Fall COVID updates, in brief

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Oct 16, 2022

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

I recognize it has been a long time since I wrote to you all, and so I want to explain. I fell quite ill towards the end of August, and at first it seemed it would be a transient thing. It ended up persisting for weeks and we are still not sure what the cause was. I was almost entirely unable to work or function. I am now feeling mostly better.

On top of that, there was a death in my extended family and another major health issue in my immediate family. All of this together has made it very difficult to find time to write my newsletter. Unfortunately I only learned after the fact that it is possible to pause subscription billing on Substack; I’ll be leaving billing paused for at least the next 6 weeks since I was gone for 6 weeks, but I’ll be getting back to writing. At least I plan to be. With the terrible events I had to weather in September I’m not sure what to expect next.

Today I want to briefly give you my thoughts on the state of COVID-19 going into this winter. These are views from 60,000 feet; in future issues I plan to drill more deeply into why I am saying what I’m saying.

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Now, let’s talk viruses.

COVID-19 of Fall 2022/Winter 2023

Let’s lean into this topic by topic.

Updated booster shots

The updated booster shots arrived, and now we have vaccine options that provide immune responses to Omicron-variant lineages and to the original Wuhan-circulating lineage.

At this time I don’t have any evidence-based recommendations I can make about the value of getting these boosters vs the older boosters. Everything I can say about them is a guess, except that they elicit good antibody responses that can neutralize a wide spectrum of variants in laboratory settings.

This does not necessarily translate to real-world effects.

However, I’ll say this. I plan to get an updated booster. I plan to get it because I did not react poorly to past boosters, and I think having more refined anti-Omicron variant immunity—even on speculation—is worth experiencing the day of fatigue that I experienced with my last booster. I’ve also had COVID-19, and it’s a lot worse than one day of fatigue. I’d like to be as protected as I can be. Why haven’t I gotten it yet? Well, I’ve been very sick and my doctor told me not to while I was still sick. I’d also like to get it alongside my flu vaccine—which I generally wait to get until the end of October so that I have full-season coverage. Not everyone is in the same health state as me, though. This is just what I’m doing for me.

The updated booster shots are now also available in the US for everyone ages 5 and older. That expansion is a relatively recent development: https://www.cdc.gov/media/releases/2022/s1012-COVID-19-Vaccines.html

I am impressed with the rapidity of this expansion; usually regulators move slower than this. I do not think that there is any reason to be particularly concerned about safety of these newer boosters compared to the last-generation of boosters. However, before using any vaccine in anyone of any age, you should talk to your doctor. Vaccines are incredible, and they are very safe compared to the diseases they present, but clinical trial data tell you about the average patient while your doctor knows about the individual patient who is you. So, have the conversation. If it’s appropriate, get the vaccine booster.

I also think it’s important here to speak to those of you who haven’t been boosted at all yet. If you are someone like that, I want to be clear that I really think you should get one of the updated boosters. There is good evidence that they are at least equivalent to the old version, if not better, and there is also good evidence that a booster dose helps a lot if taken with the appropriate timing. So, if you haven’t been boosted at all yet? Get boosted, and use the updated version. You may not notice the protective effect this has for you in preventing serious COVID-19…and that’s the point. Prevention means you don’t experience the bad thing.

New Omicron subvariants

I keep hearing news stories about the latest X.xxxx (replace X with numbers there) subvariant of Omicron that can evade all preexisting immunity, make your wife leave you, get your dog sick, and make your truck break down. At this point all the news I’ve seen about this has been media hype that tends to mislead about what a new variant really means and why it may or may not become dominant among observed infections.

Take this story, for example: https://fortune.com/well/2022/10/15/bq11-bq1-omicron-covid-variant-immune-evasive-cases-rising-us-fall-winter-wave-forecast-pandemic/

It makes a lot of hay out of a variant, BQ.1.1, that is increasing in share of overall infections, and uses this to make claims about immune evasiveness. But “share of overall infections” is not a good measure of immune evasiveness. It’s a good measure of how competitive this new variant is with other variants…which really doesn’t tell us anything about the people who are immune, and thus not getting infected with any variant.

Mind you, this doesn’t mean that BQ.1.1 can’t cause disease in people who are supposedly immune, but there have been so many stories like this at this point, about severe reinfection and immune evasion, that ended up either over-representing very extreme edge cases or simply misinterpreting prevalence data, that I have a very high bar for the evidence I need to see in order to claim something breaks the firewall of immunity that a vaccinated and boosted person will have at this point.

The world of COVID-19 is very different from where it was in 2020. Hospitals are not completely overwhelmed with dying patients using up all of the medical grade oxygen. Patients who do get severe disease are a lot easier to treat and generally have at least some protection. Most patients don’t get severe disease at all. No variant has displayed some special ability to completely erode preexisting vaccine-induced immunity and cause deaths and severe disease to the magnitude that we saw in early 2020. This is good news, and we ought to recognize it as such.

This does not mean that the future holds clear skies and exclusively happy days, but right now I’m keeping a watchful but relatively relieved eye on the currently-circulating genotypes of SARS-CoV-2.

What does the fall hold

I expect a rise in cases as fall progresses. I expect some pretty seriously big spikes in cases, in fact. I would like to be wrong, though. I think a lot of people, both vaccinated and unvaccinated, have immunity to at least some degree at this point. For the unvaccinated, that immunity came because the people who didn’t succeed at becoming immune generally died. For the vaccinated, it was bought at a less gruesome price.

We are still seeing structurally concerning levels of COVID-19 deaths, but we are not seeing pandemic wave-type levels of death. Will things stay that way through the fall and winter? It is honestly anyone’s guess.

For you, the reader, my suggestion is this: do not let your guard down too much. You don’t need to stay home every minute of every day unless you really have a completely absent immune system. Nearly everyone in our society can go out and live their lives to some degree, with different levels of precautions depending on the local epidemic situation and their personal health. Talk to a doctor and craft an approach that’s right for you.

I still maintain that the typical person should wear a high-quality (N95 or similar), well-fitting mask during trips to places where there’s no reason not to wear such a mask. You don’t need your face exposed at the grocery store or Walmart. People at higher risk should be masking in more environments.

That said, I think we will see more COVID-19 this winter and fall. It’s a good idea not to get COVID-19. At minimum, get vaccinated and boosted unless your doctor tells you that you have to do something else. Moderate protection means masking like I described above. If you need more protection, talk to a doctor about what that should look like.

When it comes to COVID-19 prevention, going into what is only our third fall-winter season with this disease around is NOT the time to get cocky and make huge changes to prevention approaches. Since that philosophy doesn’t seem to be what major policymakers are following, I can at least suggest it to you as individuals. There is still a lot we don’t know and it pays to be cautious—even if I do think you can relax a little.

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I’ve been so sick, friends. It’s hard to keep up with things. I hope you know I’m doing my best to keep going, but it helps to hear from you.

I want to hear from you, too, with your questions about monkeypox, or COVID-19, or just updates about your lives. This newsletter is a community. Reach out!

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