COVID Transmissions for 3-17-2022
China's omicron wave leads to new lockdowns
Greetings from an undisclosed location in my apartment. Welcome to COVID Transmissions.
It has been 821 days since the first documented human case of COVID-19. I did not think, when I started this newsletter, that I would still be counting that by this time. In 821, during a rebellion, Constantinople endured and repelled one of many assaults that would give its walls a great reputation for defensibility—until they were finally to fall in 1453.
Speaking of seemingly impenetrable walls, the country of China, which long described itself as having no domestic COVID-19 transmission, is now in the midst of a relatively large case wave. We’ll discuss that today.
Also, a brief note on US hospital mask policies.
Bolded terms are linked to the running newsletter glossary.
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Now, let’s talk COVID.
China’s Omicron variant wave
Official statistics in China now put daily COVID-19 cases over 5,000, the largest figure since the virus outbreak in Wuhan. While the number seems small compared to the US or UK, it is alarmingly high considering that daily cases were fewer than a dozen just a month ago.
In Hong Kong, the situation is substantially worse, with tens of thousands of cases daily.
This has led the government there to adopt new lockdowns, covering 37 million people. Some of these restricted states really fit the definition of lockdown, with citizens not allowed to leave their homes or neighborhoods, or only allowed to send specific household members out for groceries at limited frequencies. This is very different from the limited business closures that have come to be referred to as “lockdowns” in US popular press. CNN has more on the situation: https://www.cnn.com/2022/03/15/china/china-covid-outbreak-explainer-intl-hnk/index.html
Since the beginning of the pandemic, the People’s Republic of China has followed a policy approach known as Zero COVID. This policy is not complicated in its goals; the name tells you exactly what it is. Zero cases of COVID-19.
Unfortunately, China’s Zero COVID policy has, now, failed.
Obviously, not all countries have followed this approach. In a way it is difficult to blame those that have not, because no pandemic in history has ever really been controlled by human action alone.1
On the other hand, to act fatalistic in the face of this leads to large numbers of deaths, more than would occur if governments take some type of control efforts. In the case of some countries, like China, the control effort was to keep COVID-19 cases at zero. I will not provide a value judgment on whether the societal costs of this policy are worth the lives saved so far—partly because the official numbers on China’s pandemic experience are probably not entirely reliable.2 This data reliability issue is not unique but it does make it hard to weigh the precise benefits of Zero COVID policies against the measures required.
Instead of trying to say which countries “did it right,” I will lament the news that China’s attempt to keep COVID-19 eliminated now appears to have failed. This failure, in my opinion, is a result of the increased contagiousness of the Omicron variant that is thought to be dominating transmission in this outbreak.
We have seen SARS-CoV-2 variants evolve to become better and better at overcoming mitigation measures, as we would expect from evolutionary systems—Omicron is a vaccine-evading virus that is also capable of spreading at a rate that overcomes the ability of other, non-vaccine measures to control. Vaccines and nonpharmaceutical interventions combined can slow the spread of Omicron and reduce hospitalizations and deaths, thus reducing impact on the healthcare system and society, but it still appears to be able to overcome even the types of measures that were being used in China until now.
The mathematics are not very complicated; to shrink an epidemic, you want to make sure that the average number of new cases that spread from each existing case is less than 1. If it is greater than 1, the epidemic will grow. If it is 10, then a measure that cuts the spread in half will still mean you’re 5 times higher than you need to be.
Clearly, the Omicron variant has managed to become so contagious that strict measures don’t get that number under 1. This has led many to believe that it is inevitable for COVID-19 to spread to everyone it can infect, and while I am among them, this also doesn’t mean that individuals should give up on trying to delay their experience with this disease.
However, given the strict nature of Chinese measures even before the current lockdowns, the penetration of Omicron into that country leaves me wondering if we truly understand SARS-CoV-2 transmission as well as we think that we do. China had put in place very strict quarantine and testing requirements for travelers, and aggressive contact tracing procedures. So aggressive, in fact, that a recent outbreak in Hong Kong was traced back to a specific set of hamsters sold at specific pet shops. I covered this, about 6 weeks ago:
Yet Omicron slipped past these defenses. This says to me that there are elements of this virus and its transmission that do not necessarily fit into the current framework that we have used to understand it. There are those who would say that we have simply not accepted the fact that SARS-CoV-2 is airborne and thus have not realigned our priorities to focus on effective masks and air filtration—and those people are very much correct. But I do not think this provides a full explanation for this situation in China.
One area where China does have a degree of weakness is the quality of its most frequently used vaccines. Sinovac, domestically made, is an inactivated virus vaccine and it has been demonstrated that these are not as effective against SARS-CoV-2 as several other options, including mRNA vaccines. Since the effectiveness started low, Omicron variant evasion has surely pushed it lower. But since prevention of transmission by even the best vaccines provides incomplete containment of Omicron, I think this is not the chief reason that Omicron variant infections are surging in China.
I think the main reason, frankly, is that Omicron variant viruses break the rules, and we don’t fully understand all the ways that they do that.
I do not expect some wildly different picture to emerge from this situation, mind you—I am not saying that SARS-CoV-2 has some undiscovered transmission mechanism or that it has suddenly developed one. I am saying that some of our understanding of the known mechanisms may be calibrated to the wrong levels of capability. We think it can transmit X% as well if everyone is wearing a surgical mask instead of nothing? Well, perhaps we are wrong about that. Perhaps it is (X+30)%. I could ask similar questions about our understanding of SARS-CoV-2 survival on surfaces, rates of asymptomatic transmission, duration of contagious period, and more. We know certain particulars for all of these, but perhaps the particulars we know…are not so particularly right.
It will take years for us to understand accurate transmission dynamics, or even to be more precisely wrong. Epidemiologists and virologists, working in tandem, will be focusing on this for decades. However, I think it has become clear that Zero COVID is no longer a fully viable strategy without extreme lockdowns being a part of the picture.
To me, that is sad news. Even though I did not think that SARS-CoV-2 was really avoidable, I am disappointed to be right; it would have been great to have to write in the “Mistakes” section one day that Zero COVID policies actually can be effective. Unfortunately I don’t think that’s going to be happening.
On a global front, I do not think the wave in China is going to have a tremendous effect on places that already experienced Omicron variant waves. I’ve covered before that infection with the Omicron variant appears to lead to good protection from future infection with that variant. While I cannot say that this effect is durable, I do think that right now most countries that have been through Omicron-related waves probably have a lot of people who are immune to that particular variant and would be a bulwark against a new wave traveling around the world from this outbreak in China.
I mentioned last issue that there are worrying signs of rising case numbers in the UK and Europe, and wastewater signals in the US seem to be predicting another pulse of cases too. When it comes to the global situation, that is what I would be focusing on when thinking about a new global wave. What’s happening in China is, in my opinion, the ultimate arrival there of something that many countries already experienced months ago.
I will continue to keep my eye on the situation and discuss as needed.
US hospital masking policies have been requesting that people remove N95s and replace with surgical masks
Some US hospitals require you to put a fresh surgical mask on when you get there—whether you’re wearing no mask, or a high-filtration N95 that is clearly superior. The following Politico article looks at this situation and blames behind-the-times CDC masking advice for the problem, which does sound reasonable to me: https://www.politico.com/news/2022/03/16/hospital-mask-cdc-covid-00017556
Particularly in the healthcare setting, we need to do better. N95 masks can increase the risky-exposure time from just a few minutes to something more like hours. That’s the standard we need to follow, and these masks should be recommended as the option of choice for all people in the US.
I’ve been saying that for months. We need to be using high-filtration masks of a standard similar to N95 masks—there are several options, and that’s what we should be favoring.
Very strange to be writing this after thinking about China’s Zero COVID approach. We live in a world with many different ways of thinking. Some are more dangerous than others, from a COVID-19 risk perspective.
Part of science is identifying and correcting errors. If you find a mistake, please tell me about it.
Though I can’t correct the emailed version after it has been sent, I do update the online post of the newsletter every time a mistake is brought to my attention.
Correction: Last issue, I referred to an evolutionary process as a “careful” one. This was a mistake and I don’t know what I was thinking. Evolution isn’t careful at all; it is haphazard and random, and a lot of evolution involves organisms dying from unhelpful mutations. I have replaced the word with “long.” Thanks to Carl Fink for catching this one.
What am I doing to cope with the pandemic? This:
Listening: Surfing the NASH Tsunami
I’ve been listening to a podcast called Surfing the NASH Tsunami for work, which is about nonalcoholic steatohepatitis, or NASH. NASH is what happens when fatty liver gets so bad that it starts to cause the kind of liver damage that is typically seen in alcoholic liver disease. That’s an oversimplification, but it’s good enough for this venue—I try not to discuss my day job here.
“NASH Tsunami” refers to the fear that due to rising rates of obesity, there are a large number of people who are on their way to liver transplants or other undesirable outcomes, but they don’t realize it. This “NASH Tsunami” may reshape how hepatology is practiced—especially since there are not, right now, any treatments for NASH besides ones that help you reduce body fat.
Anyway, the podcast is extremely well-produced and brings in some really thoughtful experts, but I’m mentioning it here partly because it has made me feel like medical scientists in different specialties are more similar to each other than they’d care to admit.
For example, I’m a longtime listener of This Week in Virology (TWiV). TWiV is about two hours long and begins with guests reciting their local weather. It includes frequent digressions about the life histories and interests of the guests and host panel. It sometimes gets complaints about these things—but other listeners love the humanizing nature of such content.
When I first tuned into Surfing the NASH Tsunami? I was greeted by panelists providing their local weather. Then, some anecdotes about personal life history. The podcast was almost two hours long.
Maybe nobody else thinks this is funny, but it’s endearing to me that medical experts from diverse specialties have similar quirks.
Also, both of these podcasts are worth listening to, if you’re into medical science. Anyone around here fit that description?
Reader Dr. Jim Prego asked the following based on the paid Other Viruses section in the last issue:
Are there any papers or readings you can suggest that goes into ideas on HOW that evolution from just an integrated viral gene to the complexity of the placenta might have occurred? The intersection of developmental bio and evolutionary bio has always interested me.
There is a lot of literature on this, but I shared a link that can serve as a starting point:
Sure thing--this review is extensive and touches on many topics but could be a good starting point: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5033709/
You might have some questions or comments! Join the conversation, and what you say will impact what I talk about in the next issue. You can also email me if you have a comment that you don’t want to share with the whole group, or if you are unable to comment due to a paywall.
If you liked today’s issue, please consider becoming a paid subscriber and/or sharing this newsletter with everyone you know.
Please know that I deeply appreciate having you as readers, and I’m very glad that if we must be on this pandemic journey, at least we’re on it together.
Always,
JS
This fact is less exciting than it sounds when you realize I am using the official WHO declaration of pandemic as definitional—and smallpox, which humans did manage to eradicate, was never declared pandemic. Still, it tells you something of the stakes. Epidemics, we are able to control in some circumstances. Pandemics, not so much.
This is not a dig on China; no country has managed to keep good estimates of COVID-19 death statistics. Generally they are gross underestimates; China has experienced a large uptick in excess deaths during the pandemic years, despite officially low COVID-19 death statistics. This makes it hard to say exactly how successful their approach has been.
There is a cure for NASH, though not a popular one: a strict vegan diet. I know because I had NASH, and cured it this way. I was lucky; I saw my liver numbers going bad, insisted on follow-up, and had support to follow the diet for two years (and still mostly eat vegan or vegetarian). My numbers are fine now, but I still watch my blood work results carefully. Fortunately, livers heal!
By complete accident, my email to you this morning looks like a reaction to this column.