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

Omicron–Variant first identified in South Africa

Also as a reminder:

Ebola:

–No new cases this week either. We are coming up on the official end o’ the current outbreak.

Coronavirus:

–Big week in news, but short week on time, so this will be less of my prolific, flowing prose and much more staccato in pace and feel.

–Omicron. More data is trickling in, but not all the details are known yet. In brief, cases continue to be found all over the world. In the US, you are up to 43 cases per CDC reporting as of the time I writing this. This represents 21 states, and only a third or so have been tied to international travel, again suggesting that omicron is already spreading domestically many places in the world. Of those 43 cases, three fourths were in vaccinated individuals, and 1/3rd of those vaccinated people had received a booster as well. Only one of those 43 has been hospitalized.

Now, some caveats apply to the 1 in 43 hospitalization rate. That’s not an especially large “N” and the total rate could go up, could go down. But you may recognize that as about half of the hospitalization rate when SARS-CoV-2 the Original was first firing up in late 2019-March 2020. Thus far, too, the patients are on the younger side and would not be expected to be prone to severe COVID anyways.

Caveats also apply to the proportion of vaccinated patients with confirmed omicron. Many of the cases are associated with either that large Anime convention in New York, or international travel, both of which required vaccination. Scotland believes many of their cases originate from recent international climate change conference that wrapped there not too long ago. So omicron has had greater opportunity in those circumstances to run into vaccinated people, and we might expect “breakthrough” cases to be over-represented at the moment.

This does suggest that omicron can breakthrough vaccination, even booster vaccination. This is consistent with a South African lab reporting results of serum neutralization studies using blood from 12 Pfizer vaccinated patients, and finding that the ability of the antibodies provoked by the vaccine to neutralize omicron is reduced about 40 fold compared to the “regular” SARS-CoV-2. But, like with other variants, sheer force of antibody numbers can win the day.

Further, the relatively mild cases in these breakthrough patients around the world are consistent with the immune system being able to rev quickly and stomp the virus within a few days even if the initial antibody “wall” is no longer high enough to keep the virus out entirely from the drop.

Moderna is still touting their rapid work on a new vaccine form that will be specific to Omicron. Pfizer came out yesterday saying that their internal data also shows the vaccine provides sufficient protection, especially if you got a booster.

I will pause a moment to let you recover from the shock and surprise of that. I know, right? Such antibody. Much protection. Great wow. And in no way convenient for the financial incentive they have in this as well.

Just a quick reminder my employer does not review these statements, all comments are my own opinion, and thank you for your understanding.

And in fairness, they may be right. Again, if you are in a high risk category for COVID, you should be getting a booster. Evidence is pretty clear for that. We’ll talk about everyone else in a minute…

Staying on omicron though, the generally mild disease in the US cases (and elsewhere) so far appears quite consistent with the anecdotal data South Africa, to its immense credit, has been flooding the air waves with. In Omicron heavy districts, South Africa has seen hospitalizations by sheer force of numbers, but these are fewer for the number of positives versus recent waves, and the average stay and oxygen need has been less than with previous variants as well. I have yet to see a report of a death in any of the known omicron cases so far. Not to say it cannot happen, or will not, but hasn’t happened yet. But to re-iterate, the main pandemic threat is the ability to consume hospital resources with COVID patients, and omicron, at least out of the gate so far, seems less able to do that on a “pound for pound” basis versus previous variants.

In other omicron news, we have round ups of early lab results. Very few of these have been published, let alone under peer review, and are best viewed as anecdotal for now. But there is no reason to disbelieve them out of hand either. A team in Japan has estimated based on lab testing that omicron is about 4 times as contagious as delta. To put that in perspective, you have probably caught omicron just by reading this sentence about it. As a reminder, dibs on all your coolest stuff. Regeneron does not believe their antibody cocktail will be as effective versus omicron. Glaxo-Smith-Kline and Vir believe their new antibody cocktail will be effective based on early lab results.

On a quick antibody side note, you can find anecdotal comments on monoclonal antibody effectiveness for acute COVID from people who have taken them out there on Twitter and podcasts (Jocko Willink and Joe Rogan on the Joe Rogan Experience 1740 was the most recent one I was asked directly about). They usually don’t mention specific manufacturers, but I still cannot comment or even link these, and thank you for your understanding if you find them by clever Googling of things like “Jocko Joe Rogan monoclonal antibody” and the like, find a clip and have questions for me.

There remains NO suggestion that the Merck and Pfizer anti-viral pills for SARS-CoV-2 are NOT effective against omicron. Absence of evidence is not evidence of absence, I know, but mechanistically, odds remain strongly in favor of these therapies being effective against omicron too.

–Before we leave discussion of therapeutics, thank you for your understanding on the linked announcement.

–In other news, going around the horn, sure enough, the Thanksgiving bump is back in full force in the US. The winter spike has resumed as testing has resumed, and patients hit the incubation period to turn symptomatic and get tested. Epiforecasts has the US at a Rt of 1.1 overall. Your local results may vary. Indiana, for example, is getting slammered at the moment with a resumed delta wave, and is one of 6 states accounting for half of the recent increase in hospitalizations. In fact, the IU Health system has called on the National Guard for staffing assistance as hospital beds are disturbingly full for COVID and non-COVID reasons alike. Again, this is a confluence of staffing issues and case load. Anecdotally, I have friends with nurse significant others who are massively increasing their salaries by taking just one extra shift per week because the hospitals cannot find people. There are articles out this week discussing how some traveling nurses have been making triple their usual salary this year, flying in for a month or weeks at a time to cover staffing shortfalls. This has raised questions from nurses in some hospital systems as to why the system pays exorbitantly for the traveling help (which does not know the healthcare system or patients as well) rather than just, you know, pay the current staff enough to keep them on board, but those discussions for another time. Also anecdotally, I have had more offers from recruiters looking for locums pathology help in the last three weeks than I have had in the past three years, suggesting it ain’t just nurses. (locums is our fancy Latin way of saying “traveling temp doc”)

At least at first blush, this appears to continue to be a combo of delta activity and cold weather, as hospitalizations are clustered in the Midwest and East Coast. Vaccination percentage appears loosely correlated at best, as some of those states are well above vaccination rate average and others are below.

Again, I expect this to continue through the end of the month in the states. Only question is whether an omicron wave will start, and when it does, if it comes on the tail end of the current winter delta wave or takes some oxygen from delta over the next couple months.

The size of the winter wave will be telling as well. If, overall, is less than last years, that is an optimistic sign that it is settling into a more flu like pattern. In a perfect world, we are looking at a metric of hospitalizations due to COVID and not simply with COVID (some continue to count hospitalizations for anything within 28 days of a positive test a COVID hospitalization, which is nuts) as a function of total positive tests in this period. If hospitalizations per positive case are going down, this is an argument for attenuating virus severity and/or sufficient immunity to prevent the main pandemic threat from the virus.

I despair that we do not live in a perfect world though.

In an imperfect world, expect more feelingsball to be played for determination of public health policies. Again, I’m a doctor, not a politician. Thus, gentle mockery of Moderna and Pfizer above aside, I think the current and likely coming total wave size of the winter delta/omicron spike will guide a strongly recommended or required booster for a large chunk of the population. I suspect this will be mostly on the rationale that immunity wanes enough for at least mild breakthrough disease, even though hospitalization rate is the crucial medical metric. I also expect the when, who, and how many of boosters will be settled over the coming months if not year or two. I think the booster push will also happen despite effective treatments being available. But the devils of the details are still to fill in.

–Speaking of which, including the messiness of filling in those details, Dr. Fauci is out on the airwaves yesterday stating that he believes the definition of “fully vaccinated” will change from the current two doses of mRNA etc. His direct quote is that will be a “when” not an “if.” It will not be revised down. The CDC had no comment on Dr. Fauci’s pronouncement however. Meanwhile, the UK has been forging ahead to try to make three shots their new standard. This drew immediate WHO fire earlier this week. Dr. Mike Ryan, the head of WHO’s emergencies program was quoted as saying “Right now, there is no evidence that I’m aware of that would suggest that boosting the entire population would necessarily provide any greater protection for otherwise healthy individuals against hospitalization and death.” The WHO further questioned these broad booster programs in developed countries from a medical resource standpoint, as shots being used as boosters are NOT being used in under developed countries that still need primary vaccination series shots.

Meanwhile, multiple Democrat Senators defected to pass a bill against the vaccine mandates signed by executive order from the Biden Administration, specifically citing their desire that vaccination policy be based on incentives, and not punitive as the order created. Various legal battles continue to roll back enforcement of mandates in many industries and government agencies as well.

So overall, clear and consistent messaging all around, fostering a strong sense that public health and political authorities the world over are clear in their conclusions and firm in their decisions, and not at all continuing to add logs to the bonfires of their credibility.

–They will likely one day look back on this period as an example of how NOT to do a global vaccination effort in the face of pandemic or global severe infectious disease.

–Still on vaccine related notes, I am now just under a year out from my two series Pfizer vaccine. I have not gotten a booster shot yet. I have been getting my anti-spike protein antibody titer drawn over the past year. Last week was my most recent draw. The one before that was in August.

My antibody titer is higher than the largest titer the assay can measure–again. It’s been that way since after the second shot of the vaccine, which, again, was about a year ago now. The sample can be diluted to get in range of the assay, and the concentration estimated, although not as precisely as if I did NOT have a re-donk amount of anti-SARS-CoV-2 antibody floating around from the vaccine.

At least for me, that high level of antibody is about the same, if not slightly higher, than my level in August.

This titer is also higher than the such antibody, much wow titers Pfizer has touted as the vast improvement in antibody levels that a booster provides.

I am pretty comfortable with the decision to NOT get a booster given this data.

I am surprised this is not being done more routinely to determine who really is showing waning immunity, and would be the best candidate for a booster shot, to better allocate these resources. The same could also be done to determine if someone with natural immunity may benefit from a booster, if it shows their titers are low or falling.

–While I would attribute the incredible success of my immune system in response to COVID vaccination to the same favorable genetics that have left me handsome, charming, intelligent, and abundant with humility about it all, to go a long with a simply, and medically speaking, enormous pe-…

…Don’t roll your eyes at me…

You will only encourage me to write jokes like this.

Anyways, my enormous personality...

Sadly, my immune system may not be the only rock star. I’ve spoken with a few others, including a guy older than me who got vaccinated around the same time, has not got a booster, and has also followed antibody titers over the past year. He is also off the charts, and still off the charts, for his titer as well, with no indication he has caught COVID in the past year.

Anecdotally, a cohort of patients who caught COVID last April have also been followed for antibody titers over the last year plus now. From what I hear, only a handful have had antibody titer drops since then.

–Again, I am surprised this is not being done more routinely to determine who really is showing waning immunity, and would be the best candidate for a booster shot, to better allocate these resources. Especially when I see pharma companies with a financial interest in boosters and public health authorities tout antibody titers as their evidence of waning immunity, and improved immunity following a booster shot.

–Finally on boosters, again, measuring just that antibody response, there is no difference among the various available booster shots in terms of degree of response. At least according to a new paper (I won’t bore you with the link).

–Alright. Am I done with medical COVID updates this week? <checks notes> Yes. Looks like I’m done with what I wanted to cover.

–Socioeconomic COVID… Lots here this week too.

–First, a meditation for you. If a bunch of container ships are anchored in a holding pattern at sea because the port is too backed up to handle the traffic after COVID restrictions etc., do they still count as a traffic jam in that port?

Turns out, no. While that looks great if “ships stuck in port” are your metric of resolving supply chain issues, that still doesn’t get the stuff off those boats and going where it needs to in order to maintain orderly and cost effective function of global supply chains.

Right now, there are record numbers of container ships at anchor or moving in circles in deep ocean because their ports are too backed up. Still. There are still container shortages simply because the empties no one can get rid of are no longer being stored at the docks, but instead being stuffed anywhere else they can. Cargoes waiting extra days to get on the move have been reported rising number of thefts, because, as it turns out, a target that is NOT moving is easier to jack.

When questioned about the continued supply chain issues in spite of numbers showing relief of numbers of ships and containers stuck in port, and specifically how the supply chains do not appear to have resolved if you count the number of ships doing donuts in deep ocean (where they won’t count against the “in port” metric), Jen Psaki, the US Press Secretary said that the President was “pleased by the progress being made there.”

If you ever doubted that to a politician, perception of effectiveness is more important than actually being effective, read that quote from the Press Secretary again.

And this is not to pick on Ms. Psaki or the Biden Administration, because this is Press Sec 101, and they all do this, with those exact words.

Because it makes it sound like the highest levels are totally with you, definitely know that’s a problem, totally working on it–it’s not fixed yet, but progress is being made (even if YOU can’t see it), and top people are happy that the direction is headed the right way. Because it’s a problem government can totally fix, is on it, and with this new progress, the resolution to your problem is right around the corner. Huzzah!

–Meanwhile, you have articles out just today on CPAP devices (medical devices to assist breathing in conditions like severe sleep apnea, which is strongly correlated with mortality) being delayed by 6 months or more for delivery. Because the manufacturers are having to fight with every other industry for available chips, and the medical equipment makers are not always winning those battles. You also have articles on the beverage industry writ large, which is having trouble finding everything from bottles to aluminum cans–and why that is the reason the grocery industry is on average reporting 10-15% less inventory for beverages ranging from soft drinks to iced tea to beer to your 2020 throw back White Claw are harder to find. Turns out, it wasn’t just me noticing that in the grocery and convenience stores! Also articles citing industry sources claiming used car prices are not likely to go back to 2019 any time soon due to continued difficulty sourcing parts and materials to make enough new cars, thus keeping demand for used cars high.

Elsewhere, energy prices remain doggedly high. The price for energy in Singapore hit a record in the last week, for example.

In the back drop, Evergrande officially went into default this week, as offshore (read: non-Chinese) bond holders did not receive payment on their loans which were due, even after a 30 day grace period for Evergrande to find that check that they totally, totally mailed you guys. That is China’s largest property developer. The third-ish largest also managed to default this week too. Totally contained. How China responds to this matters. Again, there is not as much direct contagion risk as China’s banking system is pretty sequestered from the rest of the world. The greater problem is the rest of China’s economy is not, and as we mentioned before, 70% of the average Chinese person’s wealth is in real estate, the prices of which are now in free fall and likely to fall more as these property developers will now be forced into liquidation sales of some kind. Or China has to print, which they at least started to do this week–unfortunately at a time when inflationary pressure is quite strong, which will also reduce the wealth of their people on a purchasing power parity level. Oh, and by the way, articles I trust also claim that fully 30% of China’s annual GDP growth is powered by real estate or loans collateralized by real estate. So how will the largest, and most rapidly aging population on earth, find new growth to make good on all the social support a still largely communist system (with major corruption issues in its provinces) promises to its population? How the CCP will maintain the Mandate of Heaven may be a big question next year–and scenarios where that is an “if” question are not necessarily off the table.

Oh, and the IMF is openly warning of economic collapse in underdeveloped countries due to their debt structure coupled with economic disruption from the pandemic and pandemic responses if the G20 does not extend debt relief.

And on and on and on with socioeconomic knocks on this week.

So in TL;DR summary of all that, you are still very much at “cascading disruption” in terms of supply chains. That seems likely to persist into next year. “Cascading failure” still strikes me as a remote possibility, but there are definitely scenarios where that can happen hanging around out there right now.

Your chances of catching Ebola this week are equivalent to the chances you have asked Santa for a Thunderdome, just in case you have to dominate a post-apocalyptic wasteland dystopia like the warlord you know lurks within.

Your chances of catching coronarvirus are equivalent to the chances that, somewhere on the internet, “Mad Max Santa” would be a thing:

<Paladin>