–As reminders:

Alpha–Variant first identified in the UK

Beta–Variant first identified in South Africa

Gamma–Variant first identified in Brazil

Delta–Variant first identified in India

This is going to be a pretty short one as we come up on a holiday in the US.

–Around the horn, Indonesia is indeed blowing out new cases. The UK continues to march upward in new cases as well, and in South America, Colombia is climbing a new wave. In South Africa, the velocity of new cases is starting to level off, but there is enough momentum on the part of the virus that I don’t think they are quite at the top of the current wave just yet. Down under, Sydney has gone into a two week lockdown as Australia gets concerned about the activity of the delta strain of COVID. In the US, new cases have leveled off, consistent with the effect of the more contagious variants and more social interaction as restrictions continue to lift in most of the country

–Most of the news cycle this week was delta freak out. Frankly, a lot of this is simply not supported by the data. For example, parts of California are rattling the mask saber, even for the vaccinated again. The WHO has trotted out spokespeople to express concern. However, CDC, to its credit, has stuck with the data showing that adequate vaccination (two doses of the mRNA vaccines, and they are talking about a booster for the single shot J&J) controls the delta variant too, and has made no significant changes in its recommendations.

There have even been the “what about the children” articles, suggesting that this phase “may be the most dangerous” for children under 16, who have not been vaccinated yet. Judicious use of masking is effective at reducing their risks. But again, this is the cohort that has consistently been at the lowest risk for any symptoms of COVID, let alone COVID requiring hospitalization. Those kids who have had a challenging course of COVID have overwhelmingly had underlying medical conditions. Further, getting the vaccine yourself, if you are a parent, grandparent, or will otherwise be around kids too young to be vaccine eligible, will reduce their chance of catching COVID. In fact, is the single best proactive step you can take.

There have been articles suggesting that delta is more dangerous, causing more severe disease. Nothing could be further from the data we have right now. The best data set is the UK’s NHS currently, and there is no indication that delta is anything more than more contagious–again, as we would expect. In fact, if you look at India, even adjusting for a slightly younger average patient population there and without projecting cases in India who were infected but not tested to be confirmed as COVID, the delta variant has hospitalization and death rates at or lower than the prior strains.

And because you are not allowed to escape politics in anything, ever, there have been articles this week highlighting that the rate of new cases is higher in counties in the US that are less vaccinated. Conflating correlation with causation, these same charts were immediately cross referenced for percentage voting for Biden in the last election–even though this has absolutely nothing to do with anything even remotely medical. SARS-CoV-2 does not ask who you voted for, nor does it care, and has successfully caused significant waves of hospitalization and severe disease in entire countries that cast no votes for Biden–or Trump. Maybe that was their problem by this “logic”? Did those foreign countries not vote the right way to improve their vaccination status and current resistance to COVID? Not sure.

Next, they look only at county level data, and not an individual level to see if this is remotely sane analysis. After all, it could be that the minority Biden voters in these counties are the ones NOT getting vaccinated. It’s also completely ignoring that the number of voters who did not vote for President, at all, in the US is as high as the vote totals for either candidate. Maybe if they were too lazy to vote for President they were too lazy to vaccinated?

Dunno. No one checked.

Instead, they took this absolutely idiotic statistical correlation and ran with it. The NYT even expressly said this was a political divide, thus presenting vaccination as a political litmus test.

It’s disgusting. It should stop. But it won’t, because the business model demands capturing your attention, and all politics, all the time, is attention grabbing.

How this helps vaccination efforts is not immediately obvious either. If your public health concern is to stop the pandemic and encourage the success of vaccination programs to make that happen, is this what you would do? Make vaccination a political issue, not a health issue? How does that help push the people who don’t agree with you about other political issues to get vaccinated?

Further, this is just terrible overinterpretation of this kind of data. Okay, vaccination rates show a modest correlation to a single vote last November. Cool story, bro. That correlation also follows a rural-urban divide (as the vote happened to do). Equal cool story. Correlation is not causation though–many alternative hypotheses may better explain the data though.

For example, I know patients in rural West Virginia who were traveling three hours just to get to Huntington, West Virginia, to see a doctor. McDowell County, WV, at the very bottom of the state, did not have a single physician living in the county (and only 20 or so who practiced there at all) when I was in medical school. How easy is it for people living in places that remote, or remote regions of other states, to get vaccinated? Especially compared to urban centers?

Maybe, could be, possibly a little tougher for the rural folks to get to a vaccine center or for vaccines to get to them?

Could that explain the difference in vaccination rates as well or better than political preference? Urban centers also bore the brunt of the initial outbreaks. Coupled with easier access to vaccination (and priority access, as they are higher risk for high spread events than a rural area), and many are probably at or very near herd immunity. Rural areas eventually saw COVID, as we documented. But with fewer residents, there are fewer opportunities for SARS-CoV-2 to spread–which is why rural counties were slower to get hit to start with. That also puts extra selection pressure on the virus–the strains that will do well in the sticks are the ones most able to infect people in the less likely chance there are even people around one another, let alone still susceptible to the virus. Again, consider the two people who live in Wyoming. For SARS-CoV-2 to spread, they have to first be standing near each other when one is actively sick. The chances of having both residents of Wyoming in the same room is already small. The SARS-CoV-2 strain that spreads best in Wyoming, then, is the most contagious it can be–because its chance to spread is MUCH less likely than the “target rich” environment of a packed urban bar or restaurant. Thus, you not only expect a highly contagious variant to be more likely to spread among the unvaccinated (since they are more likely to still be susceptible to infection), you can also expect greater difficulty getting enough vaccines to more isolated areas to get them vaccinated to start with. Thus, rural areas are already less likely to be vaccinated, and if anything is going to actively spread in them, it needs to be really good at successful infection off of rare encounters with other possible hosts.

Those two facts alone explain the current trends. And all without invoking politics–just what we know about health access, health care, and basic virology/epidemiology.

Ah-maze-ing.

Finally, in extrapolating county level data to national trends, they are almost certainly overweighting very localized flashpoints. For example, in Indiana, the highest rate of activity of new infections per 100,000 residents is a county with one of the big universities nearby. This county also has one of the highest vaccination rates in the state right now. Meanwhile, there are at least a dozen very rural Indiana counties with low vaccine penetrance who had maybe a dozen cases of COVID between them last week. This is the first time Indiana has posted “0” disease activity markers on its map (scale of 0-3 with 3 being highly active transmission of COVID)–and all on these dozen or so counties without high vaccination rates. To read either of the big national papers articles on these trends, you would have expected the exact opposite of that, no?

–There has to be a better way to get information in the “information era” than mainstream media. There has to be.

Anything is better than their record through this entire ordeal.

–Now, that said about delta, in the US, we will be watching the trend closely over the next couple weeks. The 4th of July after last year, with restrictions lifting, should be a public health experiment on par with the Great Memorial Day Experiment of 2020 and the Kaiser Chiefs Best Hits Experiments of the summer of 2020.

If delta cannot lift the trend by the end of July into a real wave, the threat to all but the most isolated rural hospital in the US is largely gone. We may still see a seasonal bump in the fall (if South Africa in particular is any guide), but the main threat of SARS-CoV-2 to collapse swaths of the US healthcare system by sheer volume of hospitalizations is largely gone.

–Briefly following up continued stories, yet more biology based evidence that the Pfizer and Moderna vaccines may provide years of protection, as memory B-cells biopsied from lymph nodes remain stable in number months after the second dose of those vaccines. The current chatter about boosters is that selected populations may wind up getting a booster recommended–such as the elderly or those with the underlying health conditions known to be at most risk.

–And yeah, for a short update, this got long fast. Your chances of catching COVID in most places in the world remain equivalent to the chances that we are ending this with a cheesy ‘Murica meme.

Happy Fourth, all.

<Paladin>