COVID the Equal Opportunity Employer

Washington DC Goes Viral

This week will be a short, reader friendly summary of several topics. BA.2 is taking its time causing the secondary Omicron surge around the US. Overall the country has continued at the very low plateau of 24,000 cases/day, a level not seen since the early June 2021 low just prior to Delta taking center stage. Despite that however, cases in half the states have shown a rise over the last week. In many of those states the increase may look significant on a percentage basis, but it’s not really perceptible on the ground to the average person since we were starting at a very low level. There are exceptions, with New York, New Jersey and Massachusetts having the largest weekly increases on the east coast. Then there is Washington DC, definitely a realm unto itself, where cases have also been significantly increasing. With the recent revelations of COVID diagnoses in: Hilary Clinton, Nancy Pelosi, Merrick Garland, Raphael Warnock, Adam Schiff, Mayor Bowser, Commerce Secretary Gina Raimondo, staffers in Kamala Harris’ and Biden’s offices, as well as a rabid fox bitting 7 people around the Capital, it looks like a real viral stew there. I was going to accuse the virus of picking solely on Democrats this time around, but just this morning learned that Susan Collins is ill, so it looks like our representative democracy is still with us.

The pandemic pattern here is certainly different from the UK and Europe. I agree with the assessment of many prognosticators that the BA.2 increase here is going to be a bump, not a surge. As mentioned previously, it appears to me to be a matter of random timing. BA.2 arriving a bit later into the US Omicron wave and facing a higher barrier of combined vaccine and Omicron immunity, perhaps coupled with the arrival of warmer weather. That is very fortunate since there is tectonic change in people’s and politician’s attitude to the pandemic at this point. I suspect it would be quite difficult to bring a large segment of the population back to accepting various restrictions and mandates short of another variant wave filling the hospitals again.

Monoclonal antibodies have been back in the news and here’s the short story. This week the FDA halted the use of sotrovimab, since BA.2 is resistant to this monoclonal antibody, and BA.2 now represents 72% of viral sequences around the country. It’s not uniformly distributed of course, with pockets of the population where it is still much lower than 72%. There is one therapeutic monoclonal option still active against the BA.2 variant, Lilly’s bebtilovimab. The government signed a purchase agreement with Lilly in February for 600,000 doses to be delivered by March 31st, so there should be a supply available. What has been lacking is any attempt to reach out to frontline physicians in private practice and make them aware of the utility and availability of the drug, and a centralized system for identifying centers with supply. There is unfortunately a large, expensive stock of sotrovimab, which arrived too late into the Omicron wave, and now likely will never be used. The monoclonal antibodies, like the antivirals are effective when used early in the disease. There is now a ready supply of the two authorized antivirals Paxlovid and Lagevrio widely available. Of the two, Paxlovid is by far the superior drug. Lagevrio was narrowly authorized for Emergency Use in December because of concerns about marginal efficacy and unresolved questions about the potential for the drug to induce mutations in the virus. My strong suggestion is that if you contract Omicron BA.2 and have any risk factors for severe disease, that you speak with your doctor as quickly as possible and seek out Paxlovid. Waiting to see if you get progressively sicker is not a good strategy. As the shock of 1,000,000 Americans dying from COVID, the majority of them during the past 12 months, has worn off a bit, we are becoming aware off the huge burden of prolonged, and perhaps permanent disability affecting many people who survive COVID, sometimes after relatively mild disease. Although we don’t have the proof yet that treatment with the antivirals will decrease the likelihood of prolonged post COVID symptoms, their proven record of ability to prevent primary progression of disease to hospitalization and death argues strongly that they will. My two other suggestions are to keep an eye on the statistics for your local disease prevalence, and don’t hesitate to resume good quality mask wearing indoors if there is a significant increase in your locale. This is especially true if you managed to avoid infection with the original Omicron strain. I would also avoid Washington DC like the Plague, which as far as I know, hasn’t been reported there yet.

On the far side of things we have the report of the man in Germany who took the COVID vaccine 90 times in order to get vaccination cards, which he then sold to people who clearly were not as enthusiastic about the vaccine. He was arrested and fined, but how about making him give a blood sample? I for one would be curious about his antibody levels, and to know if he ever came down with COVID during this exercise. Finally there was the announcement by the FDA that they are authorizing a fourth dose of vaccine to anyone over the age of 50. The timing of that was unusual, coming just a week before they were to convene their panel of outside experts to address important vaccine issues and recommendations going forward. Some of the esteemed members of the panel were pretty open about their displeasure with the whole situation. They were reassured by Dr. Marks of the FDA that this was all well grounded in Science, based primarily on a recent study from Israel of fourth doses during the Omicron era. I have looked at that study very carefully and come to the conclusion that, although a fourth dose decreased hospitalizations by a significant percentage, on an absolute number of cases prevented per 100,000 the effect was very small. Also the vast majority of severe cases in the triple vaccinated group were in the over 80 yo group and most of the rest were over 70 yo. One of the major recommendations of the panel seems to be that we cannot continue to vaccinate people every four months, and that we need new research on vaccine development to transition to a more effective once a year vaccine. Sounds pretty good to me.

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