Timing is Everything

Waste water surveillance at the forefront again

Data on COVID numbers around the country are showing perhaps a glimmer of improvement. Ignoring the inaccurate new case numbers, we see a plateau in the test positivity rate, and a suggestion of slight decrease in the new daily hospitalizations and total COVID occupied beds, now 43,000. Deaths, always a lagging indicator, have continued to slowly rise, and yesterday 874 people succumbed. Against this background the CDC just announced a relaxation in its COVID guidance to eliminate quarantine for people exposed to the virus, irrespective of vaccination status; and to recommend wearing a mask in indoor public places instead. They suggest testing at day 5 after exposure. Given the quality of mask most people wear, the frequent removals to eat and drink, and the extremely effective transmission of BA.4/.5—the CDC is effectively saying, “Go forth and spread as much virus as you want”. Let’s face it, many people were not following the previous quarantine recommendations; but the CDC’s job is not to tell us what it thinks we will be willing to do. If only the IRS would take the same approach. Ending different recommendations for the vaccinated and unvaccinated was accompanied by clear statements that the CDC finally recognizes the significant contribution recovery from prior infection contributes to individual and overall population immunity. I would like to see the hardy science followers in positions of high authority digest this information, and decide how it comports with their demands that COVID recovered individuals be vaccinated with two doses of a now outdated vaccine, or face severe consequences. Those two doses of vaccine, which allow you to comply with the Federal mandate, are now providing virtually zero protection from contracting and spreading the virus, and are clearly inferior to having natural immunity from any of the Omicron variants. If you were infected at any time from January 2022 on, then you contracted one of the Omicron gang.

We have had very little hard information (but lots of heard on the street gossip) on the accuracy of the home rapid antigen tests in the Omicron era. A recent study in preprint provides some useful insights.

Performance of Screening for SARS-CoV-2 using Rapid Antigen Tests to Detect Incidence of Symptomatic and Asymptomatic SARS-CoV-2 Infection: findings from the Test Us at Home prospective cohort study. https://doi.org/10.1101/2022.08.05.22278466

This study reports that among symptomatic individuals RAT home testing twice within 48 hours was 94% sensitive for positive diagnosis compared with the gold standard PCR lab test. For asymptomatic people the number was only 67%, and that was increased to 79% with a third test at 96 hours— now you know exactly why you are familiar with any number of people (perhaps yourself) who tested negatively two or even three times, but eventually either became ill or spread the infection along.

In the last installment of this bulletin I stated that I thought Paxlovid was an excellent drug doing exactly what it was designed to accomplish, and that it was getting a bad rap unfairly in the media over the rebound issue. There are two recent preprints looking at this question, and the results are bound to surface in the COVID Infowars. The first study by Jonathan Li et al, looked at the important question of how frequent is viral and symptomatic rebound in mild to moderate untreated COVID cases. Following is the brief summary of their findings.

Findings In both the primary and secondary analyses, 12% of participants had viral rebound. Viral rebounders were older than non-rebounders (median 54 vs 47 years, P=0.04). Symptom rebound occurred in 27% of participants after initial symptom improvement and in 10% of participants after initial symptom resolution. The combination of high-level viral rebound to ≥5.0 log10 RNA copies/mL and symptom rebound after initial improvement was observed in 1-2% of participants.

https://doi.org/10.1101/2022.08.01.22278278

The second study carefully looked at the relative frequency of viral rebound in Paxlovid treated versus untreated patients with Omicron infections. (The largest prior study of viral rebound in untreated Omicron cases found 6% with viral relapse). It is a small study, but it does suggest that viral rebound may be more frequent following Paxlovid treatment 27% (3/11), and that the viral rebound is high level, similar to the viral kinetics observed during the initial infection. Some commentators are already discussing whether the high level rebound in some people treated with Paxlovid, will offset the more rapid clearance of virus seen in the majority of cases, and thus lead to an increase in the amount of circulating virus in the community. Even if these findings are corroborated by larger studies, I’m sticking to my assessment—Paxlovid is a good drug doing exactly what it was intended to do. It’s utility is in preventing the progression of severe disease and death in high risk people. Basically nobody gets severely ill during a treatment relapse. If you want to limit the amount of Paxlovid rebound virus circulating, how about not treating low risk, highly vaccinated individuals. Here is the link if you’re interested. https://www.medrxiv.org/content/10.1101/2022.08.04.22278378v1.full.pdf

Polio is circulating in London, upstate New York and now New York City, and basically the only reason we are aware this is happening is the tremendously useful technology of Waste Water Surveillance. Polio was declared eradicated in the US in 1979, prior to that it was the cause of perhaps 15,000 cases of paralysis, and many more infections, every year. Wild type circulating polio virus is endemic now only in limited regions of Pakistan and Afghanistan—so how did we get here? The original Salk polio vaccine was an inactivated or killed virus. The Sabin vaccine developed a few years later in 1961 is a weakened form of the live virus, and very easy to administer as oral drops or, (who of a certain age can forget the lovely) sugar cubes. In certain individuals unfortunately, the live vaccine polio virus grows in the GI track and undergoes reversion to a more virulent form, which is then excreted in the stool, and capable of infecting and causing disease in unvaccinated people. The polio circulating in London and New York, which paralyzed a young man in Rockland County, is of course the vaccine stain and not wild type polio. We haven’t given live polio vaccine here in the US or the UK for more than twenty years; someone had to have received the vaccine elsewhere in the world and then traveled here while still excreting live virus. The polio eradication program very effectively undertaken by the WHO in 1988 has long supported the use of the live Sabin vaccine. Now that the vast majority of polio cases that occur in the world every year are due to this live vaccine, perhaps it’s time to re-evaluate that. As far as the potential risk from ongoing community transmission of vaccine strain polio in New York goes, consider that only 80% of children are fully vaccinated, and there are areas of the city where vaccination rates are below 70%. Even though there are several hundred asymptomatic or mild illness cases for every case of paralysis, that is a very large at risk population. There is also the potential for declining vaccine immunity over time, something nobody worried about when there was no circulating polio for years. In London they are offering vaccine boosters to children 1-9 yo, but in reality older adults, years out from vaccination may be at risk; the virus doesn’t discriminate, based on age. If you could ask him Franklin Roosevelt would confirm that. Years ago, I did my medical training at Cornell/New York Hospital. In the bowels of that institution on some sub-basement there were the hulking remnants of some of the iron lung machines. I never could fathom whether they were saving them for some antique medical exhibit, props for a future movie; or whether someone with true prescience realized there would come a time when people would be convinced they knew much more than the doctors and scientists, because of wisdom gleaned from the likes of Alex Jones, over a yet to be invented Internet.

We have had incredibly mild Influenza seasons in 2020 and 2021-2022, very likely due to the social distancing and masking regimen. Experts are even claiming that one of the two strains of Influenza B seems to have disappeared. Influenza is currently at minimal levels across the US, as expected in summer, but the Flu season will start to ramp up soon. It’s reasonable to speculate that after two of the lowest years on record, and with removal of the mitigation efforts, which presumably kept the virus at bay, that we might be in for a heavy session of Influenza this winter. That is definitely the case right now in Australia, where cases are significantly higher than in pre-pandemic 2019. Much depends of course on whether a new highly transmissible, and even more virulent COVID variant makes an appearance, triggering an unlikely resurgence of masking. It also depends on how accurately the vaccine matches the major circulating Flu strains, and of course how motivated people are for more jabs.

The last epidemic up to bat today is not spread by bats. Monkeypox cases in the US have now topped 10,000–young people in the cities certainly have been energetic and busy despite the hot weather. As a result of the severe vaccine shortage, the FDA has moved ahead with the plan to give 1/5 the approved dose via the intra-dermal route, instead of the approved subcutaneous route. I wonder if folks will be signing informed consent for the experiment? Meanwhile the WHO continues with the arduous task of finding a new name for Monkeypox. We went through this with the original iteration of the SARS2-Cov19 virus. Calling it Wuhan virus was immediately adopted by scientists around the world, but quickly became verboten by the language police (who of course have no particular expertise in anything except a hyper-acute sense of outrage). Scientists donned the dunce cap and complied, but only for an interval. Now almost every scientific article I read refers to the Wuhan strain. Seems it’s fairly difficult and confusing to rename something that already has tens of thousands of scholarly articles in the science literature. Perhaps even harder for a disease which has been Monkeypox to everyone who ever cared about it since it was first isolated in some Copenhagen simians in 1958.

Everyone seems to be in a party mood, and it’s hard to argue now that we are well into the third year of the Pandemic. It’s not like the band playing on the tilting deck of the Titanic—we are doing better with progressively mounting immunity to this plague. Just try and avoid coming home with the wrong party favor. Send this to a friend who you think will enjoy and profit from the information.