February 22, 2020
This week, the CDC stated that people who have received the authorized COVID-19 vaccines do not need to quarantine after exposure to a person with COVID-19 assuming they meet all of the following criteria:
1) They've received both vaccine doses, and at least 2 weeks have passed since the second dose
2) They are within 3 months of their last dose
3) They've not developed COVID-19 symptoms since their exposure
This is a welcome change for everyone in the work environment.
Here is a link to a Scientific American Article on the mutations in circulation. (Reardon S. 2021) Also see #9 below for an excellent report on the variants.
Now to the Quick hits
1) More evidence that despite waning antibody responses to SARS2/COVID19 over time, post infected individuals have robust T cell SARS2 specific immunity in place. The authors state: "SARS-CoV-2-specific T cell immunity conferred by poly functional, mainly interferon-γ-secreting CD4+ T cells remained stable throughout convalescence, whereas humoral responses declined. Immune responses toward huCoV in RCs with mild disease and strong cellular SARS-CoV-2 T cell reactivity imply a protective role of pre-existing immunity against huCoV." (Bonifacius et. al. 2021)
This adds to a large body of evidence that we cannot rely solely on SARS2 specific antibodies as the only source of immune competency against the virus. The immune system is dynamic and learned as we are learning. Individuals that get reinfected repeatedly or soon after an infection likely have defects in T cell and interferon activity. However, reinfections are rare. See #8.
2) Teachers and risk - Risk of hospitalization with COVID-19 among teachers compared to healthcare workers and other working-age adults. A nationwide case-control study - This is the title of a new study in the Journal MedRxIV this month. The conclusion was noted that teachers are not at increased risk for a COVID19 hospitalization or death compared to similar aged and risk stratified workers. They found that before and after schools reopened, there was no increase in COVID hospitalization and the incidence remained below 1% for teachers which is the same as the general population. (Fenton et. al. 2021) Interestingly, teachers were actually at lower risk for severe COVID19 disease likely due to historical exposure to other coronaviruses in the past. Read the article and especially the discussion.
The number of studies out now has tipped the scales toward in person learning beyond a doubt.
Opinion time:
We need balance. The virtual school experiment was a necessary step in the spring of 2020 and maybe even the fall as data was inconclusive and spotty. That is no longer the case. We have lots of data. The virtual experiment was a failure for many, maybe most, especially for the most at risk. In Mecklenburg County, North Carolina alone, over 10,000 children are unaccounted for with regards to school. That is 10,000 beautiful children who are lost to learning, school mental health safety, social nourishment and so much more. Multiply this number by the number of counties nationally and we have a second maybe larger pandemic that is growing fast and furious with potentially far reaching and more damaging ramifications for the future.
3) Israeli data is hinting that the Pfizer vaccine appears to be reducing transmission of the SARS2 virus. "Our estimate suggests that vaccination reduces the viral load by 1.6x to 20x in individuals who are positive for SARS-CoV-2. This estimate might improve after more individuals receive the second dose. Taken together, our findings indicate vaccination is not only important for individual’s protection but can reduce transmission."(Petter et. al. 2021) The authors noted that vaccinated individuals were less likely to have an elevated viral load if they converted to a positive COVID status in the future and therefore less likely to transmit the virus to others. Early results are also showing that the vaccine is very effective with a very limited number of individuals getting COVID and no reported deaths to date post vaccination. 16 out of over 700,000 vaccinated individuals needed hospital care from COVID after being fully vaccinated. That is 2/1000th of a percent risk. This is a really great number moving forward. At that rate, the COVID nightmare will come to a faster resolution than feared. (Holmes Guardian 2021))(Cohen J. 2021)
The overall take away from the Israeli data is that we are hurtling toward a recovery from the pandemic as the vaccine will most definitely reduce hospitalization and death to very low numbers leaving hospitals well suited to handle the muted case volume. The infected transmission volume will decrease as well making case numbers drops further adding to the severe case reductions.
4) Therefore, based on the current data, when will the pandemic end in the US and will it be endemic? I suspect that by the beginning of summer, it will be over or at least close to over as more than 50% of America will be vaccinated and many more will have been infected and recovered. That is my sincere educated guess after a year of analysis. The wild card will be whether a new variant makes the vaccine less effective.
However, I believe that it is now and will be an endemic virus for the foreseeable future. We will all have SARS2 immunity for 1 to 2 years or maybe longer after each infection or vaccination only to have to get another vaccine or get reinfected naturally at some point after the immunity wanes. The time course of the loss of antibody activity, B cell memory and T cell memory will be followed closely after both a vaccination and/or natural immunity. As those studies roll out, we will have much better data points from which to understand the truth of the time course of things.
The wild card of vaccine efficacy will likely play out this year. If the SARS2 virus is able to mutate rapidly akin to an influenza drift, then the vaccine will require updates yearly. Hopefully, this will not come to pass. If it does not, then we should get a few years out of a vaccination. The B.1.351 variant will be the first true test against the current mRNA vaccines. If it can bypass the vaccine, a booster will surely be on the way this fall. Hopefully, we do not see a booster in our future.
Educated guessing will continue for a while.
5) The new genetic variant of SARS2 B.1.1.7 looks to be slightly more deadly. (New York Times Article) Early estimates are raising the death risk by around 20% from previous numbers for the elderly that are infected. (Mallapaty S. 2021) The virus appears to spread much faster than the original SARS2 version. Good news is that the mRNA vaccines appear to be working well against it. The two other global variants have limited data and are not circulating well in the US yet. The South African variant B.1.351 is in South Carolina in limited volume. Watching closely.
6) More on Masks - From the European Union Report, we have the following recommendations:
"Although the evidence for the use of medical face masks in the community to prevent COVID-19 is limited, face masks should be considered as a non-pharmaceutical intervention in combination with other measures as part of efforts to control the COVID-19 pandemic.
Taking into account the available evidence, the transmission characteristics of SARS-CoV-2, the feasibility and potential harms associated with the use of various types of face masks, the following options are proposed:
• In areas with community transmission of COVID-19, wearing a medical or non-medical face mask is recommended in confined public spaces and can be considered in crowded outdoor settings.
• For people vulnerable to severe COVID-19, such as the elderly or those with underlying medical conditions, the use of medical face masks is recommended as a means of personal protection in the above-mentioned settings.
• In households, the use of medical face masks is recommended for people with symptoms of COVID-19 or confirmed COVID-19 and for the people who share their household.
• Based on the assessment of the available scientific evidence, no recommendation can be made on the preferred use of medical or non-medical face masks in the community.
• When non-medical face masks are used, it is advisable that masks that comply with available guidelines for filtration efficacy and breathability are preferred."
Although many disregard the benefit of masking, our in clinic experience has been positive with regards to mask effectiveness and COVID transmission. This is experience only and not a scientific study. We have seen many many children with positive COVID status and not a single known in clinic transmission over the entire pandemic.
7) Emergency Room usage is up significantly in the 2020 time frame compared to the two previous years for drug over dose, violence and mental health. (Holland et. al. 2021) While it is not as drastic as I had expected, it is still a cautionary tale of what has happened and what may happen if we do not get a grip on in person schooling, social outlets, mental health safety nets and nutrition for the most vulnerable among us.
This pandemic has shown us in the most aggressive ways how critical primary school is to societal function. How important teaching and teachers are. How important it is for our elected leaders to be bold and keep children healthy through quality nutrition, teacher support, quality buildings, and so much more. Let us take this pandemic as a wake up call for home grown supply chains for all things medical as well as all things educational. A society that does not put its children's health and learning at the forefront of decision making is doomed to suffer decades to strife as these same children struggle with health and a lack of education over time.
On that note. What has the lack of in person quality education left in its wake? Let us start with High School heading to college. From Science, we see: "Data from the National Student Clearinghouse show that first-time enrollment at colleges and universities in the United States decreased by 13% from fall 2019 to fall 2020. At community colleges, the traditional gateway for disadvantaged students, freshman enrollment plunged 19%. Drops were largest among Black (18.7%), Hispanic (19.9%), and Native American (23.2%) students." (Avery et. al. 2020) This is a disaster for society at large as education is the key to rising out of poverty and staying healthy. According to the Brookings institution, primary school children lost significant ground compared to the prior years students in mathematics.
Looking at a December 2020 paper from McKinsey and Company, we see daunting figures for learning loss in primary school especially among minority groups. The education gap is widening and that is not acceptable. In person learning was less common in the past year for minority students and technology capabilities were weaker in the virtual learning sphere. (Dorn et. al. 2020)
8) Austrian Data regarding reinfection post COVID is very very reassuring. They recorded 40 tentative re-infections in 14,840 COVID-19 survivors. That is very low rate of reinfection at 0.26%. The reinfections were not associated with a bad outcome. (Pilz et. al. 2021)
This is great news for the previously infected. It is highly likely that despite waning antibodies against SARS2, survivors have functional memory T and B cells that are preventing reinfection for most,
9) In an excellent report called the Rise of the Variants by Otello Stampacchia, we see a cogent analysis of the variant dilemma.I encourage everyone to read it. Here is the link.
Dr. M
Reardon Scientific American
AAP Numbers
Bonifacius Immunity
Fenton MedRxIV
Allen Washington Post
Petter MedRxIV
Holmes Guardian
Cohen Science Magazine
Mallapaty Nature
European Union Report
Linas Vox
Lewis Nature
Holland JAMA Psychiatry
Avery Science
Brookings Paper
Dorn McKinsey Paper
Pilz MedRxIV
Stampacchia Report
Phillips Nature
