Ebola

–No new cases reported this week. What is new, and slipping under the radar, is the review of the response to the previous outbreak in the DRC (2018 through early this year) surfaced. The short version is here where you will find that the report was not provided to WHO partners and leaders in the response until 6 months after the outbreak was over. That was unfortunate, because the point of the review was to identify gaps and problems to allow them to be corrected during the response. One hopes this at least informed response to the current outbreak, but that is not commented on, and apparently the reporters linked above did not ask.

That link is worth following. It’s a very short read, and a fine reminder that despite the WHO’s technical expertise, it is not the organization (or effective as the organization) you think it is when it comes to epidemic/pandemic management on the ground.

Coronavirus

–Again, your local situation may vary. Overall in the US, new cases are trending down again the last couple days. Whether this is a temporary inflection point, or the start of a drop in new case rate post Thanksgiving, has yet to be seen. Regardless, transmission is still pretty much as high as it has ever been. A couple new states appear to be in the throes of the their “big” wave, including California (despite some of the most restrictive public health measures in the country) and New Mexico. ICUs and hospital beds are under pressure in many places around the country, contra some articles and analysis looking solely at the percentage of ICU beds occupied per state.

Remember, it’s the next marginal ICU bed in your reasonable ambulance drive circumference that matters. So, for example, 80% of the ICU beds might be occupied right now in a given state. But that doesn’t mean that every ICU is at 80%, and beds are still easily available everywhere in that state. For example, if you get in a car wreck on the very north part, and all the ICUs are full, it may not be feasible to get you to the center or south in time to open ICU beds there–even though the statewide data will show 80% of hospitals are full. There is also a misconception about how full ICUs usually are. Ask most hospital administrators and they will tell you that when COVID has rolled around, their ICUs have been much more full than usual. While there is some ability to flex, that’s not routinely done every year. There is also a huge issue in maintaining staffing since ICUs require more staff per patient.

So, for example, there absolutely are hospitals in Indiana that are converting space (like wait rooms) to patient rooms to handle the crush of patients right now. There are reports in LA that some of the ICUs in the city are getting perilously full.

The governor of Indiana announced additional restrictions in the state, including a three week pause in elective surgical procedures. Many hospitals in the state, however, have -already- reduced the number of elective procedures to maintain staffing and space with the current wave of COVID admissions.

Despite what some disappointingly facile analysis on the internet this week based on the economics of ICU utilization would say (“ICU’s are still under capacity, and that is not what any hospital wants economically!”), I can assure you none of them would give up elective surgical procedures (a significant source of revenue) if they did not absolutely have to.

In spite of that, there are signs of optimism. Indiana, at least, has avoided a massive post-Thanksgiving blow out in gross new cases. That may be a -little- misleading because testing is down over the last week or so. Not because the capacity is not there, but because fewer people are turning up to get tested (which is a “soft” positive sign in itself). That said, those who are showing up are a little more likely to be “right”–the positivity rate remains high, and -possibly- climbing slightly this week. The positivity rate is what I think is driving yesterday’s political action. Otherwise, the census of total COVID patients in the state is falling, and new admissions are steady to declining. Both of those are still at quite high numbers compared to earlier in the year, but are trending in the right directions at least.

If you have access to similar data in your local area, that is what you are looking for.

–So basically, again using Indiana as an example, what is happening in many places in the state is this:

You have had sustained high spread for awhile now, and are getting uncomfortably closer to that dotted line of “how many very sick people hospitals can treat”. Current treatments, space contingency plans, and vaccines (especially for front line healthcare workers to keep staffing numbers up) will help raise that line, but some places are still getting closer than they would like to be.

–Now that brings us to a reader question on last week’s discussion. So is it “better” to have a full lockdown, or no lockdown, or intermittent lockdown?

I don’t know. Let me explain why.

First, understand what you are being invited to do with that question. You are being asked to create a model.

Remember, every model is wrong. Some are useful.

The essence of the question is which strategy has a lower AUC (area under curve) of excess morbidity and mortality. So if we pull up the “flatten the curve” figure again:

We are being asked to decide which strategy has a smaller area, since that would mean less excess deaths/morbidity. So the blue curve might be the “no lockdown” strategy, where we take COVID in one big hit, the local healthcare system is probably at least temporarily overwhelmed, and you get all the excess death in a window of probably a couple months, both from COVID itself but also from COVID cases and other diseases you could not adequately treat because “bed’s taken.” The yellow curve is one of the either full prolonged lockdown or intermittent lockdown strategies. You have excess deaths/morbidity from COVID, plus some extra deaths (or at least shifts in deaths) due to lockdown from problems like mental health, difficulty affording needed medicines with higher layoffs etc. due to lockdown but possibly/probably balanced by fewer deaths due to car accidents, for example.

Now the question calls for you to speculate which strategy has less AUC. Those prone to defend their opinions to the death will choose which one they think has a lower AUC, and now you see me write “debunking” posts about the extremes to which they go to “prove” the “facts” support their choice.

Remember, every model is wrong.

I can’t tell you which strategy is best. I have my own opinion, sure, but it’s cheap. And the reason I don’t know for sure (and neither does ANYONE else) is because there is no control group.

None. Comparisons to other countries are inadequate. There is too wide a variance in health care, underlying diseases that may be improved or worsened with lockdown, effectiveness of lockdown, age and demographics between countries to make that solid evidence one way or another. Those confounding variables can also vary significantly even within a country. You can get some sense of how that strategy is working for a particular country or area, and you might be able to project how it might work for another, but you don’t know for sure. Because this is all happening, real time, to everyone in the world.

And no one really took a full lockdown strategy anyways. Even Sweden, which was relatively unfettered, was still impacted by everyone else’s lockdowns, such as cruise ships no longer docking in its ports and airliners no longer landing at its airports from other countries that had restricted travel from their borders to reduce spread.

No matter what they tell you, everyone arguing a specific course of action as best regarding lockdown yes/no and how hard, is speculating. If they are spewing “facts” at you, realize any fact they come up with will be insufficient by themselves to prove they are right, and almost certainly were gathered because the fed the confirmation bias for that person’s model of choice.

That’s why I keep saying lockdowns yes/no and how hard are a political decision, with a lot of feelingsball to them. You can get some basic facts about how many beds are available, what your COVID positivity rate is, what your usual hospital demand is for all the other causes at this point in the year etc. But which AUC strategy is best comes down to if you think a lockdown will help, if it’s necessary, how much of one, and how enforceable you can make it. All of that is political feelingsball at the end of the day, and frankly, it’s a damned-if-you-do, damned-if-you-don’t choice as you can see from the constant arguing of opinions about this.

There’s no control group. So only God knows if another strategy would have been best for your country/state/region/city/town.

–Speaking of debunking, the latest this week was a post that went viral on the Pfizer vaccine, where a “former VP of Pfizer research” claimed that the Pfizer vaccine could cause “mass sterilization of women.” The gist of the article (which is poorly written from a scientific standpoint) was that this VP claimed that the Pfizer SARS-CoV-2 vaccine contains syncytin-1, which has high expression in ovary and, the article claims, placenta. Because of this, the immune system would be trained to recognize as foreign syncytin-1 protein, and would attack the normal ovary and placenta to sterilize women. The former Pfizer VP was urging that the vaccine not be approved until this side effect could be tested, as it may be a late effect of the vaccine.

If that wasn’t scary enough, the Pfizer VP was quoted as also being concerned about the vaccine containing polyethylene glycol (PEG), and “70% of people develop antibodies to PEG” meaning many people could develop potentially serious allergic reactions to the vaccine.

They also included the claim that “spike proteins also contain syncytin homologus proteins” which is absolute gibberish. My best guess is they were trying to claim that spike proteins had stretches of amino acids that were similar to synctin homologus proteins, but really had no idea what they were actually saying.

They’re journalism majors, people. They have former VPs of Pfizer research for all this science stuff!

Alright, so the only part of all that super scary is that the guy they quoted was, indeed, a VP in charge of Pfizer allergy and immunology research–9 years ago. He has played no role in the current development of this vaccine, and as near as I can tell, does not have a lot of previous experience with this mRNA vaccination technology.

Again, the vaccine is mRNA for the SARS-CoV-2 spike protein and is delivered in lipid nanoparticles. “Lipid nanoparticle” is a fancy way of saying “super tiny fat droplet.” That is how it gets into the cells for the vaccine to work (mRNA by itself won’t make it).

The ONLY way Synctyin-1 is in that vaccine is if it was part of the lipid nanoparticles to help target them to the right cells. But it doesn’t matter which cells will take the lipid nanoparticles up for this vaccine, and Pfizer and their partner have not attached ANY proteins to the lipid nanoparticles that I am able to find. Including synctyin-1. I can find nothing to support the claim that this vaccine contains syncytin-1.

The SARS-CoV-2 spike protein does not have ANY significant similarity to human syncytin-1, or other syncytin-1 like proteins, where the kind of autoimmune attack the VP and article are apparently worried about is likely.

Further, millions of people have ALREADY been exposed to SARS-CoV-2 and its spike protein, including women of child bearing age. If there was a huge risk of sterilization, we would already be seeing problems with fertility in women who caught and recovered from SARS-CoV-2 earlier this year, and have tried to get pregnant since. That we have not argues that this risk may be a little exaggerated by the article.

Same for the risk of allergic reaction to PEG based on 70% pre-existing immunity. And yes, pre-existing. PEG is in a whole host of common cleaning products and it, or one of its derivatives, is almost guaranteed to be in your toothpaste. PEG is in these vaccines to keep the lipid nanoparticles nano. Otherwise, like mixing oil (high fat content) and water (like your blood), the oil will separate itself into one blob of oil. Similarly, left to their own devices, the lipid nanoparticles in an injectable solution would sort themselves into one giant lipid particle that could not be injected. Hence, PEG, which works chemically to keep the lipid nanoparticles happy as nanoparticles and not trying to congeal themselves just because they are surrounded by water. There are a host of other injectable drugs which are “PEGylated” to improve their ability to mix in water and get sufficient dose of those drugs into the patient. There are no known issues with excess severe allergy that I am aware of because of the PEG.

So in short, yes, the guy did work for Pfizer, but everything else in there is pretty much wrong.

–That said, the Pfizer vaccine was approved already in the UK and the first vaccinations with it started this week. Two patients were reported to have allergic reactions, but the severity is not known at this point. Both patients have a history of severe allergic reactions, apparently.

It’s worth mentioning that the vaccine trials specifically excluded patients with a history of severe allergies.

It is not clear yet if the vaccine caused the allergic reaction or something else did. That will be investigated in the coming days. Also unclear is how many people with severe allergies in the UK got the vaccine to know just how common this is.

Out of appropriate caution, the UK is now recommended that people with severe allergy (defined here as having required epinephrine before or needing to carry an epi pen) NOT get the vaccine until this is sorted a bit, and that the vaccine should only be administered in facilities that can handle a severe acute allergic reaction.

We will see how widespread this recommendation becomes, but the moral is we need more detail on what happened, and how many people with severe allergies got the vaccine already (to know the denominator).

Also perfectly willing to bet it was NOT the PEG that caused the reaction.

–On the socioeconomic front, expect varying degrees of additional lockdowns around the world still, which may show up on store shelves randomly around you.

–The World Food Program is projecting 2021 to be worse than this year for hunger and famine around the world. This is partially crop failures in various parts of the world, but also severe economic dislocation due to COVID making food less affordable for the poor and laid off. This has been especially harsh on the poor as the cost of food goes up due to reduced production. You can find the FAO Global Food Index here where staples like cereals, dairy and vegetable oil in particular have been on a rocket ride. On the plus sugar and meat have been stable to falling.

You may want to consider donating to one of the many fine local or international charities that work to reduce food insecurity around the world.

–On the plus side, more acreage is expected to be planted next year due to the rising prices of agricultural goods, so as long as growing conditions are good on average around the world, the situation will hopefully stabilize by 2022.

–Also on the social front…

This has been a weird year. Weird for everyone. The holidays are typically a time to recharge. We have these rituals as a centering bond of community with each other. In fact, the ability of friends and family, especially around the rituals of the holidays to buffer difficult times is why some special bastard HR departments prefer to lay off employees before the holidays–or so I have been told.

Those rituals will not be the same this year. They simply will not be.

And everyone who has been holding it together with the thought that at least they can make this Christmas still, or Hanukkah or whatever your tradition is, that at least this rock will hold in the raging storm…

…well, they may find it does. Or at least close enough.

But there is a chance that for some of your friends and some of your family, this is where it all catches up. The inviolable holidays getting weirded by 2020 will be a bridge too far.

Maybe even for you.

Just know the chance exists, and be prepared to carry each other. And if it’s you who find yourself with the wave catching up, remember it is still the holidays, and reach for that support networking without hesitation or shame.

Regardless, remember that you have made it through a gruelingly difficult period, no matter who or where you are. Which means you now know you can. That may be more useful than you think in the coming decade. You’ll also know, by the cold light of January 1, what worked and what didn’t for you when the world took a huge detour for everyone at the same time. Keep the former, ditch the latter. As a wise man said, “the hit is the gift.”

Just wanted that percolating before the holidays hit… : )

Your chances of catching Ebola are equivalent to the chances that Ohio State scores even a single point against Michigan this weekend.

Your chances of catching coronavirus are equivalent to the chances Ohio State would have scored points, had the game not been called off for coronavirus.

<Paladin>