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

Transmissibility: All the +

Immune Evasiveness: All the +

Vaccine Effectiveness: Check (for hospitalization)

Also as a reminder:

Coronavirus Update–

–To start with, about obviously…

I cannot comment on the FDA’s decision to suspend the EUA for Eli Lilly and Regeneron monoclonal antibody cocktails for treatment of early COVID again (they did this right around Christmas too) due to concerns raised by in vitro experiments that suggest these antibody cocktails may be less effective against omicron. They are believed to still be effective against delta.

There is a GSK and Vir biotechnology antibody that does inhibit omicron available on the market. You can read more about the FDA decision and GSK/Vir’s antibody here. You will also see that the Lilly PR folks, when asked for comment on the FDA decision, pointed to a previous statement in December about another antibody (bebtelovimab) currently under development that inhibits omicron. You can find that statement here.

Again, thank you for your understanding.

–In a totally, absolutely, and utterly unrelated link, you can find our previous discussion of how the current most active strain of COVID is determined and discussion of early therapy in the context of our review of the Dr. Malone interview on the Joe Rogan Experience, where this was touched on in the less conspiracy fueled portions of the episode.

–Around the horn…

In the US, overall cases continue to fall, although again your results are going to vary heavily on your geography at the moment. Cases are falling rapidly up and down the East Coast in particular. Indiana’s cases have dropped precipitously this week, as has testing volume. Hospital census of COVID-19 patients is coming down as well in Indiana, although admissions remain flat (and still far below what would be expected by the new case load). Out west should continue to see a little more activity for another week or two. In short, the omicron wave is peaking right about where we said it would (end of this month). Leading indicators of COVID activity tracked by Carnegie Mellon at their COVIDcast Dashboard (Google searches for symptoms and chief complaint of COVID like symptoms and related doctor visits) are showing significant drops this week as well.

Even Dr. Fauci expects the omicron wave to be abating in the US by the end of February. Again worth noting that hospitalizations, although still brisk via sheer force of numbers and continued (if dwindling) delta activity, are far lower on an infection per infection basis.

China, on the other hand, continues to see new cases (again, no surprise as we covered last week). However, Beijing itself is the new hotspot. This is less than ideal as the Olympics are set to kick off in Beijing next week. The (short) socioeconomic take on this is below, but you can pretty much guess by now, at this point in the pandemic.

The UK cases have stabilized. This appears to be activity mostly in the less densely populated counties around London, and no other real clear associations that I can find. My best guess is this is just a slight rebound as omicron finishes working its way through, especially as Boris Johnson lifted a bunch of restrictions to defuse anger about his parties breaking all of those restrictions in response to the changing epidemiology.

Denmark has lifted restrictions, even though its new cases are parabolic as omicron hits the big wave there. Japan and India are also seeing massively elevated cases, which, around the Olympics starting next week in China, is probably a bad portent for omicron hitting East Asia in earnest at a bad time. Again, more on the socioencomics of this as relates to China below.

South Africa, the other “lead omicron indicator” nation, is back to mild sustained activity, with a Rt <1, suggesting cases will continue to dwindle for a little while.

–In other actual data, a couple papers from the CDC hit this week about boosters versus symptoms/hospitalization in the omicron wave. One was published in the CDC’s own journal, the MMWR. It covered hospitalization, but I’m not going to link it because frankly, I don’t find it particularly convincing. They didn’t sequence to know what variant any of the subjects actually had, and the calculation of efficacy is based on proportion of positive COVID cases among unvaccinated versus 2 doses more than 6 months ago (booster eligible, but unboosted) versus boosted patients and their model of how many people are unvaccinated vs booster eligible vs. boosted in the general population. They claim that in the omicron wave, for example (early omicron, where there was still a lot of delta around), that the booster restores vaccine effectiveness from 57% (2 dose vaccine >6 months ago) to 90%+ with the booster. But in their raw data, three times as many people with the booster were hospitalized with COVID versus those with just 2 doses who had not gotten their booster yet. The only way to get those vaccine numbers is to have the model assume a much, much higher proportion of the general population has already got their booster shot than the headlines lamenting the “stalled” booster efforts in the US I have been seeing all week. Without more detail on their model, I don’t know how they came to that conclusion. Further, the effectiveness of 2 doses with no booster was 81% in the delta wave–but somehow dropped to 57% in the omicron wave, despite the CDC and everyone else now knowing that omicron is significantly less likely to hospitalize than delta. That discrepancy was not discussed in this paper.

On the other hand though, the CDC’s paper in JAMA was much better executed. You can find it here. I’m not thrilled that sequencing was not done to confirm which variant was causing the particular positive test, but their evidence is overall pretty good for a booster reducing the likelihood of symptoms in association with a positive test. Timing of booster was not investigated though, and like we have discussed before, there are strong anecdotal reasons to suggest the impact of the booster may be short lived. Regardless, symptomatic infection was not uncommon with vaccine or booster, but certainly higher for those without a vaccine. Shocking no one reading this, I am sure. You doubtless know this from personal experience and your own friends/family right now. But the booster did reduce the chances a bit. Presumably, by reducing chances of symptomatic infection it reduces the chance of hospitalization as well. How much over just 2 doses of the vaccine I think remains unclear, but there is probably some small to moderate effect there.

And again, for reasons inexplicable, no one seems to be looking at spike antibody titers prospectively to see if there is, indeed, a level where the risk of symptomatic infection or hospitalization or worse goes down to help better define for whom and when a booster is indicated.

Socioeconomic:

–Tangentially connected I know, but <sigh>… Poor damn Neil Young. You probably saw the headlines this week where Neil Young demanded that Spotify choose between continuing to host his music on the platform and continuing to host Joe Rogan’s podcast on the platform, as he was concerned about Joe Rogan’s podcast spreading “misinformation” about COVID.

Spotify glanced at the demographics and dollars involved and said, and I quote, “bet.”

To translate that for those of you older than 25, Spotify empathized with Lynard Skynard and decided that Spotify didn’t need Neil Young ’round anyhow either.

Yes, the “Sweet Home Alabama”/”Southern Man” connection and Joe Rogan’s famous UFC commenting gig have spawned many a meme about this decision, which you have probably seen as well.

Neil, to me, is the songwriter’s songwriter–which is to say he is that rare artist where the covers of his songs are frequently way better than his original. For example, just go to YouTube and pick any of Pearl Jam’s live covers of “Rockin’ In the Free World”–and even those performances where Eddie is drunk and/or high just obliterate the original. And then realize that Pearl Jam showed up -just this week- in a clickbait-y article to tell the kids what their favorite, and I quote the article directly, “Sad Dad Band” says about them.

Now we do some brutally depressing math. Music like Pearl Jam, which was current in the late 1990s-early 2000s, is ~20-30 years old. That’s like listening to “classics” from the 60s and 70s on the way to the Pearl Jam concert back in the day.

And that, my friends, is when most of poor damn Neil Young’s catalog was written.

All jokes aside, the broader point here speaks to the Bonfire of the Institutional Credibilities. The movement to deplatform and silence, to censor, those espousing, or hearing out, “misinformation” about COVID is a sad commentary in its own right. After Dr. Fauci lied about the masks early on, gloated over doing so, he sacrificed the integrity of the medical/scientific leadership that had made him its public face. That he was not fired, and instead has gone on to other mixed messaging gaffes between the NIH, the CDC etc., cost a lot of credibility as well. Then you politicized vaccination, with the enormous unintended consequences as we have discussed, and on, and on.

The problem now is that the honesty and communication for the medical/scientific leadership writ large has been so poor that a significant percentage of the population is simply tuning them out. The many sins of omission and commission by that failed leadership have torched their credibility utterly with many people. Are we surprised by that? Is that not the known and predictable consequence when integrity and honesty are breached? And so now they are left with the last recourse of the scoundrel, turning to censor whatever they define as “misinformation.” There is a lot to disagree with Dr. Malone about–I think he was hyperbolic in several instances, and you can re-read my review on that podcast. But he too has credibility–and in places, there is some data and science on his side. It’s not wall to wall misinformation, and the rush to ban speech is, in itself, a tacit admission that the current medical/scientific leadership has completely lost its credibility.

If they had not destroyed their credibility with a sizeable swath of the population, it wouldn’t matter who Joe Rogan had on the podcast. The authority and wisdom of the leaders of the NIH/CDC/FDA etc. would be enough, and only the most conspiracy minded would NOT be turning to them. Instead, they have sowed the wind (especially via politicization of COVID), and this is the whirlwind they reap.

Clumsy attempts at censorship either. Google the “Barbara Streisand Effect” if there is any doubt of that. Instead, we invite all the attendant evils of censorship on top of the current integrity and credibility problem.

The way to overcome poor ideas and poor speech is with better ideas and better speech, communicated in a way that the other party will listen, and from a baseline of true mutual respect. That takes patience, integrity and honesty, all virtues that have not been evidenced in great quantity by leaders at many levels along this pandemic trip. But also before the pandemic ever hit, and at this rate, will probably continue this trajectory for awhile after too. You cannot lecture the rubes or own the libs and expect to see real change of hearts and minds. Human nature doesn’t work like that. All you will do instead is harden schismogenesis.

And now poor damn Neil has paid the price, learning in an unfortunately public way that the name has died before the man.

–The Deadline reporter interviewing Bill Maher about the 20th year of his “Politically Incorrect” show was surprised by some of Bill’s answers about COVID (Deadline even fact checked one in article, and it’s a fair correction). You can, and should, read them here. He is explicitly describing the bonfire of the medical/scientific leadership’s credibility (and by unfair extension, you too my fellow doctors).

–Bill tangentially scores on another perplexing silence through this pandemic. Treatment is one thing, he says, and you cannot help age and some of the underlying conditions that are known risk factors for COVID. But some of the other big ones, obesity especially, are modifiable. They also increase risks for other known risk factors, like hypertension and diabetes. Bill goes so far as to essentially say that those who have not been openly advocating for a healthier baseline for the population coming out of this “have blood on their hands.” I am not sure I would go quite that far, but there is certainly an opportunity here to rise to the challenge of the pandemic and come out better, not only with greater mental and emotional fortitude and resilience, but physically better too. I have been contacted by readers looking to modify some of their risk factors. I’m happy to mention some things that have worked for me, and there are some other options you can discuss with your doctor as well. I also had a brief email exchange with some readers who work in health care insurance (trying to fix the problems there) about how to get folks to take healthier steps–although it seems many of the obvious ways to try have already been tried, and with less success than one would hope!

–Speaking of interesting new ideas to common healthcare problems, Mark Cuban opened his own low-cost online pharmacy for generics to explicitly remove some of the “middlemen” between the manufacturers and the patients. The cost savings can be eye opening. It doesn’t take insurance yet though– read why and more about it here.

–But back to the bonfire of medical/scientific institutional leadership’s credibility. Our South African correspondent reached out with some gems after we went to “press” last week. One was an editorial comment published in “The Lancet”, a highly cited British medical journal (and among the oldest):

“Scientists should be prepared to evaluate their own attitudes and approaches to the pandemic. For we have made mistakes too, and how we exit the pandemic and learn the lessons of our response depend on a fair accounting of our own successes and failures. Philip Ball, writing in The New Statesman, has described the “strange insouciance in the UK scientific community”, the unwillingness of scientific advisers to hold politicians accountable for poor decisions, a very British reluctance to speak out that quickly shades into fatal complicity. A liberal sprinkling of knighthoods and honours plays its part in dampening criticism. The response to omicron is a case study in error. On Dec 14, 2021, Dr Angelique Coetzee, a South African doctor with first-hand experience of managing patients infected with omicron, pointed out that the UK’s reaction “is out of all proportion to the risks posed by this variant”. Her message was clear: “I can reassure you that the symptoms presenting in those with Omicron are very, very mild compared with those we see with the far more dangerous Delta variant.” Coetzee explained that COVID-19 deaths in South Africa were not rising dramatically and nor was the average length of time people were in hospital. She suggested that “This huge overreaction is scaring people unnecessarily.” Her advice was ignored. Indeed, the UK Health Security Agency actually fuelled public fear by predicting 200 000 omicron infections daily. The result was our own version of the Paul–Fauci culture war. “It’s Boris versus the scientists”, proclaimed the front page of the Daily Mail on Dec 16, 2021. It took a month for the UK Health Security Agency to agree with the testimony of Coetzee that omicron caused a low severity of disease in adults.

An honest appraisal of the past 2 years of pandemic management might include the conclusion that from the very beginning there has been an over-reliance on mathematical modelling and too little emphasis on the experience of health workers on the front lines of care...

But now countries need to encourage a vigorous debate about a future and fairer vision for their societies. And scientists, clinicians, and public health practitioners should find their voice in this most important phase of the pandemic.” –Richard Horton, Editor-in-Chief of The Lancet, “Offline: COVID-19 as culture war”, 399:10322, p. 346, 22 Jan 2022

The rest is a description of politicization of COVID. But the cited section above, if it is not saying the unsaid part out loud about the credibility of the current leadership of the major medical/scientific institutions, I don’t know what is.

—Early innings, but something different, and hopefully better, will be coming out of the crucible.

I don’t think that will stop with just the medical/scientific institutions either.

–So on China’s continued new cases. I don’t expect the Olympics will be great for China’s numbers, and their “Zero COVID” policies will probably be challenged during and after the games, since they are too close to the start of the Olympics to call them off. Restrictions on fans, crowds, and a strict Olympic bubble are highly likely. The real fun will start if omicron gets rampant during and after the games, and China sticks to its “Zero COVID” guns. You already have significant port closures and delays, and that’s before the Lunar New Year next week, which is a major Chinese holiday and will see additional reductions in goods and transports as a lot of vacation gets taken in China. Throw some omicron fires onto the post-Olympics window for China, and, well, supply chain relief for anything made in China or using essential widgets that are either made in, or must pass through, China, is unlikely.

And the lead time on all of the ripples from those global supply disruptions will be a few months at least.

Again, I am no expert. But at least based on the effects from the lockdown period, and current levels of congestion at nearly every level of transport of goods and how quickly that has cleared, and my layman’s best guess is mid summer to early fall to clear this–assuming everything goes perfectly. I think in turn the inability to get goods and widgets to where they need to be (to make new goods) will continue to support a supply driven inflation through the early part of the year. You may even dip into recession if you can’t make enough new goods, and wage increases continue to be below the rise in inflation, meaning people can buy less stuff.

Now, my very non-expert understanding of economics tells me lower demand should in theory eventually even out the higher prices from reduced supply. But, this assumes the currency value remains constant, which is, uh, an open question given mixed plans around the world between easing and tightening money supply. And it’s a lagging effect anyways.

Regardless, this is the milieu into which this “Zero COVID policy” in China butterfly is going to flap its wings. The section at the end of that linked Bloomberg article subtitled “Raising Prices” is the most illuminating. You have the American dairy farmers associations warning of coming “milkflation” this week, as the total dairy herd has been thinned these past couple years. Farmers could not afford to feed the dairy cows, and so they were sent to market. Labor costs and feed costs continue to rise, and those are about to be passed on. The DC Homeland Security and Emergency Management agency was tweeting this past weekend to encourage residents to “take only what they need” as stock piling in advance of a snow storm was stressing already low inventory on shelves with the continued supply chain lags. The IMF cut global economic growth estimates for 2022, explicitly over persistent supply chain issues exacerbated by omicron/delta activity and COVID restrictions in many places in the world (but most probably especially China). In the same report, the IMF explicitly cautioned the US Federal Reserve on its tightening plan (to try to contain inflation); the US Federal Reserve at its meeting this week made it clear it intends to try to fight inflation this year. On the plus side, US GDP was revised upward, mostly due to consumer holiday spending, but also increased business investment (which, God willing, is moving supply chains closer to the consumer) and inventory building. Again, I’m not sure if that is just the total price of widgets, and thus NOT adjusted for inflation, or if they are actually managing to stock more total widgets. The latter helps out with inflation, as more supply should help alleviate the supply driven inflation everywhere right now. The former…not so much.

When I read stories like this, where the median supply of chips for US manufacturers has fallen from 40 days in 2019 to 5 days or less in 2022, I’m a little concerned it’s the former. Tesla’s stock got hammered because it highlighted continued supply chain issues like these chips that may restrict the total number of cars it can build.

Just more data points along the way.

As SARS-CoV-2 itself shifts (hopefully, finally) from pandemic to endemic this year, it is the lagging socioeconomic effects that will be the biggest challenge in 2022.

–The camp section of Dr. Viktor Frankl’s “Man’s Search for Meaning” is worth a read, if you have not read it before, or have not in awhile.

–During the Fed’s press conference, Federal Reserve Chairman Jerome Powell was asked “I’m wondering if you can talk to us about any metrics the Fed uses to assess how inflation affects different groups of Americans, especially lower income earners, and are you worried that the Fed underestimates or can’t effectively measure the effect of inflation on some of the most vulnerable households.”

Mr. Powell’s response was:

“I think the problem we’re talking about here is really that people who are living on fixed incomes, who are living paycheck to paycheck. They’re spending most or all of their…what they’re earning on food, gasoline, rent, heating, things like that. Basic necessities. So, inflation, right away, right away, forces people like that to make very difficult decisions. That’s really the point. I’m not aware of inflation literally falling more on different socioeconomic groups. That’s not the point. The point is some people are just really prone to suffer more.”

For what it’s worth, survey based estimates are that 54% of Americans lived paycheck to paycheck in 2021, regardless of age or income. Nearly 40% of those making more than $100,000 in salary were living paycheck to paycheck. Rising federal reserve interest rates will raise interest rates in general, including on adjustable rate loans, such as credit card APR or APY, and anyone who bought their home with an adjustable rate mortgage (which, thank God, are at record lows of new mortgages over the last couple years).

“The point is some people are just really prone to suffer more,” says the Federal Reserve Chair.

–Your chances of catching coronavirus many places in the world is equivalent to the chances you think I am going to mention that story about the escape of laboratory monkeys in transit through Pennsylvania when their truck was involved in a traffic accident.

After all, by now, you know the activities of the Army of the Bioterrorist Monkeys when you see it. Suffice to say, the right calls went out and the situation has been resolved–with extreme prejudice.

However, your chances to catch coronavirus in most places in the world this week are ACTUALLY equivalent to the chances of small moments of complete awesome–if you look for them…

<Paladin>