September 12th, 2022
Coronavirus Update 70 plus other stuff
North Carolina is in a good place.
No MIS cases.
In NC, we are at 5% of admitted patients needing a ventilator and 12% needing an ICU bed for Covid.
The 7 day moving average of cases for the US in recent weeks is 65,000 although we all know that this is vastly less than accurate with most people getting, using and not reporting positive home tests.
The risk of death is 0.000033 once vaccinated with a two dose series or survived natural infection.
As it stands today, the United States has had 1.05 million deaths. The case numbers will continue to vastly underestimate true case volume so I will stop reporting the number as it is meaningless now.
If you did not read the newsletter about an Integrative approach to proper health in the COVID era and frankly all future infectious diseases, read this link and this link.
As with the first newsletter on this topic, keep solace with the fact that there is a 99+% chance of survival for all of us regardless of vaccination. However,
mathematically, you now have a 99.9998% chance of survival once vaccinated and the vaccine safety for the mRNA vaccines continues to look good.
Omicron US strains: as of August 13th data - variants make up: BA.4 is 2.2%, BA.4.6 is 9.2% and BA.5 is 87.5%. This Covid wave is still inline with volumes from wave three which was delta.
BA.5 is showing no signs of increased disease morbidity.
Little else to report here. (CDC Variants)
From Monica Gandhi: " The rate of severe COVID-19 in the US is down. Hospitalizations can be misclassified as being from COVID since we swab everyone admitted to the hospital for SARS-CoV-2 (the UK stopped this practice in August). A nice chart review in an ID journal showed that vaccination rates and immunity are high, and many of those hospitalizations are just “with” COVID or incidental.
The US rolled out Omicron-specific boosters BA4/BA5 plus the ancestral strain bivalent, but they seem to be most important for older people. A paper published in the New England Journal of Medicine showed those most at risk for severe breakthroughs are 65 years of age or older. " (Gandhi 2022 Mashup)
Finally, I am likely to slow down the frequency of these newsletters about Covid unless something new shows up to discuss.
GOOD NEWS: This information is so important to help us all understand risk. Stratified risk is the only true way to measure personal risk. Let us look at some CDC data from the spring Omicron BA.1 and .2 spikes versus the fall 2021 delta wave.
Median age of hospitalization has increased from 60 years old with Delta to 64 with BA.1 and 71 with BA.2. Any underlying medical condition associated with hospitalization increased from 89% with Delta to 92% with BA.1 to 95% with BA.2 respectively. Length of hospital stay decreased from 4.8 to 3.9 to 3.3 days. ICU admission was down from 24% to 18% to 13% of admitted patients. Mechanical ventilation decreased from 14% to 8% to 6% of admitted patients. And Finally, death from 12% to 8% to 5% overall. (Link)
What we can glean from this data set is very clear. With successive SARS2 mutations coupled to increased population based exposure to virus via infection or vaccine, we are now seriously in a reduced risk state unless you are older than 65 years with a comorbid disease or younger than 65 with a serious disease. 95% of hospitalizations were related to a comorbid disease regardless of age. The other big takeaway was this: if you are in this high risk group, getting every available booster is vital to your survival based on the risk reduction data. For everybody else, the data is clear, you are ok - to boost or not to boost is up to you. But, absolutely work on your general health.
Interestingly, the media coverage remains weak on risk stratification truths. Multiple outlet headlines on this data only discussed booster risk reductions. WebMD says: CDC Says 44% of People Hospitalized with COVID Had Third Dose or Booster “Adults should stay up to date with COVID-19 vaccination, including booster doses,” the CDC said. “Multiple nonpharmaceutical and medical prevention measures should be used to protect persons at high risk for severe SARS-CoV-2, regardless of vaccination status.” (link WebMD) or CDC report: 44% of people hospitalized with COVID got third dose, booster. (USAtoday) There was so much more to discuss in this data set as shown above.
Quick Hits and other musings -
1) From JAMA, "peak neutralizing antibody levels were reached at a median of 84% approximately 1 to 3 months after infection. Neutralizing antibody levels remained reasonably high with a median of 69.8% at 9 to 13 months after infection. However, during the acute phase of infection (<1 month), neutralizing antibody levels were highest in those younger than 5 years and lowest in the 12 to 16 years group. Neutralizing antibodies in participants younger than 5 years remained little changed in the point estimates up to 16 months after infection. ( Yung et. al. 2022)
This is a really useful analysis for a few reasons: 1) younger children have robust antibody responses that wane more slowly than older age individuals. 2) re-infection in little children will be less common due to circulating antibodies. 3) severe disease will be exceedingly rare in this 0-5 year old age range based on robust immune responses. 4) children are not the spreaders of this disease as was noted early in the pandemic. Let us stop the worry related to children being spreaders or trouble in general.
2) "Since the initial COVID-19 outbreak in Massachusetts, USA, there have been periods without excess mortality, corresponding to times of low prevalence. However, we also have observed two substantial outbreaks not accompanied by excess mortality. The first instance, (late February–June, 2021) corresponded to the phased vaccine rollout period, during which the mean age of newly infected people dropped precipitously and prevalence among people older than 60 years was low, probably temporarily reflecting exceptionally high vaccine-conferred protection against SARS-CoV-2 infection among the vaccine-eligible population. The second instance occurred late February–June, 2022). Unlike February–June, 2021, the mean age of newly infected people did not fall during the corresponding 2022 period, and in fact rose. The uncoupling of excess mortality and new COVID-19 cases, in the absence of decreases in the mean age of infected individuals, suggests that in our highly vaccinated state, current levels of immunity are considerable, leaving many, if not most, individuals at high risk with substantial protection against the most severe outcomes of SARS-CoV-2 infection. However, given newly emerging variants and the unknown duration of protection from infection and vaccination, further monitoring is warranted." (Faust et. al. 2022)
This is key data. Overall national risk continues to drop and show that at risk groups that vaccinate are in good shape. This is the key to the reality that most everyone else can relax and live life. For those at risk, vaccinate and lower your risk. Normalize life otherwise.
3) In a well written review of the association between Covid illness and Irritable Bowel Syndrome, we see that covid disrupts the GI/intestinal microbiome, affects food choices through dysgeusia, vagal nerve dysfunction affecting bowel motility and sensitivity and fatigue affecting movement and metabolism. All of these events, conspire to alter GI function leading to the constellation of feelings related to IBS. (Chan et. al. 2022) See below section 2 for details.
4) From Deo and colleagues we see data about rebound Covid symptoms. This is a phenomenon that I experienced first hand in March of 2020. I had 3.5 days of mild Covid symptoms before feeling great for a day and a half. Then I experienced a big rebound in fever and symptoms for 2 days before having a month of fatigue and a slow return to my baseline. In this study: The study population included 568 participants who received SARS-CoV-2 RNA testing on days 0-14, 21 and 28. Viral rebound was defined as ≥0.5 log10 viral RNA copies/mL increase and symptom rebound was defined as a 4-point total symptom score increase from baseline. Baseline was defined as study day 4 (primary analysis) or 8 days from symptom onset (secondary analysis). 12% of participants had viral rebound. Those that rebounded to Sars2 were older. Symptom rebound occurred in 27% of participants after initial symptom improvement and in 10% of participants after initial symptom resolution. The combination of high-level viral rebound to ≥5.0 log10 RNA copies/mL and symptom rebound after initial improvement was observed in 1-2% of participants. (Deo et. al. 2022)
This is in a non treated group making the paxlovid rebound data not a purely drug related phenomena. This is an important piece of information as it shows us that this virus may take a prolonged time frame to resolve in a sub group.
5) From the Annals of Internal Medicine: Baseline pulmonary severity of illness was strongly associated with plasma antigen level, with mean plasma antigen level 3.10-fold higher among those requiring noninvasive ventilation or high-flow nasal cannula compared with room air. Plasma antigen level was higher in those who lacked antispike antibodies and in those with the Delta variant. Additional factors associated with higher baseline antigen level included male sex, shorter time since hospital admission, decreased days of remdesivir, and renal impairment. In contrast, race, ethnicity, body mass index, and immunocompromising conditions were not associated with plasma antigen levels. Plasma antigen level of 1000 ng/L or greater was associated with a markedly higher odds of worsened pulmonary status at day 5 and longer time to hospital discharge. (Study Group 2022)
For those that end up heading towards the hospital in the future, this is a metric that can be used to predict risk and the need for medical interventions. Antigen is a word for the fragment of immune irritating protein identified in the blood, in this case SARS2 fragment.
6) A very nice analysis of patients that had been vaccinated with 2 doses of the ancestral strain of Covid vaccine, had a BA.1 or BA.2 infection and then did they or not have protection against BA.5. From the text: We found that previous SARS-CoV-2 infection had a protective effect against BA.5 infection and this protection was maximal for previous infection with BA.1 or BA.2. (Malato et. al. 2022)
This is of interest for those that will choose to receive the fall Covid booster as the RNA genetics of the spike protein are from the ancestral strain as well as BA.1. In real life, those infected with BA.1 or .2 (me included in February) should have nice protection against BA.5. For me, the antibody levels in my blood are probably very low now 7 months out, but my B and T cells are primed and ready to deal if I see BA.5, assuming that I have not already.
7) From a research group out of Tel Aviv university we see that the group found two antibodies that neutralize all known strains of COVID-19 – including Omicron – with up to 95% efficiency. The antibodies were isolated from individuals with ancestral strain as well as other variant infections. There is a strong possibility that these pooled antibody treatments may prevent serious disease and illness if clinical effects can be shown thus reducing and or eliminating the need for repeated booster shots. (Li et. al. 2022) Time will tell as this is very preliminary data.
That's all this week,
Dr. M
Yung JAMA
Faust Lancet Infectious Dis
Chan Clin Gastro Hepatology
Deo MedRxIV
Annals of Int Medicine Study Group
Malato NEJM
Li Nature Commun Biology
CDC MMWR
CDC Variants Page
CDC Covid Deaths
