COVID Transmissions for 8-6-2021
Who says no to booster doses? WHO does.
Greetings from an undisclosed location in my apartment. Welcome to COVID Transmissions.
It has been 628 days since the first documented human case of COVID-19. In 628, the Muslim legal system sharia is introduced. It calls for both women and men to receive both secular and religious educations, something quite unusual for this period in time. Not exactly what a lot of Westerners think when they hear the word “sharia.”
Speaking of the unexpected, today I want to demonstrate why the WHO is right to say we shouldn’t be focusing on booster doses. Read on…
And have a nice weekend.
Bolded terms are linked to the running newsletter glossary.
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Now, let’s talk COVID.
WHO calls for moratorium on booster doses
The WHO has called for booster doses to be put on pause given the extremely high number of people in the world who are still unvaccinated: https://www.cidrap.umn.edu/news-perspective/2021/08/who-calls-moratorium-covid-19-boosters
I have to say, this is right. This is obviously and mathematically right. As far as our best estimates indicate, the effectiveness of the vaccines has dropped very little. Even against mild disease, it has dropped only between 10 and 30 percentage points, with effectiveness around 85% seeming most likely for the mRNA vaccines in this world with the Delta variant. That’s down from 95%. The best that a booster can offer us is a restoration of effectiveness, gaining back about 10% efficacy.
Right now, the countries with the best vaccine uptake have still only reached around 60-70% of their populations. That means that 30-40% of people are unvaccinated even in the best case scenario. Vaccinating those unvaccinated people will give them 85-95% protection. Vaccinating the vaccinated another time will improve existing protection by at most 30 percentage points, and will take about the same number of doses as vaccinating the unvaccinated. Even if you only reach half of the unvaccinated, the case for focusing on new vaccinations is very strong. The average protection of the population will go up much more if we add new vaccinees.
Then, of course, we have to consider the many countries where existing vaccinated populations are not nearly so high. Getting those countries up to higher levels of vaccination will have massive impacts on their local situations, far more than boosters in the small number of vaccinated people there would.
These population-level considerations will matter for individuals as well, too. Preventing COVID-19 at the population level is how we also best prevent it at the individual level.
The WHO is right. We need to vaccinate the unvaccinated. Boosters can come later.
Moderna announces they expect booster doses to be needed, but also that the effectiveness of their vaccine lasts at least 6 months
That having been said, the companies that make the vaccines continue to press on to make booster doses: https://www.wsj.com/articles/moderna-says-vaccine-remains-effective-for-six-months-11628165429
This is odd, because in the same update they announced that their vaccine generates enduring protection for at least six months—which is as long as it has been available.
I refer you back to the WHO story at the top. The public health argument there is how we get the pandemic under control. Once we’ve gotten it under control, we can worry about using boosters to keep it under control. It’s important to keep our eyes on the ball.
What am I doing to cope with the pandemic? This:
Seeing family
Some of my wife’s family are in the US from parts abroad, thanks to vaccination, and we were able to get dinner with them last night—outside. It’s safer. I won’t be indoor dining until NYC requires vaccination for it next month.
The particular relatives we saw are also regular readers of this newsletter, and so they asked to see the “undisclosed location in my apartment.” This information is, of course, highly classified.
Anyway, I am really grateful that vaccines made it possible to see our family. This is just one example how they’ve let us do that, but I’m grateful for all of them.
A lot of comments on the last issue!
r hunter (capitalization as provided by reader) shared the following:
Hmm. I guess I'm not as worried about the "4.4% for at least 28 days" number as you are, because when I compare to the flu, there have been years where there was a bad flu circulating around and anecdotally it sure seemed like at least one out of twenty kids I knew who got the flu was still not feeling great 3-4 weeks later.
The 56 day number is rather more concerning, though! Two months seems like a long time for a kid to be sick, and going back to the flu analogy, I don't think I've ever seen a kid who was sick for two months from the flu (and there are enough kids in our school/other communities that odds are, if this were common at the 2% rate, I feel like I would have heard about it).
My reply:
I think we're looking at things in that paper that are more severe than what one would see with a bad flu, particularly in that 28-day range. By 14 days even a very severe influenza should be wrapping up and any lingering symptoms are very mild. That doesn't seem to be the case here.
But we agree on the 56 day item. That's the item of biggest concern here. I'm surprised it only drops by about half over that additional month.
Lisa Schwartz had some questions about different patient situations:
Hi John,
Two questions:
1. Based on your readings of Covid in children, if a 5 year old tests postive for Covid and is asymptomatic, what is the chance of later illness? How long after the positive result is the child safe to travel?
2. In a breakthrough case in a 67 year old adult with mild symptoms, would you recommend monoclonal treatment as an extra precaution?
Thank you!!!
Lisa
I know I just shared something about the chance of long-term COVID-19 in children, but I don’t think we know enough to get quite so specific. The question about monoclonal antibody use is interesting, though, because monoclonal antibodies are indicated for use in mild-to-moderate cases, but it seems like not every healthcare practitioner out there realizes this. Either way, here is my reply:
Hi Lisa! Good to hear from you.
1) I really can't say. We don't know enough yet. Asymptomatic infections may not have the same long-term dynamics, though. As far as the timing to travel after the positive test result, there's CDC guidance on this, saying that a person who tested positive should isolate until 10 days have passed from the positive test.
2) I would recommend that person talk to their physician. I'm not licensed to make a specific treatment recommendation here. However, I would also note that monoclonal antibodies are specifically indicated for use in adult and pediatric patients with mild-to-moderate COVID-19 who are not hospitalized. While I cannot recommend the use of any specific medical intervention, I do think that this patient's profile clearly matches the indication for these products. A physician should be able to make that determination for certain, though.
Then, reader Sam had the following comment:
I keep seeing that Lancet study described on social media as "reassuring," indicating that long COVID is "rare" in kids, even by people I respect. Of course, it's neither of those things, for reasons well articulated by you. Under normal circumstances, seeing a parent willingly subject their kid to a one-in-fifty chance of permanent injury would warrant a call to Child Protective Services.
I do wonder, though, if the apparently low incidence of post-acute symptoms in children relative to adults tells us anything about the mechanism(s) underlying long COVID. Certain autoimmune conditions are less common in children. And children may be less likely to harbor dormant viruses that could perhaps be reactivated by SARS-CoV-2 infection.
My reply:
Yeah, I don't want to speculate too much about post-acute COVID symptoms but certainly I think it's reasonable to compare adults and children in terms of the former group having a more extensive immunological history. I do think there's a possibility that the accumulated immune environment in adults may have something to do with all of this, but it's hard to say exactly what.
To round it out, Carl Fink shared an interesting resource on worldwide vaccine development efforts:
Hi, John,
I though this resource might be interesting to you:
The Scientist tracks all known vaccine candidates.
Scary stuff in there, for me. Many (many!) Chinese and Russian vaccines have entries like this one: "Clinical testing was completed by the end of September, according to Reuters. In October, Russian President Vladimir Putin announced its approval ahead of a Phase 3 trial, NPR reports, and on November 30, Reuters reported that the country will begin mass vaccinations." (Russian "Vector" vaccine.) There are several vaccines being administered widely, not just in those two countries, that have not actually had a Phase 3 trial.
It's scary because people who think they're protected (even though there is no way to know if that's the case) will act as if they're safe, increasing the spread. No distancing, no masks--they're vaccinated, after all.
My thoughts:
This is a cool resource! The Russian ones are particularly worrying because in many cases they lack any sort of outside validation. Most of the Chinese entries have something specific that I look for here--an emergency authorization from the WHO. Those involve a real review and a data package. I'm not seeing that for the Russian entries, largely.
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Always,
JS
"The best that a booster can offer us is a restoration of effectiveness, gaining back about 10% efficacy."
Why do you say that? Have you seen a study indicating that? Because I see no obvious reason that it would not increase efficacy beyond the original two-dose regimen, especially if you change to a different vaccine for the booster. (There have been studies showing that using different first and second doses produces better antibody and t-cell response than two of the same agent.)
I agree with your conclusion, which I agree is obvious, but that one sentence puzzles me.