COVID Transmissions for 1-25-2021

So they say B.1.1.7 is more deadly, too.

Jan 25, 2021

Good morning and welcome to COVID Transmissions. I hope you all had a nice weekend!

It has been 434 days since the first documented human case of COVID-19.

I’m focusing in today on the headline from Friday that involved claims out of the UK that the B.1.1.7 strain is more deadly. I’m skeptical of these claims but I wanted to talk through some of my thinking “just in case” they are true, as well.

Also, in “Talk Back,” we have a brief discussion of transparent masks.

As usual, bolded terms are linked to the running newsletter glossary.

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Now, let’s talk COVID.

UK suggests that B.1.1.7 has a gain in mortality

Boris Johnson, Prime Minister of the UK, suggested Friday that the B.1.1.7 SARS-CoV-2 variant may have worse mortality than other lineages. CNN covered this here: https://www.cnn.com/2021/01/22/uk/uk-variant-scientists-johnson-intl/index.html

Look, this is the second time in a row that Boris Johnson has said something deeply concerning about this virus that wasn’t well-supported by data. My initial reaction, especially after seeing the small numbers of patients it is based on, is that it could just be error in the data.

It’s not even based on observed deaths in hospitals. It’s a small signal from overall mortality in patients with this variant vs others. It could be that people who go this variant are more likely to get in car crashes after recovery (that would be weird), or this is just data noise. I’m not keen on making big conclusions off something like that. If there is genuinely something inherent about this virus variant that makes it more deadly, I would expect that it would be detectable both in deaths of hospitalized patients as well as overall deaths in wider populations of infected patients.

Speculation ahead!

On the other hand, last week I told you about evidence that this variant has some mutations that could escape antibody responses, and because of that, I do wonder if the UK hasn’t detected a real effect here. I remain skeptical, but a lot of what we have seen with this variant would make neater sense if it also caused a slight elevation in mortality.

The ability of a virus to evade antibody responses can improve its ability to survive until it is transmitted. This might appear to be a gain in “transmissibility” without actually being such a gain. If fewer infected people have good immune control over their infections with this variant, it will survive to transmit more without actually gaining any new transmission functions. However, if that’s happening, you would also expect it to be slightly more deadly, and everything that was said before Friday suggested it wasn’t any more deadly.

So, if it really is modestly more deadly, then this all fits with a variant that has evolved due to pressures from the antibody response in typical patients. However, this is really shaky thinking when it comes to what data we have. The data for a transmission gain are…moderate quality. We don’t really know the magnitude of that gain, but I feel safe putting it around 30-50% for now. We don’t really know if there even is a gain in mortality. And the antibody-evasion studies are still pretty preliminary too, and only look at specific single mutations, rather than the full picture of the mutants present. So I’m out on a limb here—don’t go telling your friends that what I said after the italicized warning is fact.

However, let’s say I’m right. Does this mean that the immunity of recovering persons is not adequate against this variant? No, it doesn’t mean that. These changes affect the affinity of very specific antibodies against the virus, but the immune response is made of many antibodies. What they may do is slightly delay or weaken the antibody response during a first infection, buying the virus a little more time to survive to transmit to a new host. I don’t expect them to have a really substantial effect on complex, multipartite immune responses.

However, it does suggest these viruses could eventually drift in sequence enough to evade existing antibody responses fully—if we give them the opportunity. It took about 9 months of widespread circulation around the world for these variants to emerge, so maybe it would take a matter of years for SARS-CoV-2 to develop a new strain that would be truly distinct from the predominant strain now. We’ve talked about this possibility before, too, and it isn’t a doomsday scenario either. The virus will not change all at once, so while it changes slowly, we will continue to “train” our immune systems with new exposures before it full escapes existing responses. When everyone is vaccinated, I expect that SARS-CoV-2 variants will emerge that cause mild colds in some people, or even no illness at all. These will “boost” us and generate immunity against new lineages.

There’s kind of a Ship of Theseus metaphor here—eventually, SARS-CoV-2 may evolve into something that looks much less like its original form. But during that time, our immune responses will adapt too.

It would take something really unprecedented—like, say, a serious disruption to the delivery of doses of vaccine, or a country with a plan to delay delivery of second vaccine doses—to make things change much faster. I hope that any countries planning such delays reconsider.

Let’s leave the world of speculation for a minute, though. I do have a real bone to pick with the UK government’s handling of their communications on this variant. First they claimed based on preliminary data that this variant was 70% more transmissible. This turns out to not have been really true. They also claimed it didn’t cause more severe disease at that time. Now they’re claiming it causes more mortality, which I do think would qualify as a change in disease severity, so we can’t live in a world where both of those statements are true. At best, the UK government spoke too soon. At worst…well, I’d rather not speculate, but their messaging has been uneven and misleading.

There are those who tell me that it is good for the government to alarm people about a virus that they are not taking seriously, because COVID-19 is a very deadly disease anyway. I am firmly against this concept. Misleading the public, even with the best of intentions, always backfires.

I first saw this during the West African Ebola virus epidemic some years ago. Western media made a big deal out of this as a potential threat to many other countries, when in reality, Ebola virus is very easily identified and would be unlikely to spread a great deal through travel. Even if it had spread in a substantial way in, say, the US, it would have been more readily treated in US hospitals and much easier to contact trace than SARS-CoV-2 has been. Panic-inducing news reports eventually gave way to what we could have predicted at the beginning—that the outbreak would remain relatively local to West Africa, where it was a serious tragedy, but would not be very impactful elsewhere. The problem is, people who were panicked by these news reports could easily have felt lied to when the advertised disaster did not appear.

Fast forward to 2020. In the initial days of COVID-19, I heard many people say that concerning media reports of introduction of the virus to the US was just media alarmism. People cited that the Ebola virus outbreak was also reported on in the same way, and nothing came of it—and they were right about that historical perspective. What they were wrong about was that this time around, the reporting on COVID-19 was another example of such sensationalism. Misleading messaging has been with us for as long as the boy who cried wolf, and that story is not wrong in how people react to it. If you sound the alarm falsely, people will not respond to real alarms in the future.

When I message in a way that minimizes alarmism, it is not because I do not take these threats seriously or that I am concerned about starting a panic. It is because I believe that it is important for my messaging to be trustworthy. I assess the risk in a given moment, based on the evidence that I have at hand, and I state when I am speculating. I do these things because there may come a time when I tell you that you need to panic. I want you to be able to trust that statement if it comes.

What the UK government has done serves to erode public trust when the messaging is confusing or inconsistent. Rates of virus transmission are going down there, and the predicted explosion in cases has not materialized to the extent forecasted. Part of this is due to disease control measures the country has taken, but it also doesn’t look like the doom and gloom prediction of an uncontrollable variant virus has come to fruition. As the public in the UK and around the world notice this, they are going to be angry. That will undermine trust in future cautionary statements made by the UK government. That trust is not easily regained, and the risks of such mistrust are very great.

So I try not to blow things out of proportion, even out of the best of intentions. Sometimes this means I get things wrong, but at least I can course-correct when that happens.

That said, COVID-19 remains an extremely serious matter and a virus that can kill or disable a person for life. You should be acting with extreme caution because of this. That hasn’t changed, and has always been true.

What am I doing to cope with the pandemic? This:

Newsletter copy editing, part 2

Following up on Friday, I’d like to note that I got more responses from people who said they preferred the fully written-out links than people who preferred the inline style; I’m going to be sticking with writing them out fully. One particularly important point made by a reader was that substack replaces links with a redirect that goes through substack itself, making it hard to tell what the intended destination is if I don’t write it out fully. Given that, I want you all to be able to see where it was I intended to send you.

Carl Fink wanted to go a little more in depth on monoclonal antibody naming conventions, and I thought some of you might be interested in this:

Trivial, but: "-vimab" is specifically monoclonal antibodies intended for use against viruses.
https://www.ama-assn.org/about/united-states-adopted-names/monoclonal-antibodies

I wasn’t sure, when I commented on what “mab” means, that anyone would want all the details, but hey, it’s good information.

Also, reader JG left the following:

1. I deeply appreciate your insights into various articles and headlines in COVID Transmissions and elsewhere. If I do hear a troubling headline or story, I wait for your breakdown/opinion I am almost certain to get the following day before worrying too much.
2. I've started to see ads for transparent face masks. What is your take on them? Do they work?

(1) is really high praise, so I’m flattered and thank you for that. Here is my reply:

1) Thank you! If you notice anything that you'd like me to specifically cover, please feel welcome to email it to me. I don't always get to things super fast, but It helps to have my attention called to things that people are interested in hearing about.
2) I think this really depends on the mask. I'm sure that as a barrier, they work fine, if designed to cover the face properly. They probably are a little less flexible around the edges, so I'm not sure how well they would seal. Clearly if they seal too well, you can't breathe, which is probably safer for others but not ideal for you. I think the best advantage of such masks is that they help people who rely on lip-reading due to hearing impairment, but they do still need to be effective. I've seen some masks that have a plastic window over the mouth but are otherwise made of cloth around the edges. Those might actually be better. I wonder if there is an N95 mask in that style. That sounds like it would be pretty great.

You might have some questions or comments! Send them in. As several folks have figured out, you can also email me if you have a comment that you don’t want to share with the whole group.

Join the conversation, and what you say will impact what I talk about in the next issue.

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