–We start this week with more news that I cannot comment on:

https://investor.lilly.com/news-releases/news-release-details/lillys-neutralizing-antibody-bamlanivimab-ly-cov555-prevented

Thank you for your understanding.

–We’ve got some pictures to start, because the story they tell is beautiful:

At the top, that is the rate of new cases of COVID nationwide. You are in the green pretty much from sea to shining sea, continuing the downtrends we mentioned were starting last week. Consistent with that, you have an Rt that is in the green for all but 11 states. Included in that are states with known variants suspected of higher contagiousness, such as Indiana, Colorado and New York. Granted, the error bar on the Rt is into the 1.1 range for Colorado and New York, suggesting reversals may be possible there. But the trends starting last week are continuing solidly this week as well.

Around the world, South Africa and the UK are both seeing declining cases this week (despite having variants of concern circulating). But results vary locally as Colombia and Spain are seeing increases in new cases right now.

–Speaking of new variants and new case trends, after we went to “press” last week the CDC released some models on the spread of the UK variant in the US. The long story short is they expect the strain to become the dominant strain by March, but again, there is no evidence of reinfection, no evidence it is past the vaccines, and no evidence it causes more severe disease or severe disease more often.

Remember, every model is wrong. But some are useful. I’m going to include Figures 1 and 2 from their document below.

Alright, first things first. The Y-axis is new cases per 100,000 people. Higher numbers here are bad. The X-axis is months from January to May of this year. The graphs on the left in both figures assume an Rt of 1.1. Those on the right assume an Rt of 0.9. Those are reasonable guesses based on the Rt.live chart above, with more states, and the Johns Hopkins map, trending towards a Rt of 0.9. That is to say each new case of COVID is infecting less than 1 new person, and the pandemic is in the early end game.

Figure 1 shows the impact of the UK strain, or something similar, if it gets past the vaccine. It’s not. But just to show you what that would look like. Notice something–the Rt plays a dominating role in what happens. Presumably, the Rt of the more contagious variants, in a break out like that, would be closer to 1.1 or higher and the left chart. That shows a sustained high number of new cases through May and beyond as the pandemic basically restarts–BUT WAIT!!!!!

All models are wrong, remember? The chance that a new variant is already past, or gets past, the vaccine and current immunity is very low. That left graph if Figure 1 is highly unlikely. You don’t live in that world.

In fact, consistent with the Johns Hopkins and Rt.live graphs we started with, current new cases in the US fell to ~56/100,000 people today as I type this. The graph on the left in Figure 1, assuming an Rt of 1.1, projects that new cases should be going UP in the US, into at least February, and then dipping until the new variant really lights a fire. The current data all fit an Rt closer to 0.9, which is the graph on the right in Figure 1–the steady decline in new cases we have seen all month.

In that world, the Rt drags the virus down to almost gone by March, when the new variant becomes the majority of dwindling cases. If it is past the vaccine, the pandemic starts to re-ignite around May. Again, all the evidence right now is that the virus is not past the vaccines, and is not likely to do so. Figure 1 on the right is your current “worst case” scenario, and is low probability.

Now check out Figure 2, because this is the most probable scenario. The CDC is conservatively estimating that 10-30% of the US is already immune to SARS-CoV-2 by January 1. Again, you can ignore the left graph in Figure 2, because all the current trends say that the Rt is not as high as 1.1, and fit the right graph better.

You also have effective vaccines going out at around 1,000,000 doses/day. Thus, Figure 2, Graph on the Right is the most reasonable approximation of the world in which you currently live. In that setting, cases will continue their decline through March, even though the new more contagious variants start to take over the majority of new cases. We can expect that–again, selection pressure right now is for variants of the virus best able to successfully infect in the increasingly rare moments they encounter someone who is NOT already immune. The worst the more contagious variants are likely to do is stabilize new cases briefly in April through May at ~30,000 new cases/day–for the entire country. Spread across the entire country, that’s not a threat to take down any local health care system. The CDC doesn’t extend the graph far enough, but gravity re-asserts itself after May, and cases will dwindle again into July as vaccine, treatments, plus natural immunity eat the new variant(s) alive.

So I stand by my “most likely scenario based on current trends” is the pandemic in the US is effectively over medically no later than July.

–What about the new Biden Administration’s slew of COVID executive orders this morning?

Brilliant example of transitional leadership done well.

That is to say, most good leaders, when starting in a new role, look for easy, highly visible wins that fit with their “brand” (much as it pains me to write brand in that context).

Biden campaigned heavily on the promise that if put into office, he would quickly enact all reasonable, science based measures to end the COVID pandemic in the US quickly.

To that effect, among the measures included today were:

1) Mask mandates on all public transportation including airlines.

Already happening, so this is easy to do and appears effective.

2) Require negative COVID tests before re-entry to the US from abroad and mandatory self-quarantine.

Also largely already happening, so also easy to do.

3) Achieve 100 million vaccines dosed in the first 100 days. The CDC and Public Health Service along with FEMA will set up vaccination centers. Distribution to pharmacies for easier vaccine access.

As I type this, you are already at just under 1,000,000 doses per day, and during flu season, the US typically achieves 3 million vaccinations per day with existing infrastructure. Right now, distribution is limited only to the pace of manufacturing. In many states, some of the pharmacies are already appointment based vaccination centers.

4) Improve testing access and bring more testing capacity online.

Many states, given the trends in the Johns Hopkins map above, already have excess testing capacity. There are fewer tests being done in some states right now not because of lack of capacity or availability, but because fewer people are feeling sick or are a known contact of a COVID positive person to get tested. They’re already talking here about moving our drive through testing here at work to three days a week if current low utilization numbers continue over the next couple weeks. So again, sounds effective, easy to implement, and will look like a resounding success as long as current dropping new case trends continue.

5) Re-open K-8 schools within the first 100 days.

In many states, they already are open. The first 100 days put you in March-April for the hold outs.

By that point, under the most likely scenario, you are talking about 30,000 new cases per day across the nation–so hardly any new cases at all in most towns and cities across the country. There will be little argument against keeping the schools closed–especially since they will only re-open for what, a month or two at most? Again, easy to accomplish given the current trends.

So again, look at Figure 2, graph on the right above there. The current trends all favor the Biden administration right now. They are in an incredibly rare and envious position: All they have to do is not trip on their own dicks by doing anything to get in the way of those trends. Then, they just have to NOT be horribly unlucky and have the virus hit the lottery with a mutation past the vaccines and current immunity. Those are both really easy to achieve right now. And if they just keep the positive momentum rolling, and not get a bad beat, they will have immediate delivery on a big, early, signature win.

Thus today you have a bunch of “new” changes with much fanfare, none of which are likely to reverse the current positive direction.

Not knocking it–again, that is great transitional leadership to find the big, early, easy win. It builds momentum and confidence in the leader, and the country could use that right now.

But now that you’ve seen it, watch the next time there is another visible leadership change around you, and how the effective leaders step in and immediately try to hit a big, early, easy winner to build momentum for their leadership. It’s leadership 101. (and yes, even Trump did this. Go back to his visit to the Carrier plant in his first couple of weeks in 2017)

–Again, in politics, perception of effectiveness is as good, or better, than actually being effective.

–In vaccine news, I got my second dose yesterday morning. As you recall from the publication of the Phase 3 results, the most common side effects of fatigue, headache, muscle pain and/or fever tended to occur in younger patients after the second dose, but overall were comparable in incidence to the flu shot.

The word on the street has been that the second dose is indeed a bumpier ride in terms of headache etc.

Holy Hell, are the rumors true. I was rekt (yes, spelled that way) this morning. At least for me, the left shoulder soreness started around bedtime last evening. When I got up this morning around 3 am to go to the bathroom, that shoulder (where I got the injection) outright hurt. We’re not talking tetanus booster sore and stiff either, but more “I can feel the outline of my humerus under my shoulder by where the pain is.” This morning, it felt like a really solid hangover. The kind of hangover where I wish I had at least had the party I am apparently paying for today. The Whoop strap had me solidly in the red (meaning likely impaired physical performance in any kind of workout or athletics, and higher chance for injury). Also in “hangover” range, but not the worst either.

But, there is some good news. The word on the street is that this kind of reaction typically does not last more than 24 hours, and I have been feeling gradually better as the day has worn on.

The other good news is that all of these symptoms are a sign that the vaccine is very effective in provoking an immune response. That’s right–all the usual cold and flu symptoms you typically get are not the virus itself, but the reaction of your immune system to the virus. The aches and pains, fatigue etc. are the ringing alarm of cytokines flooding your body telling your immune system to march to war, and marshaling resources to do that. Even the fever. Turns out you, as a whole, can survive and function at a higher body temperature. Many bacteria and viruses cannot, and it’s actually your immune system cranking your temperature up to slow an invader down.

So like with any cold or flu, you can manage the symptoms by taking drugs like Tylenol or Ibuprofen. The former is thought to work by blunting immune signals to the brain that cause you to perceive pain and raise your temperature (why Tylenol works for pain and fever). The latter works by chilling your immune system out a little bit. So if you are demanding “physician heal thyself” with symptoms like these, I have NOT been taking anything after the vaccine. Either of those would be good options and I would feel better, but I also know I am feeling crappy because my immune system, either by virtue of asymptomatic exposure to SARS-CoV-2 months ago or by a vaccine to SARS-CoV-2 spike protein, is now loaded for bear whenever SARS-CoV-2 spike protein shows up. And a whole lot of it showed up at once in the vaccine booster yesterday.

My plan is to let the army of T-cells primed for the spike protein do their thing and hunt down all the cells that picked up the spike protein mRNA in the shot yesterday. By the way I am feeling, that process is well underway.

For the record, this is my personal approach to colds and flus too. I just take the symptomatic hit, rather than treat the immune system trying to fight it. I only take the anti-inflammatories for symptom control if I absolutely have to because I have something I need to do and the fever/aches/pains are getting in the way. I have no proof that playing through the symptoms shortens the overall length of the cold/flu, but I tell myself it does, so it must be true, right? : )

–In other vaccine news, California temporarily halted distribution of one lot of Moderna vaccine due to a handful of adverse reactions in quick succession. But, they all happened at the same clinic, and it seems to be an issue with the way that clinic was distributing the vaccine.

–Also heard from a reader about someone in their circle who caught COVID within a couple days of their second dose. There are a few stories in the news like that as well, but they are in the vast minority. The reason for the booster shot is to get 90% efficacy–which is to say 90% of those taking the vaccine to mount a protective immune response to the virus. Some % of patients will have a protective immune response by just the first dose, but not enough and not a great high throughput way to check–so everyone gets a booster. If you are one of the individuals who needs the booster to mount a protective response, you won’t be protected for 10-14 days after the booster shot. So this patient, like the ones in the news, got caught in the “window” before the full response was mounted. It’s possibly the vaccine will help take the edge off and make severe disease less likely, but no one really knows for sure. And again, some patients, even with the booster, will not mount a protective immune response to the vaccine and will still be capable of catching COVID, even 14+ days after the booster shot. With enough people recovered or vaccinated though, herd immunity will eliminate their risk over time as the virus can no longer find enough susceptible hosts left to make its way over to a person whom the vaccine does not work for.

–There have been a couple recent papers looking at the cost and benefits of lockdowns. The first comes from John Ioannidis at Stanford and finds the implementing ANY non-pharmaceutical intervention (social distancing of ANY kind) was associated with a reduction in growth of new cases. But, more restrictive forms of social distancing, up to and including lockdown, did not demonstrate a benefit over regions implementing less restrictive forms of social distancing.

Again, it’s an interesting idea, but these studies are difficult to impossible to do much with, because of the potential for confounding variables everywhere in them. What it shows is that the restrictions put in place were largely a political choice; political choices varied; enforcement, demographics and duration undoubtedly varied; but that there is no obvious benefit to long sustained lockdowns.

Which, I think, the Black Death Choose Your Own Adventure should have told us.

Another publication of the intuitive comes to us from the National Bureau of Economic Research, which found that during lockdowns, other causes of death tended to increase. In particular, what they called “deaths of despair,” or suicide and overdose. Which again is why these public health calls are a game of pick your poison, with data at best helping you make a more educated guess. Do you risk a hospital system overrun by COVID and deaths from “bed’s taken” by not shutting down, or do you lockdown hard and trade deaths of despair for deaths from pandemic and health care system overrun?

Neither option is a great one. And once you have made your choice in pandemic, there is no way to know what would have really happened had you gone the other way.

You’ll likely see more post-mortems like this. Just remember, none of them are conclusive and you will undoubtedly be able to massage the data, or find some one massaging some data, in a way that favors the choice you would have made.

–Lastly, on the social side, thanks to everyone who reached out on the Podcast about ideas to corral the companies whose business model is exploiting your attention.

I didn’t plan it, but what was interesting was that I had inquiries from both sides of the political spectrum. As divided as the country seems, at least from my small sample size, everyone can agree that social media companies, in particular, are fostering that divide rather than helping it.

Maybe the middle starts there?

–Your chances of catching coronavirus remain high, but falling in many places throughout the world.

<Paladin>