“Remember, remember the 5th of November

The Gunpowder Treason and Plot

I know of no reason

Why the Gunpowder Treason

Should ever be forgot…”

Here’s hoping you brought your penny for the Guy…

Ebola Update:

–Nothing from the WHO in the last two weeks, but scans of available news reports suggest no new cases. If that holds through early next week, the WHO will hit the 42 day marker to officially close out the current outbreak. Again, I will be monitoring juuuuust a little longer since they know they have contact chains they don’t have complete tracing on still. The other big news in Ebola is that researchers in the US found antibodies to Ebola in patients as early as 2018, suggesting the virus had been circulating on the OTHER side of the DRC from the current outbreak long before the outbreak there was recognized in 2019. Not clear if this suggests there is variability in severity of Ebola disease (which would be new–its attack rate for severe hemorrhagic fever is believed to be quite high), or if recognition of concerning symptoms was lacking. But it raises the possibility that those poorly traced contact chains in the existing outbreak could still be simmering, either in the Equateur province or, if an infected contact made it out of the zone, someplace else entirely. In short, don’t be surprised when Ebola pops up again. However, I would remind you that returns from the current outbreak in terms of vaccination and treatment are promising for fast containment–once the next outbreak is recognized.

No word on if Ebola was traveling back in time to trigger 2018 antibodies, and oddly enough, have not heard much lately from that lady in “Plandemic.”

Coronavirus:

–Speaking of pandemics, the ‘Rona is running rampant worldwide still. Europe is taking it especially hard, and more at least local or watered down lockdowns are being announced on the continent. That said, the US has not been slouching either. Activity remains concentrated in the Midwest, and probably will be for a few more weeks. In the Indiana experience, activity is becoming more widespread as sheer force of numbers of new infections are finding pockets even in Indianapolis and its suburbs, which had been spared. Now, new cases in Indy and the ‘burbs are similar to the new cases in New York, in that the rate of lift off is nowhere near what it was in March-May, but is definitely higher than the previous baseline.

But Indiana has set new records for new single day infections for a couple weeks now. Positivity rate is just below what it was in March-May, and although vastly more tests are being done, you are still catching a lot of disease. I do think this closer to the true burden of SARS-CoV-2, as more people take advantage of testing availability to get tested even when they probably didn’t need to (i.e. were asymptomatic) than we saw in March-May, when testing was more limited to those with definite symptoms. There are rumblings of rationing of testing reagents again, as the nationwide volume of tests marches higher, and I just saw a headline that N95s are getting in shorter supply again.

While hospitalization rate as % of confirmed cases is going down (SARS-CoV-2 was doing a better job of hospitalizing folks in March-May), the sheer number of cases continues to occupy hospital beds. Indiana is one of something like 11 states with new records in SARS-CoV-2 bed occupancy. Death rates are going up, but still not quite to March-May yet, again consistent with the highly infectious, but perhaps less severe strain doing most of this damage. Although I have not heard of swamped hospitals yet, I am sure some are pulling out contingency plans, at least here.

The current disease activity has come close to home as well. One of the teachers at one of the area Catholic schools lost a protracted battle to COVID complications (yes, this teacher had a couple of risk factors for more severe disease before you ask). My son was also put on quarantine by his school, as one of his buddies apparently has been out with cold/flu symptoms since last Wednesday, got tested over the weekend, and popped positive. My son was identified as a frequent enough playground contact with the kid that we have to keep home and isolated.

My son is perfectly fine, before you ask. Again, he’s in one of the least risky demographics for SARS-CoV-2. In fact, he is literally bouncing around the kitchen as I speak and on the day we were told he would have to be quarantined, he was already at the tail end of that 2-5 day window post exposure when most patients who get symptoms will start to have them. He’s never had anything approaching symptoms of COVID. But we have to keep him home for 14 days. Interestingly, no restrictions on my daughter, who goes to the same school–but was not in contact with the kid who got sick. Now, the school did kind of hang out there that it was 14 days from when the sick kid was last in school or “you could get him tested.”

So, let me ask the question now IMMEDIATELY on your minds: Did you get your son tested?

Nope!

He doesn’t have symptoms. Remember the couple talks we have had about the Golden Rule of Medical Testing: never order the test if the result does not change what you do? What would change if we got the test done on him?

If he’s positive, we would keep him at home on virtual learning until he was not a risk to infect others, and watch for symptoms in him (and us)…

…which you might recognize as “what we already doing even WITHOUT the test.”

If he’s negative, well, we -might- be able to argue him back in to school a day or two earlier. But, as we mentioned, the test is less sensitive in asymptomatic patients. How much less sensitive we don’t really know. But a negative test doesn’t prove the virus isn’t somewhere in his respiratory tract–it just proves that the swab didn’t find any right then. We can work around the inconvenience of virtual learning for a few days–we have some practice from earlier this year. Why put a happy healthy first grader through a NP swab just to buy an extra day or two, at best, of back to in person school?

We are also absolutely not getting everyone else in the family tested. Again, no one has symptoms. There is no guarantee my son was even exposed to an infectious dose, and has then brought it home to us. We are contacts of a contact at best right now. If he had brought it home to us, well, we too have exited the window where most patients, if they are going to get symptoms, tend to get them. We still follow social distancing precautions as they are set up wherever we go. A test would not change what we do at this point, and, I still cannot stress this enough, the PCR tests are designed for, and most clinically accurate in, the setting of a patient WITH symptoms. If you don’t have symptoms, and the result doesn’t change what you do, you don’t pass the Golden Rule of Medical Testing.

–In other news, more out that I cannot comment on:

Regeneron had to halt a study of their antibody cocktail for SARS-CoV-2 in a late phase study in patients already hospitalized with severe disease.

You might want to review the section from last week on “things I cannot comment on” if that is a surprise to you.

Again, thank you for your understanding.

–Next big story is pretty late breaking–first headline I saw on it was yesterday. Denmark is reporting that SARS-CoV-2 spread to minks, which are apparently farmed there. This mink variant spread back to at least 12 people Denmark knows about, but has a mutation (no more details than that, unfortunately) that makes Denmark health authorities worried that the strain may present a challenge to current vaccination programs. In short, these 12 patients had a less robust response with antibodies than would be expected for SARS-CoV-2. As a result, Denmark plans to cull something like 17 million minks in the country to prevent spread of this variant.

Unfortunately, this raises a lot more questions than answers. For example, it’s not clear how severe the disease was in the 12 people who got it. Which is important, because it’s not clear if they were given antibodies, either from convalescent plasma or some of the therapeutic antibodies in clinical studies, or just had a less robust or undetectable antibody response as their disease progressed. But, as we have mentioned and as has been published, the LESS symptoms you have, the LESS likely antibodies are to be detected. If these were relatively asymptomatic or mildly symptomatic patients, NOT finding a whole lot of antibodies, especially in only 12 patients, might not be that much of a surprise.

Plus, I don’t even know if they even LOOKED at T-cell response in these patients. As we have mentioned, all the vaccines that have been reporting recently are showing strong T-cell responses too–in some cases, prior to seeing antibody responses. We know the T-cell response is durable (in fact, a small study in the UK this week released results showing that T-cell response was still detectable at least 6 months after infection and even after antibody responses had waned). We also have reviewed papers with evidence that a T-cell heavy response is the more protective response to SARS-CoV-2 anyways. That’s a very important piece of information that is completely absent in the reports on this culling in Denmark.

Hard to say if they are doing the culling from an abundance of caution, given it is SARS-CoV-2, and they have a chance to contain the beach head, or if this really is a variant that can get around current vaccine efforts with less robust antibody and T-cell immune responses. Also unclear how clinically significant the infection with this strain was in the 12 known patients with it, and that’s a pretty important detail too, even if 12 is probably not enough to know for sure if it as dangerous, more dangerous, or less dangerous than the currently circulating strains.

You can find one of the better (but still detail light) articles on the mink strain in Denmark here.

–In the world of COVID testing, some of the antigen tests have been putting up better numbers. For example, there are publication results on a new entry currently available in Europe here. They looked at 412 symptomatic patients and found 100% specificity for their test versus PCR for SARS-CoV-2, which is to say that when the antigen test said it was positive for SARS-CoV-2, it really WAS SARS-CoV-2 present. The chief concern for the antigen tests is cross-reactivity with other, similar, and very common viruses, especially SARS-CoV-2’s coronavirus cousins. Now, that said, it would have been nice to see comparison to a broader respiratory panel, and also at least in vitro results versus other known coronaviruses for specificity. Again, this test is also not available in the US. If these kind of results hold up, it could very well be a useful rapid screen for SARS-CoV-2.

–That said, the FDA issued a warning this week AGAINST a lot of the rapid antigen tests, precisely for the false positive problem–they are most likely calling other viruses that are present, which are not SARS-CoV-2, SARS-CoV-2. You can find the Reuters write up here.

–Brief social commentary: Dawned on me today as headlines about the counts and recounts and court challenges, and are there irregularities and no there are not and did dead people vote not really sure, and courts making decisions oh, whoops, that headline from a big name mainstream media organization on that court decision was wrong…

…I have no idea what is going on in the states still counting votes. No idea at all. There is rumor everywhere, and no one, and I mean absolutely no one, reliable enough to give a clear answer on if there are issues, what those issues are, and what the resolution will be.

That lack of transparency and trust is a huge problem, and both of those died on, or even before, Jeffrey Epstein’s “suicide” (speaking of which, any updates on investigation of the videos, photos, and black book? Ever get that interview with Prince Andrew? What happened to the guards–were they ever interviewed by anyone in media on the record?).

Half of this country will never accept the Presidential election result as legitimate. Where, and how, do we go from here?

–And you thought 2020 couldn’t get any better!

–Your chances of catching SARS-CoV-2 are equivalent to the chances you thought I was going to make some kind of political joke here.

–Your chances of catching Ebola are equivalent to the chances I did.