COVID Transmissions for 11-5-2021

Molnupiravir approved in the UK while the pandemic begins to ebb again

Greetings from an undisclosed location in my apartment. Welcome to COVID Transmissions.

It has been 719 days since the first documented human case of COVID-19. In 719, the Umayyad Caliphate invaded what is today Southern France, while in the north of Frankish territory, Charles Martel invaded and conquered Frisia, in the modern Netherlands. The map of Europe was very different then that what we might expect from today’s political lines.

In COVID-19 news, the pandemic is receding in most countries, except certain ones in Europe where vaccination rates are still low. That’s another map-related surprise to me, to a degree.

The news stories today focus on a variety of issues: a huge death toll in the US, the potential off-ramp for the pandemic in 2022, the approval of molnupiravir in the UK, and a vaccine success story for a totally different virus.

While not all the news is good, things are looking up. Have a great weekend.

Bolded terms are linked to the running newsletter glossary.

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Now, let’s talk COVID.

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750,000 deaths in the US

Yesterday, the US passed 750,000 COVID-19 deaths. Many of these deaths were preventable, because they occurred after vaccination became available. Certainly the ones that took us over this grim milestone were preventable.

I look at that number and I wonder what we could have done differently. Would it have been enough to have adequate testing at our ports in January? Would it have been enough to just close the country down in February, and pay people to stay home for that month? Would we have avoided the worst of this? Would rapid antigen tests earlier in the pandemic, and a universal mask mandate, have helped?

Numerous studies suggest that we could have drastically reduced the death toll if we had taken more extreme measures earlier. It is a sad reality of human risk evaluation that we underestimate the seriousness of exponentially-growing threats. We are averse to causing alarm, and by the time something has gotten “big” enough to overcome that, it is very difficult to contain. This was worsened by the ability of COVID-19 to spread silently through asymptomatic people.

Many of the fears that caused the US to have a lethargic and divisive response came down to being worried about disrupting lives, but for 1 in 440 Americans who are now dead, and those who loved them, life is disrupted forever. This is even more disruption when you consider long-term effects on survivors. And the economy was still disrupted as well, to the tune of around $15 trillion. Yes, that’s what the estimates are looking like.

For years, people are going to be writing about the mistakes we made and what we can learn from them. Whatever those lessons are, we really do need to learn—because this won’t be the last pandemic.

Forecasting pandemic off-ramps

Despite the grim milestone just mentioned, there is a way out of this.

Reuters just ran an interesting article, consulting many experts, looking at a global view of the current state of the COVID-19 pandemic and forecasting when it could come to an end: https://www.reuters.com/business/healthcare-pharmaceuticals/country-by-country-scientists-eye-beginning-an-end-covid-19-pandemic-2021-11-03/

The article includes thoughts from many people far more experienced than myself with this type of thing, and far more knowledgeable, but I think I can add some of my own comment here.

First, when we talk about “ending” the pandemic, what we mean is ending the emergency phase of this where society itself is paralyzed by the existence of the virus, and instead enter the endemic phase, where COVID-19 is a structural consideration in the infectious disease specialty of public health. As the article notes, endemic does not mean it’s not a threat. It just means a threat that we are used to.

Current trends around the world mostly suggest a drop in case and the approach of a steady-state situation, but the global north is on its way into winter. Winter means low humidity, and holidays where people gather indoors. I am not so certain that we are out of this yet.

However, we have found ways to manage. Many countries now have adequate testing infrastructure, allowing us to rapidly identify cases. In some of these countries, inexpensive rapid antigen tests are available that can identify who is likely to spread the virus. Vaccines are highly effective, particularly at keeping people out of the hospital. In the cases where they do not succeed—either because they weren’t used or because the patient didn’t have an adequate immune response—we have some first-line treatment options. Monoclonal antibodies and the on-its-way molnupiravir are also on the table as ways to predict those at high risk who may become sick. If those do not work, there are in-hospital options too, like fluvoxamine, tofacitinib, steroids, and more that can cut the risk of death or the need for high-flow oxygen or ultimately ventilators. Each of these is another layer of protection in the public health structure.

Early on in the pandemic we talked a lot about flattening the curve. These interventions have the ability to flatten the curve and keep the hospital system functioning in the endemic phase—if we use them. There are still some groups who need better protection options, such as children under 5 years of age, but vaccination is coming sooner or later for these groups. In the meantime, masks, isolation, and testing remain the best prevention options for those who cannot be vaccinated.

Eventually, COVID-19 is going to become another of many things that are of little concern to most people, but which can be a grievous threat to those who have difficulty fighting off infection. We will be able to reduce the mortality in these groups meaningfully, but eventually, we will hit a wall. While COVID-19 is not currently like the flu, when all is said and done, I think we can get to a place where it is like that in terms of the public health impact. Maybe, with the very best treatments and vaccinations, it could become even less of a threat than the flu. I’d like to see that happen.

This is all speculative, though, and relies on the idea that some new variant will not emerge that changes the game completely. We have seen the pandemic burn hot, cool off, and burn hot again more than once now. It’s not beyond the realm of possibility that things could change again. If that happens, we’ll need to adjust the timeline and prepare to deal with the next wave.

Whatever happens, I’ll be here to talk it through.

Molnupiravir approved in the UK

The UK became the first to approve Merck’s new oral antiviral molnupiravir: https://www.cnn.com/2021/11/04/health/uk-authorizes-merck-antiviral-molnupiravir-covid/index.html

They won’t be the last to approve it, I think. This drug is effective, safe, and useful.

I covered the data supporting molnupiravir in a recent issue, more or less exactly a month ago:

COVID Transmissions for 10-4-2021

Non-COVID news: HPV vaccine prevents almost 90% of cervical cancers

The HPV vaccine, which prevents the sexually-transmitted human papilloma virus, was one of the biggest 21st century healthcare breakthroughs. HPV is a deadly virus, but in a somewhat roundabout way. The virus itself typically causes no symptoms, or very minor ones—genital warts, sometimes. Infection usually resolves on its own after a couple of years. However, during that infection, the virus can inactivate two key “tumor suppressor” genes, p53 and pRb, which prevent cells from becoming cancerous. With these suppressor genes turned off, the chance of cancer shoots up. Often, this manifests as cervical cancer, which is particularly dangerous because it is hard to detect until it is very advanced. Almost all cervical cancers, at least before the invention of this vaccine, were caused by past HPV infection. The vaccine made those cancers preventable.

It was also the focus of bitter battles from antivaccine agitators, who used the fact that it was a new product alongside the sexually-transmitted nature of the disease it prevents to whip up parent hesitancy about getting the vaccine. These actions almost certainly have led to cases of cervical cancer that could otherwise have been prevented.

This week we got big results looking back on the effect of the vaccine when it first became available. This took a long time because the emergence of cancer after HPV infection is not immediate, so studying the long-term effects required a lot of patient and careful study. But the results are now in, and they are unambiguous: the vaccination prevented 87% of cervical cancers in recipients in the UK: https://www.cnn.com/2021/11/04/health/hpv-vaccine-cancer-rates-study/index.html

In the US, less than half of young adults are vaccinated against HPV. This means that a huge number of people in the US are unprotected from outcomes like cervical cancer. Those who get the vaccine have a much lower risk of these cancers. It’s another instance where antivaccine activism gets people killed. If there’s someone in your life who is a candidate for this vaccine, I strongly encourage you to talk to them and their healthcare provider about protecting themselves from this avoidable risk of death.

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

The 5th of November

Today is the 5th of November! That is a red letter day in history, the date of an event that is important to remember.

I am speaking, of course, of the invention of the flux capacitor, which makes time travel possible:

Image is a digital display with “NOV 05 1955” shown in red LCD digits.

I’m joking, of course. It does happen to be the date that the screenplay for Back to the Future was finalized, in 1985, which is the reason they used that date (in 1955) in the film.

I’ve always thought it was funny that it coincides with Guy Fawkes Day/Bonfire Night in the UK, given the “remember, remember” poem. I find the Back to the Future connection more relevant to my own life, I’ll admit.

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Always,

JS