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

Updating the chart above:

Ancestral: B.1.1.529 Omicron (and cousins)

Transmissibility: All the +

Immune Evasiveness: All the +

Vaccine Effectiveness: Check (for hospitalization)

Also as a reminder:

Monkeypox

–Fetch lives for another week at least. The CDC made a recommendation on their website to wear masks when traveling to reduce exposure to many viruses, “including monkeypox”. This prompted headlines this week about the CDC “recommending travelers wear masks to prevent monkeypox.” Since then, the CDC has modified its language, removing the reference to monkeypox specifically from its mask recommendations.

Which is almost a shame, because man, was I locked and loaded with a Sciencepalooza about just how inefficiently monkeypox is transmitted, if at all, by respiratory spread in humans. I was even about to get all cynical with CDC, suggesting that this might be a way to backdoor masks on planes since a Federal judge blew their mandate out of the water and DOJ is unlikely to prevail in its legal challenge.

And now?

Now, my thunder…

She is stolen.

On the plus side, common sense has prevailed at CDC on recommending masks for a virus that is overwhelmingly transmitted by contact with infected skin lesions or by fomites, which is medicalese for “things touched in common by infected and noninfected persons on which the virus falls, and now moves to the noninfected person”. But just to make myself feel better, the high points are that exactly one clade of monkeypox has ever been shown to transmit through the respiratory route–and the clade of monkeypox circulating is NOT that one. Even then, it was only demonstrated in lab conditions with prairie dogs in an experiment designed to give the virus every possible chance to transmit by the respiratory route–only to be successful all of 11% of the time. The clade of virus circulating was also tested, and did not transmit in those prairie dogs at all by respiratory means. The only other time respiratory “infection” was proved was in monkey studies where locking them in a box and spraying them with concentrated virus couldn’t do it (seriously), so they injected huge doses of virus directly into the trachea of monkeys (also seriously) and then high fived over successfully “transmitting” monkeypox by “respiratory” route. So I suppose if someone shoots a syringe full of live monkeypox straight down your trachea, then yes, you might be at risk of contracting monkeypox.

“But wait… isn’t a large part of the current outbreak being called basically ‘sexual transmission’ of monkeypox?” I hear you ask, Hypothetical Reader, “So if a hot load of virus straight down the windpipe could transmit the virus… does that mean that sexual transmission of monkeypox thus far was by…”

And I am going to stop you right there, Hypothetical Reader, because this is a family update, sir, and we will NOT be finishing that thought on these pages!

To get back to. the. science. papers looking at monkeypox outbreaks in Africa going back to the late 80s and early 90s found that even among close contacts in “poorly ventilated”, small cramped quarters with actively infected patients did not appear to provably get the virus by respiratory means. In fact, even locked in a room with someone with active lesions led to secondary infection only 3-11% of the time. Monkeypox is NOT easily transmitted between humans.

Which means that yes, if you back calculate the current number of cases and assume they were ALL sexually transmitted, then indeed, those folks were getting after it.

This is an odd cluster outside of Africa and veterinary work, yes, and with proven human to human transmission. But the second coming of COVID this is not. We’ll continue to follow only because of these periodically ridiculous stories like recommending masks to prevent the spread of monkeypox.

Coronavirus

–Around the horn, official stats likely continue to underestimate the true case load from the omicron cousins. That said, the US is up slightly, but still pretty much level. South Africa is coming down in new cases. Shanghai picked up a couple new cases last Friday, and this week is mass testing millions with new restrictions on at least one part of the city already. There are videos on the Twitter of CostCos in Shanghai getting cleaned out of fresh and frozen food with massive lines.

–If you are traveling, I would be a little more mindful than you would think. Again, even this week, I am hearing from more friends and family who traveled recently, and have come back positive. Continued speedy recovery to those positives I have heard from this week.

–In full disclosure, I was traveling to a medical conference this past weekend with a large, and international attendance. Masking was required in the educational sessions, with about 80% compliance (they did not throw out non-maskers) and proof of vaccination (at least the initial series) was required to attend. I suspect because it was a medical conference, masking was a little more common. I also decided last Friday morning, given the friends and family activity mentioned above, that high anti-body titers be damned, I would finally get a booster on the way up. My rationale was purely the pathologist in me, figuring by the time I arrived at the conference, my immune system would be revved up with an army of memory, spike protein specific B- and T-cells arming in response to the booster. Let the omicron cousins run into the fully operational Death Star. I am now well into the window where symptoms should be happening, but have not tested positive. No one in my travel team has tested positive or been symptomatic, but we did finally hear from someone at a meeting I was not at letting our team know one of theirs had popped.

But since the “time selective” booster was a slight addition to my plan last week, I figured it was worth sharing. If you have already had a booster though, unless you are one of the people at especially high risk who might benefit from a second booster shot, follow the CDC’s tool and recommendation for that second booster. In most cases, it will tell you that you don’t need it. I just had a booster “to burn” and the timing seemed like it was best to pull that lever.

Also for additional detail, I crossed booster manufacturers to get the appointment I needed to get to the conference on time. So I have a full Pfizer initial and Moderna booster. Other than a sore shoulder for a few days treated with ibuprofen, no other adverse effects.

–Also, now that I no longer work for a manufacturer of the early COVID treatments, and have no positions long or short or intentions to open positions long or short in any of the manufacturers of those treatments, were I to get COVID and I was high risk (I am not), I would try to get one of the acute treatments. You may have to take whatever is available. That’s fine. In terms of keeping you out of the hospital, there is no huge difference, and only a handful of studies looking at equivalency of the available treatments anyways, which have not finished enrolling. The main difference is between IV and oral administration. The monoclonal antibodies are IV, so there is a needle stick and you have to wait there until the full bag is in–but those are one and done. The pills, whether Merck or Pfizer, take up to 5 days.

Personally, if I did have a choice, I would go with the monoclonal antibodies first, just because it’s a one and done deal. After that I would go Pfizer, and then Merck (only if there was nothing else).

The question of whether to combine a monoclonal antibody and either the Pfizer or Merck pill is an interesting one. There is no data on the safety of the combination, or any potential efficacy boost, but it’s tempting because they go after the virus in very different ways. However, I can’t find anyone that has even started that trial, except maybe one in Europe that will give the pill if a specific monoclonal antibody is already on board. Anecdotally, I have heard of one patient who did not disclose they were already on the Pfizer pills and got one of the monoclonal antibodies (I don’t know which one), and had an adverse event–“we nearly lost him.” Hopefully, that was reported to the CDC and FDA, but it’s an N of 1 and may have more to do with something specific to that patient, and not anything unexpected from the combination of the two therapies.

–In vaccine news, Novavax finally got a recommendation from the FDA Advisory Board for its COVID vaccine, a stepping stone to full approval. This is a two shot vaccine, and a more traditional vaccine type. Similar to the hepatitis B vaccine, this is an isolate of the SARS-CoV-2 spike protein that is modified and presented in a way to provoke an immune response. It’s been approved in other parts of the world since the fall and winter, but honestly, I am not sure how many people in the US have been holding off primary vaccination until this one became available. The FDA advisory committee also flagged the potential for myocarditis in this vaccine, similar to Pfizer and Moderna’s mRNA based vaccines.

Socioeconomic

–Best of times, worst of times… So while Shanghai and China have re-opened, the tidal wave of shipping disentanglements has not materialized. Mostly because the price of shipping containers has been dropping, since major retailers like Wal-Mart, Target etc. report they are stuffed to the gills with inventory they ordered based on the spending splurges of 2021 that are now sitting unbought on their shelves. I suspect, but cannot prove, that is because money that would be going to buying appliances, TVs and other durable consumer goods is instead going to the gas pump, food, and housing. Target has announced it will be slashing prices to try and dump some of its excess inventory, a rare moment of deflation in otherwise persistent inflation…

–Speaking of which, India and Egypt swapping fertilizer and food to try and prevent shortages. Biden has announced a visit to Saudi Arabia, a country he promised to make a pariah because of the Kashoggi murder and overall human rights record. But Saudi Arabia has a lot of oil, so… The US and Canada furthered discussion on development of critical minerals (read “rare earth metals” among others) and jointly ensuring that supply chains are more resilient to external shocks. Speaking of Canada, a major Canadian potash producer announced plans to ramp production to try to alleviate shortfalls from the Ukraine-Russia war abroad. You are up to 23 countries that have banned food exports to at least some extent. The cost of food is inexorably rising everywhere, with multiple non-governmental agencies ringing alarms on a potential (I would argue nearly certain) global hunger crisis later this year. Which makes the argument made in this op-ed worth reading–particularly with planting in the major biofuel crop growing regions of the US still behind schedule due to weather.

–Anecdotally, my drive to the medical conference takes me through a very rural, heavily agricultural part of Indiana that I have been through a few times before around this time of year. Most of the fields appear planted (Indiana weather has not been bad). However, there are more fields lying fallow than I have seen before. These appear from the interstate to be the more marginal fields, and it’s possible they are late planting those, or switching to another crop since those particular areas might require more fertilizer to be worthwhile (and fertilizer is expensive). Not enough that I am in way alarmed, to be clear. But definitely a few more than I remember from previous trips that way.

–Finally, in 1997, Wired magazine gazed into the future, found it bright, but also suggested some “black swan” unlikely, but significant if they occurred, scenarios that might derail that future. Take a look at their list here:

Your chances of catching coronavirus are equivalent to the chances that you can guess what the world would look like when several of those boxes, instead of merely one, were checked at just about the same time…

On the other hand, I feel way better about my optimism bias now.

<Paladin>