Greetings from an undisclosed location in my apartment. Welcome to COVID Transmissions.
It has been 636 days since the first documented human case of COVID-19. In 636, the Arab-Byzantine War was in full swing, and the Byzantine armies were failing. Areas that had been under Imperial control since the last Jewish Revolt against the wider Roman Empire were being taken by the Rashidun Caliphate, who the locals largely saw as liberators. Emperor Heraclius, leaving Syria in 636 for what would be the last time, said, “Peace be with you Syria—what a beautiful land you will be for our enemy.”
This feels timely. I find myself really distracted tonight by the collapse of the government in Afghanistan. It is hard to watch this kind of history being made. I feel deeply for those going through this in the midst of a pandemic, even more so based on reports that the Taliban has banned COVID-19 vaccination in at least some parts of the country: https://futurism.com/the-byte/taliban-bans-covid-vaccine
Meanwhile I am also saddened—what a weak word for it—by the recent earthquake in Haiti and its staggering death toll. This hasn’t been a very good weekend on the world news front.
To really cheer everyone up, I saw the return to schools that is coming in the fall described as a “children’s crusade” today, referring to the medieval story wherein a child-led crusade to retake Jerusalem became an unmitigated disaster. I’m not sure it’s going to be quite as bad as all that, but it’s not going to be good, and I’d like to talk about that a little bit today.
Also, some reader comments and responses.
Bolded terms are linked to the running newsletter glossary.
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Now, let’s talk COVID.
US pediatric hospitalizations, visualized
This is the kind of thing I really hate to share:
I want to explain a little bit of what we see in this animation. For those of you who cannot see it, it shows the growth in daily pediatric hospitalizations in the USA over the pandemic. The numbers bounce around from 100—200 daily for the periods of 2020 and 2021 that are covered, until July 2021 when an alarming exponential pattern emerges and the daily numbers spike to around 300.
What I want to address is why this is happening. Firstly, children under 12 in the US cannot be vaccinated on-label at this time. If there are physicians or clinics doing it, they are doing it at their own risk of lawsuits given that a pediatric dosage is not yet approved. I can’t imagine that off-label administration to children under 12 is commonplace. Even so, there is a large population of children who are vulnerable, and when adults get sick, children get sick too.
While children have been thought of as more resilient to COVID-19 than adults—and do generally appear to be—the more a virus spreads, the more people it can reach. Even if 95% of children experience no serious disease, 5% of a big number is still a big number. Please note that that proportion is made up for illustrative purposes. National data from the American Academy of Pediatrics can be found here: https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/children-and-covid-19-state-level-data-report/
Something that aided us earlier in the pandemic was that schools were closed. This was, generally, not that great a thing for children or teachers in terms of the business of learning, but it was good for controlling the spread of COVID-19 in schools. As schools opened up more, outbreaks started to be reported.
With the more contagious Delta variant appearing, we are seeing a surge in cases in the US and that is extending to children. This surge is certainly focused among the unvaccinated, with vaccinated breakthrough cases representing a small fraction of what is being seen nationally. Again, children are largely unvaccinated, so when you see numbers about that population, remember it’s not just people outside hospitals holding protest signs with varying levels of grammar. It’s kids. It’s people who aren’t allowed to take off work to get the shot, but who live so close to the edge that they can’t risk those jobs. It’s people who are just scared because they have heard about terrible things in the history of medicine like the Tuskegee experiments or the mutilations performed by Dr. Mengele. While I want these folks to get vaccinated, I want to be clear that there are a lot of legitimate barriers to vaccination, as well as legitimate emotions that form a barrier as well. We have a lot of work to do to bring down these barriers, but we also have other problems in the near term.
Specifically, schools are soon to be reopening around the US. In many areas, for some reason, protective measures have been banned from schools. In even more areas, they are not being required. This is, frankly, going to be a terrible thing. Even one child’s death is a terrible thing. If the curve we’ve just seen continues to rise—and everything happening suggests that it will—there are going to be many more pediatric deaths than one.
The US—and most of the world—protected children well throughout the pandemic. I hope that vaccination is expanded to all school-age children as soon as possible, so that we can continue to do that. However, until it is—in fact until about 6 weeks after that expansion—I fear we will see more like the above.
However, it’s not all bad news. Even in Texas, where there is a battle between the Governor and certain local authorities on the ability of schools to require masks, I am hearing stories of those local authorities really pushing back—and fighting the Governor in court. As of last night, the Dallas independent school district was supporting a mask mandate for tomorrow’s start of school:
I hope that more schools do the right thing and protect kids. And again, I hope there are safe and effective vaccines available for children soon.
What am I doing to cope with the pandemic? This:
Playing: X-wing Miniatures
Some of you may be aware of this, if you’ve been with the newsletter for a long time, but I am a player of the Star Wars: X-wing Miniatures game. This is a board game where you simulate a Star Wars fighter battle with small squads.
Something I like about the game is that it requires you to out-think your opponent in real-time, because you choose the direction your ships are going to go in secret, simultaneously. The ships can only shoot at each other if you have positioned yourself well and predicted what your opponent is going to do. This turns it into as much battle of wits as one of dice and squad choices.
Anyway, yesterday I went to an in-person X-wing tournament (everyone was masked and vaccinated), and had a great time. Several folks I know read this newsletter were there, so thanks for coming out to play!
Carl Fink shared a study that I think is pretty interesting, that notes an association between certain dietary behaviors (in a similar vein to the hypothesis about blood glucose I shared last week):
Relevant to your August 11 column: https://www.mdpi.com/2072-6643/13/6/2114/htm
Eating vegetables and drinking coffee are associated with diminished risk of COVID-19 in the UK health biobank. As a coffee drinker, I find this encouraging (even if the reduction is modest).
Eating at least "... 0.67 servings/d of vegetables (cooked or raw, excluding potatoes) was associated with a lower risk of COVID-19 infection." 2/3 of a serving a day? Do a lot of people in the UK eat one serving of a vegetable less than 2 out of 3 days?
Of course, this is associational, not experimental, so causality is not demonstrated.
I think Carl summarized this very well. My thoughts are as follows:
At first glance these both sound like indicators of socioeconomic status, but I see in the paper that the authors made an effort to control for this. That said, no posthoc control is ever really perfect, but still, perhaps these are indeed general things that associate with COVID-19 outcomes. Coffee, I know, has been the subject of very close research for a very long time, and the last I checked in on that research it was closely associated with good healthcare outcomes when other factors are controlled. Likewise, eating more vegetables provides nutritional benefits. So I think--as you may be saying as well--that this may suggest it's worth exploring further how COVID-19 outcomes relate to overall nutrition. I have a feeling that all of this--including any blood glucose link--may be just part of a bigger picture. It's rarely ever just one thing that is the root cause of complex disease.
Also, funny point re:vegetable-eating frequency. I guess part of it also depends on what you classify as a vegetable, and how you define a serving. The vegetable "fixins" on a Big Mac might not be quite enough to hit one. A lot of people make meals out of fast food and takeout frequently, where vegetables might be infrequently present or perhaps just an afterthought. I'm not a nutrition researcher though, so, I'll try to stay in my lane and not speculate. There are enough people out there making wild claims that bridge COVID-19 and nutrition research, I don't need to be one of them.
Interesting stuff here!
Carl also asked for some clarification on my thoughts about testing:
I was saying back in January of 2020 that we needed a rapid antigen test, costing $1. Honored that you agree.
I've also had a very hard time figuring out how weekly tests matter, given the incubation period of this virus (which is seemingly even shorter for the Delta variant).
You wrote, "Even if the test result is very fresh, 40% of those negative results might actually be people who are positive. By comparison, vaccination prevents 85% of cases—meaning that vaccinated people are about 15% as likely to be positive as unvaccinated people are. A random person who has received a negative test but is unvaccinated might well be more likely to be infected than a random vaccinated person." Aren't you comparing apples to oranges? 85% is the degree of protection (and that's not a very hard number) for the mRNA vaccines used in the USA. 40% is the *lower bound* of the false negative results of PCR tests. Comparing failure to detect actual viral infections with the *ratio* of the probability of being infected between vaccinated and non-vaccinated people ... I fail to see how they're directly commensurable.
(Why compare the worst PCR results with the best vaccine? Why not compare the 5% number to Sinovac's or Janssen's vaccine?)
"By the way, if you’re vaccinated, and you feel sick? Go get tested. It’s really important." I have hay fever. As I type this, I'm slightly sniffly. I suppose I could get tested every day, but in practice, given the current costs, I don't want to. One problem with COVID-19 is that it causes so many, and such diverse, symptoms. The only distinctive one I am aware of is losing smell and/or taste, pretty rare otherwise.
I do feel the need to clarify this, and also to answer Carl’s question about differentiating symptoms that may not be particularly distinct:
Well, a couple things here. In the US, overwhelmingly, vaccinated people have mRNA vaccines. The number of Johnson and Johnson vaccines is several orders of magnitude lower, such that a random vaccinated person is much more likely to be mRNA vaccinated. If I wanted to be especially rigorous I would find the average protection level with a "generic" vaccine and use that but since there is such a difference in uptake between the two major classes of vaccine, I don't think that would make a dent. The typical vaccinated person is about 85% protected.
Now as for how this compares--I could have showed my work a little better here. Let's start with some fixed probability that a random person is infected with COVID-19, and we'll just call that X for the sake of this. For a vaccinated person, X is 15% of what it would be if the person is unvaccinated, so it's 0.15X. If the person has been tested just moments ago and got a negative result, the odds are a range between 0.05X and 0.4X--and in this instance I am more concerned with the highest estimate of the danger because I cannot be sure just how well their test was conducted. Plus, we know that since tests are not instantaneous, with more chances to get infected post-test, the tested unvaccinated person's "safety" is never going to be at that 0.05X number. It's always going to be higher. So I don't think the low end is useful to use there.
We suffer in this attempt to estimate from the fact that testing accuracy is not well-understood while vaccine protection is well-understood. I'm pretty confident that vaccine-mediated protection is between 80 and 90%, such that the average value of 85% is reasonable to use so I feel pretty certain that the odds of a vaccinated person having COVID-19 are around 0.15X. I'm not confident at all that any spot in the range of false negativity is "the" number, so I started with the worst-case scenario but also considered the low end later on.
Re:testing, it's worth looking at the CDC's definition of symptomatic. It won't help you in particular to differentiate hay fever from COVID-19, but it's useful in general: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html
As for hay fever, I think your best bet is actually to take something for your allergies. COVID-19 won't respond to antihistamines, because it doesn't activate histamine pathways. What's more, testing really should apply to any new or unusual symptoms. Since you typically have this allergic reaction, it's neither new nor unusual, and if you're slightly sniffly every day, but experience nothing else, you can be reasonably sure (provided you've had at least one test) that you don't need a new COVID-19 test. If that pattern changes and you develop sudden fever, cough, worsening congestion, etc., then it's a good time for a repeat test. It's not the easiest situation to navigate, but it doesn't have to be one where you're completely uncertain of what to do.
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.
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Always,
JS
Hey John,
Thanks for continuing to do this work for so long. Your posts are great sources of relief, as I like understanding things that make me upset as best as I can.
In that vein, I was wondering what you think about this article?
https://news.yahoo.com/troubling-cdc-vaccine-data-convinced-132851003.html
Basically, the Biden administration is reportedly moving towards a booster shot campaign because there's new evidence that vaccine protection is waning over time, maybe faster than expected. What do you make of this? Would love to get your take.
Hope you're keeping safe and thanks again for what you've been doing!
- Mcc
Hi, John,
To clarify: my comment about other vaccines was meant in the context of the disease being a global problem(as you have written about), thus my mention of Sinovac. It now seems that the commonly-exported China-manufactured vaccines are not very effective (emphasis on "seems" as I am not an expert), and at this time I believe they're the most-widely-administered worldwide. Of course, nations that can't afford more effective vaccines can't afford truly widespread testing, either.
You mention the Taliban apparently banning vaccination. Could this be because a CIA pretense of working for a vaccination program resulted in the death of their buddy, Osama bin Laden? That's a rhetorical question, inevitably that contributes to their attitude. The CIA may well have killed more people than Osama ever managed with that poor decision.