Again, will be short-ish since renewing my board certification this year requires passing this test this week.

Ebola–

Now at 84 confirmed cases with continued geographic spread.  In fun new developments this week, response providers are on strike in three separate towns.  Travel checkpoints have had security issues and difficulty screening all travelers due to “community resistance,” “poor security,” and dense congestion.  Contact tracing remains inadequate.  Vaccination continues at a trickle that won’t stop anything.  Multiple positive cases are still out in the community, and not Ebola treatment centers.  Multiple known contacts are showing symptoms at the time the WHO went to press with this week’s update.  In short, much more likely to get worse before it gets better.

Coronavirus

–I don’t have time to screenshot the usual suspect websites, but the US continues to be mostly green (falling rate of new cases) from coast to coast.

–That said, reductions in testing in the US are spreading.  But for the right reasons!  If you recall from Sunday’s brief update, turnaround time on testing is suboptimal many places in the country simply because more tests are being requested than the labs can process in a reasonable amount of time.  The log jam is what is pushing turnaround time out.  To reduce the back up, several states have put out statements asking people to not get tested unless they have symptoms.  Not only because the test is more accurate if you are symptomatic, but getting tested when asymptomatic just piles up tests like this–while not changing what you should actually do.  For example, if asymptomatic, but a close contact of someone recently diagnosed with COVID, the recommendation is still to self isolate and monitor for symptoms.  You should do that no matter what a COVID test says.  These states hope that reducing asymptomatic testing will free up testing for hospitals and at risk populations–where the test is medically meaningful, and a rapid result is needed.

–See?  It’s not just your crazy pathologist here saying this!

–So while reductions in new cases are encouraging, keep in mind, there is a little less testing happening to clear the jams a bit.  Regardless, positivity rates across the nation are declining (the CDC website is better for this than Johns Hopkins, for the record).  Hospitalization rates are flat to declining.  Your local rates may vary.

–The rt.live calculations this week are consistent.  Also note you can click “details” state by state and scroll down–they actually adjust their numbers to reflect testing volume.  Slightly more states than not have an Rt range below 1, which is “virus in retreat.”

–Also worth mentioning:  the US has run far more coronavirus tests than anyone else in the world.  Even with a slight dip to clear jams in some states.

–Speaking of around the world, Sweden’s numbers are still holding strong.  Given the rest of Europe is looking very much like “delayed first wave” still, that’s very encouraging.  New York, similarly, holding strong for months now.  Again, the base case is that once you get over the big initial hit (whether you delay it or not with hard lock downs–still going to happen), there is likely herd immunity or near herd immunity that follows.  If Sweden holds out through the end of the month and beyond, I am going to be more convinced that the magic herd immunity number is lower than we assumed in our UFC based calculation, and is closer than ever for many states.

–If true, continued virus activity will be VERY local.  And probably too small to seriously threaten a healthcare system.

–Some tests also continue to have accuracy issues.  ThermoFisher just had to send out bulletins to help labs avoid problems with their very popular kit.  You can read about it here:  https://www.bloomberg.com/news/articles/2020-08-17/fda-flags-accuracy-problem-with-widely-used-coronavirus-test

–More evidence that T-cell based immunity is the main driver of resistance to SARS-CoV-2 (and antibody testing will underestimate the number of people who are “immune” to the virus).  The following got published this week in Cell:  https://www.cell.com/action/showPdf?pii=S0092-8674%2820%2931008-4

Patients who had more severe disease are more likely to have antibodies (probably because their immune system “chose” that route incorrectly as discussed around the paper last week).  But, you can find high numbers of SARS-CoV-2 fightin’ T-cells in patients who had mild disease, AND in patients who were merely exposed to the virus (asymptomatic patients).  Further 28% of unexposed blood donors (in 2020, before the arrival of SARS-CoV-2) had T-cells from prior coronavirus infections capable of responding to SARS-CoV-2.  Like the paper from last week, the effective T-cell responses were driven by interferon gamma.

–What this means is a confluence of studies are beginning to demonstrate our hypothesis that virus specific T-cells are the main driver of resistance and clinically effective response to SARS-CoV-2.  Further, you are starting to get lines of evidence suggesting an antibody heavy response, especially early, may be an immune system going wrong.  We still hypothesize that the patients with the most severe disease are those that stay on the antibody button too long until the immune system freaks out in a septic shock syndrome (goes Ah-nold), but still waiting on studies for that.  Lastly, SARS-CoV-2 is close enough to its cousins, the common cold, that a large percentage of the population already has T-cells capable of fighting the virus off.  Meaning the “magic number” for herd immunity is on the lower end.  Cross reacting T-cells also raise the “degree of difficulty” for SARS-CoV-2 to mutate its way around and cause a true second wave. 

–Yes, there is light at the end of the tunnel.

–Your chances of catching Ebola right now come with apologies to the Babylon Bee headline sent to me by a reader and an internet famous knock knock joke–lest you think I am this creative on my own.  Those chances are equivalent to the US expatriates among our readership hearing a familiar chime one day soon, and rising to answer the door.

There, on the threshold, is a majestic bald eagle.  The eagle waits, eager, casting its penetrating gaze to and fro with each bob and weave of its head.

In one mighty talon, it holds your mail.

Yes, ever since Trump reorganized the US Postal Service with a flock of trained delivery bald eagles to save money and deliver faster, this is how your mail from the states has arrived.

You open the door.  The eagle pierces you with its stare, searching for positive identification that it’s really you.  Colt Crockett, your mail delivery bald eagle, delivers American mail to Americans only, of course.  Colt sees the shining light of liberty which radiates from the soul of every American, casual though your gaze back might be.  Satisfied, Colt Crockett nods sagely.

He hands you your correspondence.  Ordinarily, Colt wraps it in a selected reading from The Federalist Papers.  But not today.  For today is a special delivery, the kind that he wraps in a copy of the Declaration of Independence he transcribed by hand. 

Talon?

Whichever.  Colt took his time on this for a reason.

And you know.  You know without opening it.  Solemn reverence…that is how you accept the delivery.  Accept it like your most sacred responsibility.
Colt Crockett knows too.  Your eyes lock for one long moment, before he gives one fierce nod, then rises aloft to soar once again as high as the dreams of the free, and the hope of a country.

You walk back inside, the package clenched tightly in your hand.

“US post, then?” your spouse asks.

“Yes,” you say, but your eyes are miles away, across a shining sea, where your heart finds itself among purple mountains and fruited plains.

“It’s my absentee ballot,” you say.

“Odd.  Didn’t hear Colt knock,” your spouse says.

“Of course not,” you say, puzzled, but then you remind yourself that your spouse wasn’t born American.  Bless them–they just don’t know.

“There’s never a knock dear . . .

. . . for freedom rings.” 

–Your chances of catching coronavirus are equivalent to the chances you got this far and said “wait, this is the short update this week?”

<Paladin>