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

–Fair bit to cover this week. First, around the horn, the US is seeing an uptick in cases. This is accompanied by not unexpected scare headlines. We will be watching the rate of change closely, but at the moment, the rate of increase in daily new cases is closer to the alpha (UK variant) wave earlier this spring and the slight rise seen in the summer of 2020. You have undoubtedly seen panic headlines about superspreader events, like Las Vegas healthcare workers, who, despite vaccination, had several catch the Delta variant at a pool party or a superspreader event at a concert where everyone was supposed to have been vaccinated.

We’ll get to what the headlines are not mentioning about those momentarily.

Elsewhere, parts of Europe, such as Spain, are dealing with rising new cases. The UK hasn’t quite found a top just yet (and we’ll see what the crowds at Wembley do to the numbers over the next couple weeks). Indonesia is finally making the headlines I expected last week, with some hospitals running short on oxygen.

Of interest, there are reports that Indonesia has authorized the use of ivermectin. Before you read too much into that, it’s just Indonesia for now, and they are definitely at kitchen sink time with the way delta is working through their large population right now.

In Japan, they hit a 6 month high in new cases, even as the Olympics are set to start soon. Tokyo tried to close bars again; the bars were not having it, and from what I read, appear to have successfully reversed that decision. This shows the heavy lift that new lockdown orders will be in some places going forward.

We will discuss South Africa and Cuba, although in a separate section because obviously.

–Alright, so what the headlines are not mentioning. First, the hospitalization rate has not appreciably budged. At all. I personally know a new vaccine breakthrough case (guy at the gym). He’s a first responder, and was vaccinated through work months ago. A little over a week ago, his girlfriend suddenly could not smell anything. She got tested; she was positive. That meant he had to get tested for work. PCR also showed the presence of SARS-CoV-2 on him. That’s analytically positive–the nucleic acid for the virus is there, and it’s a “positive” test in that regard. And it’s not known how likely someone with this exact finding, and no symptoms, fully vaccinated, is to spread the virus. Presumably low, as the antibodies from vaccination should be locking up a whole lot of the virus–but we don’t have a study proving that, although that study would be a little challenging to pull off.

As we have discussed before though, clinically positive for COVID is symptoms plus positive PCR. My man’s girl is clinically positive (although that has been her only significant symptom). My man has not had a symptom at all.

This is not uncommon in these “delta variants break through the vaccine!” or “despite vaccination, X people at Y popular event get COVID!” headlines you are reading.

What’s missing, or buried a paragraph or two down?

We have the data on how many of those cases are severe enough for hospitalization.

Of the people with two vaccine doses who then became at least PCR positive for COVID in the US, a whopping 0.003% have been hospitalized or died. That is orders of magnitude lower than the risk of the annual flu–and not nearly enough to threaten to overwhelm healthcare facilities.

–“What about the unvaccinated?” though, I hear you say, Hypothetical Reader. Glad you asked! First, are we talking about people who already got COVID, recovered, and decided not to get the vaccine?

If we are, the data from Israel released this week suggests that they are at least 6 times less likely than those who got vaccinated (but had NOT contracted COVID before) to get infected in the current wave. That’s right–natural immunity following recovery is MORE effective than the vaccine, at least in this limited data set.

Now, that makes some intuitive sense. The vaccines provide B- and T-cell responses to the spike protein, which is the most effective target for virus neutralization. However, it’s not the only target on SARS-CoV-2 that your immune system can hit. Patients who came by their immunity naturally will make antibodies and T-cell responses to all of the other proteins in SARS-CoV-2. They may not be as effective as hitting the spike protein individually, but they probably have some contributions to reducing viral replication, and the sum of those parts may be greater than the whole. Further, that means a successful SARS-CoV-2 variant not only has to change the spike protein to reduce vaccine effectiveness–in patients with natural immunity, the virus variant will also have to mutate around all of those OTHER targets as well. While staying at least as contagious. That’s a higher evolutionary burden for the virus, and one it will struggle to meet.

So what about my guy now? Will he develop antibodies to the other virus proteins, now that he has an asymptomatic infection controlled by his previous vaccination? Very possible. A lot depends on how much of a hammersmash his vaccine induced spike proteins did to SARS-CoV-2. If enough viral particles got through, or got cleared by the immune cell “vacuums” that suck up antibody coated things, digest them, and show the pieces to the B- and T-cells to generate additional protection against the vacuumed up stuff, then yes, he could have a total response going forward that looks like natural recovery. In addition to the huge levels of anti-spike protein antibodies from the vaccine.

But that’s not a guarantee. If the vaccine was too effective, not enough of the virus will have lingered to be killed, digested, and presented to the immune system to provoke a large and durable enough response to the other proteins. That really becomes a function of viral load (the amount of virus initially present, plus any that managed to get around the antibodies long enough to infect a cell or two and replicate) and time (how long the viral particles got through were able to hide before the immune system killed them). That will be impossible to predict for any given patient.

So don’t go think you are now super immune just because you got PCR positive, asymptomatic COVID on top of your vaccination! : )

–Yes, that gets back to “should people who already got COVID really get a vaccine?” The Israeli data is more evidence that natural immunity is probably enough, and a vaccine is at best a booster. In my mind, the best argument for vaccination in this setting is social, not medical. Places you want to travel are almost certainly going to want proof of vaccination. Some jobs might require it. That said, if your COVID infection was asymptomatic or mildly symptomatic when you had it, there will be an open question about how durable your immunity is and will be, and a booster might not be the worst idea.

–I am also very interested in the safety data from the ongoing studies of the vaccines in kids age 5-11. Their risk of clinically significant COVID is already very, very low (it’s not even much of a flu to them). I get the rationale if you are pushing for eradication of SARS-CoV-2, but I also think there is already enough vaccine resistance (which is already being reinforced by the media) that eradication similar to smallpox will difficult to impossible in the near term. I think we will know by the fall if the current vaccination rate plus natural immunity from infection (and rare re-infection) is sufficient herd immunity to effectively halt SARS-CoV-2. I think we’re awfully close already. Yes, this may push the critical decision points until after the start of school. Timing is what it is though.

–Speaking of vaccines and safety, J&J’s vaccine was reviewed by the FDA for ~100 cases of Guillen-Barre Syndrome (out of nearly 12 million recipients). This is a rare side effect, but Guillen-Barre is a severe one. What happens is that the immune system loses the script again, and attacks the myelin sheath around the peripheral nervous system. That’s a fancy way of saying it strips off the “insulation” around the “wiring” of the nerves in the body (but not the brain or spinal cord). This presents as an ascending paralysis, meaning fingers and toes get numb first, and then you start to lose the ability to move them, and the paralysis gradually moves up. Sounds bad, but it’s very treatable (a long list of things that are NOT vaccines can also cause Guillen-Barre, so, while rare, is not unknown to medicine). Typically lasts 14-30 days. Most patients are fully recovered within 6 months, although some may not lose the tinglies for up to 3 years. Still a lottery level event with the J&J vaccine.

–Speaking of vaccination in general, and unintended (perhaps) consequences, we had continued emphasis on a political bifurcation of vaccination rates. They trotted Fauci out to be officially troubled by an anti-vax speech some dude gave at a conservative conference, and officially horrified that the audience cheered the difficulty the Biden administration has had achieving its vaccination goals.

Well, what did you expect to happen when mainstream media outlets, for weeks, have been deliberately misrepresenting vaccination rate data to fit a political narrative? You’re surprised that some idiot on the other side took you up on your litmus test challenge and ran with it?

Again, if your goal was to actually persuade the ambivalent and increase vaccination rates (and not stir the political tribalism pot in a cynical bid for ratings and attention to get those advertising dolla’ dolla’ bills, y’all) is this how you would do it?

Do you know nothing of human nature?

But now we have vaccination songs and “join us at the restaurant, join us at the concert” advertising to increase vaccination rates.

And the threat possibility of door to door visits to encourage vaccination.

Yes, I, too, find lecturing, infantilization, and then more aggressive lecturing to be the least effective forms of persuasion as well.

Sigh. Instead, we get a political tribalism narrative based on poll data–which makes you think that the groups not getting vaccinated are completely different from the demographics that the CDC’s actual data on vaccination shows. Not only do these screeds ignore the CDC data almost entirely, they even ignore their own polling (on average, ~16% of Democrats surveyed have said they are not vaccinated with no plans to get vaccinated–and if the entire country were like them, would never get to a 90% vaccination rate either).

–How often do you hear about “listening”? Be a better listener? Even public (pious and probably performative) “listening” tours, where someone who would be our leader nobly descends from Olympus to talk to the common folk, hear their problems in their own words, and thus prove they now understand them, and can go forth to find solutions for them?

How rarely does that listening actually seem to happen in the real world?

You want to reach the vaccine hesitant demographics better? This is what you do. You get a good sample size of them into a room. You ask each of them “on a scale of 1 to 10, 10 being ‘definitely getting the shot today’, how ready are you to get the COVID vaccine?”

“A 2. Interesting.” Now you ask each of them the critical question:

“Why aren’t you a 0?”

-Now- you’ll get the answers that will actually move people.

“Well, I don’t want to accidentally die of COVID. Would seem an embarrassing way to go right now.”

“Well, I don’t want to accidentally give it to grandma the next time I see her…”

“I would like to go the Caribbean, but don’t have plans to go in the next year…”

Then you ask the other important follow up question. This one gets them to tell you how to fix their biggest hesitation.

“What would it take to convince you to answer 10, and get the shot?”

“Well, I need to be convinced that getting the shot won’t get me deported. My family is counting on the money I send back home…”

Cool. We’re going to set up a clinic, staffed with people who look like you, and anonymize everyone getting the shot. We may even just give you a blockchain address, and use blockchain to trace who got the shot–and that blockchain wallet QR code can also be used to report side effects back to our clinic if you have any. You can return to have those treated anonymously too. We’ll walk you, or people you trust, through it all to convince you that no one is collecting names, locations, immigration status etc. Deal?

“Well, after Tuskeegee, I just don’t trust the government. Who knows what is in the shot I get?”

Cool. We’ll create a way for you to follow the entire manufacturing process, or at least enough of it to prove to you that shot you get has the vaccine, and only the vaccine, in it.

“The government will use the vaccine to control me. I’ve seen the videos! I know the truth they are trying to hide!”

Cool. We only need one of you to volunteer to get the shot–the rest of you can watch. We’ll bring in a member of the Illuminati, and put them in a room. The volunteer will get a vaccine dose and a button to push. The button will release a pack of “Roasting Weenies” Security Dachshunds in the room with the Illuminati guy. If the volunteer can still push that button, will that prove to you guys that the Illuminati cannot control you through the shot, and you will all line up to get one?

You get the idea.

But why has no one appeared to have done this?

–Back to the COVID science, thanks to a UK reader, there is a paper out that is small numbers, but reasonable statistics suggesting that a protein called Annexin-2 may be the main target when the immune system is going Ah-nold and predicts which patients are developing severe COVID. Could be a very easy way to screen and treat earlier for the patients who are running into issues.

–On the socioeconomic issues front, I am sure I am not the only one noticing persistently high prices for gas and food. Even the “core CPI” (which excludes these “volatile” but “essential purchase in the modern world” commodities) was higher than the Fed expected this week. Again, the debate remains not if inflation is happening, but how high, how sustained.

Already, the WHO is warning that world hunger has hit a 15 year high, with 811 million people (10% of the entire world population) going hungry in 2020. As food prices remain persistently high, this is likely to worsen.

Deus impeditio esuritori nullus.

The last time there was sustained inflation in food prices, it coincided with the Arab Spring. Already in the past week, we have massive protests in the street against the latest in a long and undefeated line of failing communist societies in Cuba. You also have massive protests in parts of South Africa, where 2 of the 9 provinces with high Zulu populations have protested the arrest of former President Zuma (a Zulu) on obstruction over a corruption case pending against him. The South Africa riots look an awful lot like the riots that were taking place across many big cities in the US last year. Parts of South Africa are perfectly peaceful–you wouldn’t know riots are going on. Other parts are like Durban, the 4th largest port in the Southern Hemisphere (it would be ~ the 3rd or 4th largest port in the US by tonnage for comparison), where warehouses have been looted and burned and port operations have been impacted. The South African government has called up the reserves to help the police regain control in the affected provinces (similar to the US National Guard being called up in select states and cities).

Politics may be the trigger–but supply chain disruption, lockdown/re-opening disruption, inflation (especially food) are all providing the dry powder.

Cuba and South Africa will likely not be the last countries where sizeable pockets of the citizenry reach their limit and take to the streets.

–Which brings me to the gestalt. And maybe it’s just me, and I’m misreading the zeitgeist. It’s just a weird feeling out there right now. The US government releases a report acknowledging years of UFOs, and admits they don’t know what they are. Again, as we discussed previously, that proves exactly nothing (and certainly not aliens). But you would barely know it. Any other time in the last 40+ years I’ve been around (fortunately, not that much of a “+” to that yet), that would be a huge story anyways. All over the news.

I’m not even sure it made a cycle.

Everyone seems so focused on the anticipation and dread of the next shoe to drop. We want to be back to normal, and we reach for normal, but normal is somehow slippery. Or maybe we just don’t trust our grip on it. The politicization of everything, coupled with the very solitary brush with mortality that is a pandemic (when you realize it could infect you), and lockdowns, and it’s been like living in a Albert Camus fever dream of existentialism at times.

That’s a lonely, sad place.

And let’s face it.

There is truth to this.

And there is truth to this (especially that a lot of outcomes are possible right now).

The feeling is that the world is on a delicate balancing act right now. It’s going to break in one direction, hard, and picking up steam as it goes to whatever the new equilibrium will be. But we don’t know which yet. And we don’t think there is much that can stop the break from happening.

We all know, we all can feel it (like a Phil Collins’ song before the drum break).

But no one says it. Or we just speak around this feeling.

There are times now I run into people that I haven’t seen since in person since the pandemic started, and there just feels like this wall. We recognize the person, we remember the relationship, but it’s like there is this whisper barrier between us. That awkward re-learning of the relationship with an acquaintance you ran into after years apart. Those first few minutes spent groping, trying to figure out how to condense all the time and experience that has passed since you last saw each other. So much that it now feels an impediment, rather than the path, to re-connection.

On the other hand, at the lab, we’re the band of brothers after over a year testing COVID, through everything that 2020 threw at us. Same for all those in the bubble at home. I made it to jiu jitsu class the other night. By pure accident, several of the other of my “generation” of blue belts made it too. We all started around the same time, got our blue belts around the same time. Some of them I have not seen since before the pandemic. But it was like no time had passed at all. No distance.

Why is there no rhyme or reason to when that wall, that distance, feels there?

I don’t know.

But the fact that the wall isn’t there always is the sign. We’re not stuck in Camus’ nightmare–we’re starting to wake up from it. Don’t let the world, in its anxiety, divide you. Whatever direction the future takes, we can make it a bright one. “Many possible outcomes” isn’t a curse, but opportunity.

And we’ll need to be salty to seize it, as the decade rolls along…

“‘What does ‘salt of the earth’ even mean? I’m not good at metaphor.’

‘Salt preserves meat from corruption. It slows its decay. I want …a people who hold back the evil of the world. Salt also enhances the flavor of things. I want … to renew the world and be part of its redemption. Salt can also be mixed with honey and rubbed on the skin for maladies. I want my people to participate in the healing of the world, not its destruction.’

‘Then why not just say that?’

‘Come on Matthew. Allow me a little poetry, huh?'”

“The Chosen”, Season 2, Episode 8: “Beyond Mountains”

–Your chances of catching coronavirus in most places of the world… In real football, there is a defense called the “prevent” defense. It’s used when your team is up big, but the other team has the ball, and your defense plays way back, trading ground for time. If there is truly more distance for the other team to cover than time for them to cover it, the prevent works. However, coaches sometimes underestimate how long it might take the other team to score, and if called too early, a prevent defense can be a disaster.

Hence, the old football adage that “the only thing a prevent defense prevents is you from winning.”

I am often surprised watching high level soccer (the other football) how often a team will get a one goal lead, and then sit back for huge chunks of the second half, surrendering initiative to try to defend what they hope will be the game winning margin. I get it, goals are rare in soccer to begin with, and even more rare with enough bodies packed in the box. But the “prevent defense” of soccer seems to work about as often as the football one when called way too early in the second half.

Your chances of catching coronavirus are equivalent to the chances that England has learned this lesson a very hard way this past weekend.

<Paladin>