming that the natural infection is providing immunity, which is not always true. In my practice, I've seen many reinfections that are clinically relevant. I'm also seeing infection in vaccinated people, but in my personal experience, these are not clinically relevant infections. I see also from the huge paper that was published in The New England Journal of Medicine, describing the situation in Israel, 35 days after the vaccination there are mostly asymptomatic or almost asymptomatic cases. Now, I believe it would be important to know if these people are contagious, because if these people with very mild disease are not contagious, I would call them healthy people with a positive PCR test.

Topol: You described it as a miracle, and I couldn't agree more. You mentioned the HPV vaccine. This is in that same extraordinary group, the result of an immune response that is unusual to get from a vaccine.

The Relevance of Variants

Topol: I had the privilege of working with you on an essay about the COVID-19 variants and how to assess them. Thousands of variants have been noted over the course of the pandemic. Only a few of them have surfaced to a potentially worrisome level.

You pointed out that we don't have standardized assays, that we have all sorts of claims — what I've called scariants — because they just scare people even though they aren't functional. Some of them are functional, such as the English B.1.1.7 variant, the South Africa B.1.351 variant, and the Brazil P1 variant. But there are so many others and even those have not been fully assessed. Can you comment about the need for a standardized assessment and whether the vaccines work against these variants?

Burioni: Unfortunately, there is no way to know whether a vaccine works against a variant other than clinical observation. It's very difficult to establish a protection correlate. Also, in the past, we had other vaccines that were very important, such as the Salk vaccine, which was not sterilizing. We know that the Salk anti-polio vaccine was providing only IgA immunity, or mostly IgA immunity, and the relative lack of IgA in the gastrointestinal tract was allowing virus replication to a certain degree. But this vaccine has been fundamentally crucial for winning the fight against polio.

We should observe from the clinical point of view, to see whether variants are able to cause disease in vaccinated people. Once again, variants are taking a foothold when they have an advantage. The English variant is very simple; it spreads more efficiently. The Brazilian variant was able to reinfect people who had recovered from the previous infection. It is able, to a certain degree, to overcome natural immunity.

It's now clear beyond any doubt that the immunity that is elicited by these mRNA vaccines is incredibly strong. Two things about the mRNA vaccines are unbelievably positive from the point of view of a vaccine specialist. First, the immunity is stronger when compared with that of the natural infection. And second, and even more important, is how well they work in elderly people. The flu vaccine does not work very well if you are over 60 or 70 years old, and these are the people who need the protection most. We have these wonderful tools, we have many vaccines, and we have to use them all. In the future, when vaccine supply is not an issue, we will choose the best one.

In Latin we say ex malo bonum: from something bad comes good. I believe mRNA vaccine technology will be extremely important in the future for other infectious diseases and for other diseases in general. This exposure we have now will be beneficial in the future.

This virus is incredibly contagious. In Italy, the flu season starts at the beginning of January and ends at the beginning of March. We are 60 million, and depending on the flu season, we see from 5 to 8 million cases. Our National Institute of Health isolates between 4000 and 6000 influenza viruses every year. This year, the number of isolated influenza viruses in Italy is zero. This is the first year in the history of Italy without influenza. Other respiratory diseases also disappeared. The usual respiratory disease caused by another virus, by other coronaviruses, by rhinovirus in small children, this year they disappeared.

And pharmacies didn't sell any of the usual products — decongestants, antihistamines, the usual over-the-counter drugs — because all the respiratory viruses have died out because of the precautions we took for COVID. Still, this was not enough to kill COVID. This is an incredibly contagious disease, and it's even more contagious now with the English variant. So that's the difficulty of the fight, and that's why it's so important to vaccinate quickly and to vaccinate as many as we can. That's the only way I can see for getting out of this situation.

The Future Is Up in the Air

Verghese: What do you see in the future? Looking into your crystal ball, what is the next year going to look like in Italy, the United States, and globally?

Burioni: It's very difficult to make predictions in general when you talk about something that appeared in the world just 1 year ago. In this case, it's even more difficult because the virus that appeared 1 year ago is changing. Today we have a virus that is different from the virus we had 6 months ago. We also see some differences in COVID symptoms. Viruses change, which is expected. The measles virus that appeared in the 11th century probably also developed many variants in the beginning, and then one variant, the best one, took over, and now we see only that variant.

Personally, I believe it will depend very much on vaccinations and whether we will be able to vaccinate the majority of people. At that point, we will need to see what happens to vaccinated people. There are two possibilities: The first is that some variant will cause a clinically relevant disease. This is not certain; we'll have to see. I personally think it is unlikely because it's not easy for a virus to escape such strong immunity. We don't see any signs at the moment, but viruses can be unpredictable, so we have to be cautious.

Then we have to see what the current variants lead to in the vaccinated patients. If the majority of them will be almost asymptomatic, and if transmission is reduced, it's likely that we will live in a world where, once everyone is vaccinated, this would be the fifth coronavirus causing a nondangerous respiratory disease. We'll have COVID in a very mild form, children will get this very contagious virus as they get other respiratory viruses, and they will develop immunity or they will be vaccinated against it. I hope that this will become a mild respiratory disease, as it already appears to be in vaccinated people.

Topol: We share that optimism for sure. Now here's a difficult question. The UK B.1.1.7 variant has spread throughout Europe, but the patterns are quite heterogeneous. Italy, the Netherlands, and now Germany and France are showing the signs of marked spread, whereas other countries, such as Denmark and Spain, show few signs of spread, even though this is dominant in all of these European countries. How would you explain this disparity in the pattern?

Burioni: One of the features of this virus, which is uncommon and is not shared by other viruses, is the deep heterogeneity of the infectivity between one person and another. Some patients are not infectious at all whereas others are extremely infectious, and if they are in the wrong place at the wrong time, then that particular virus can spread extremely well. Unfortunately, we have learned from experience that when something happens in Europe, no more than 4-8 weeks later, it's everywhere. The initial virus was in Italy at the beginning of March 2020, and then it spread through all of Europe. This was also the case for the wave that followed during the summer in France and Spain.

Here in Italy, we were seeing the Spanish strain, because many young people from Italy went on vacation in Spain and brought it back here. So this should not be a surprise given the fact that there are patients who are extremely infectious and others who are not infectious at all.

You can see family units where one person got infected and the infection did not spread to other members of the family. On the other hand, you also can see instances where one person was infectious, and that person went to a church or a theater and caused an outbreak. This disparity in infectiousness may be one reason for this difference between one country and another, or between states in the United States.

Topol: Many different vaccines have now gone through large trials. The mRNA vaccines have efficacy for symptomatic infection reduction of around 95% while others are around 70% efficacy. Should people have respect for these efficacy numbers or does it not matter?

Burioni: We should have a huge respect for these numbers because up to now, what was seen in the clinical trials has been replicated in real life. In Israel, more than 1 million people participated in that real-world study and the numbers were the same.

Right now, two numbers are the most important. The first is the efficacy against severe COVID-19 infection. That's important because mild infection is not a problem. It's a discomfort, but I wouldn't say it is a medical problem. Severe infection is a medical problem, not only for the patient but also for the health system. So these are very important numbers.

The other important issue, which is more complicated, is the vaccine's effect on transmission. We need to know if any given vaccine is able to stop transmission, because if a vaccine is preventing the disease but is not preventing the transmission, then it only protects the single person who is vaccinated. If another vaccine prevents the disease and also stops the transmission, with that one, we can protect the community.

From my experience as a virologist, I've never heard of a vaccine having a 95% effect on preventing disease that doesn't have a profound effect on transmission. Not a single one that hasn't been a huge obstacle to transmission. The latest data from Israel are showing that the Rt [rate of transmission] went down to 0.5, even in the presence of this terrible variant, which is almost too good to be true because this means that transmission is affected. Without a relevant animal reservoir, and if transmission is affected by the vaccination, we can get rid of this virus. That is the end of the story.

Topol: Roberto, you're a gem. We've learned so much from you. For every person listening on Medscape, you're hearing wise words that are much more than just about the pandemic; it's about science. It's about speaking the truth of science and making science exciting for everyone in simple words. We know you've paid a price, Roberto, for standing up to defend the science. We greatly appreciate all of those efforts, and we learn from and appreciate your expertise in trying to interpret what's going on with this unpredictable virus and the final chapter. Roberto, thanks so much.

Verghese: Thank you so much, Roberto.

Burioni: Thank you. It's been an honor.

Eric J. Topol, MD, is one of the top 10 most cited researchers in medicine and frequently writes about technology in healthcare, including in his latest book, Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again.

Abraham Verghese, MD, is a critically acclaimed best-selling author and a physician with an international reputation for his focus on healing in an era when technology often overwhelms the human side of medicine.

Roberto Burioni, MD, PhD, is an author and a virologist in the Laboratory of Medical Microbiology and Virology at the University Vita-Salute San Raffaele in Milan, Italy.

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