I have not posted for a while on this thread. The main reason is that I had no clue where we were headed like everyone else. The beginning of the pandemic could, and was, projected with some accuracy.
The last time I posted I was of the opinion we were transitioning to the endemic phase. I was sure wrong about that, and so were most. Unfortunately what has befallen us is an evolving pandemic. This presents huge challenges, and a high degree of uncertainty.
The reason for this, is that this virus has evolved rapidly, and developed highly significant immune invasion from both natural infection and vaccine induced immunity. At first each variant appeared to trade virulence for transmissibility. This is the usual course of events. However B.1.1.529 shows not only the most escape but seems to be causing more prolonged illness, and may be more serious disease. The B.1.5 variants are dominant now. The bad news is that recurrent infections are now being seen after 90 days from natural infection and vaccination.
The good news is that most patients are staying out of hospital, although this is slowly trending upwards. ICU cases are on the low side and relatively stable. The gap between the vaccinated and unvaccinated has narrowed, because virtually everyone has encountered this virus now. So people either got vaccinated the easy way or the hard way. This infection has resulted in a significant increase in myocardial infarction and stroke. But there is a small but significant decrease in that incidence in those who have had at least three doses of vaccine.
The other good news is that there are better treatments with some caveats. These include better antibody treatments and oral anti virals.
Recurrent infections do increase the incidence of long Covid. About 1 in 8 patients now seem to experience long Covid in one form or another. This has great economic implications.
Now I will change gear and tell you of our personal experience. There are generally broadly applicable lessons in this.
My wife who has no co-morbidities, attended her bridge group 15 days ago. An attendee was coughing, and told members not to worry as he had tested negative for Covid. Well within 48 hours 7 attendees developed Covid. He tested positive three days later. My wife developed a slight sore throat the evening of the next day.
The next day she was significantly unwell, with sore throat and bad cough. She was negative by antigen test, but went for a PCR. She was negative the next day by antigen, but was notified her PCR was positive the next day and her antigen test turned positive that day. She has had a rough course, with severe cough being the prominent symptom. Her sore throat passed fairly quickly, but she still has some nasal congestion and a severe cough. Her first negative antigen test was the eleventh day and has remained negative since. This is now her fifteenth day. I have remained free of symptoms and my antigen tests have been persistently negative. We now know of a total of nine individuals who were infected from that one proband. There are almost certainly more. All of these we know of were fully vaccinated. Both my wife and I have had four doses of the Moderna vaccine. We both had our last immunizations mid March. So my wife was about four and a half months post her fourth vaccination. So, that corroborates that this variant has highly significant vaccine escape after 90 days. We have followed others who were infected and they have had a similar relatively severe course.
This brings up the use of Paxlovid. The advice was wife received from the local health provider was against taking the drug, but would provide it if she insisted. The reason seemed reasonable at the time. The first was that patients taking the drug, all had severe diarrhea during the course. I should add our next door neighbors, who are in their thirties and have a ten month old son, had Covid-around a month ago, despite full vaccination. They took Paxlovid, but not the baby. They both had quite a severe course, especially the baby. Their course was significantly shorter than my wife's. They did have severe diarrhea.
The other reason that the advice against Paxlovid, was that my wife is on medication where there were significant drug interactions with Paxlovid. I would have also, if I needed the drug. So her drug regime would have needed significant modification. However, hard data as to how this should be done is virtually non existent. I am not aware of any pharmokinetic studies giving hard data on how to make these modifications. The fact remains though, that Paxlovid does seem to shorten symptom durations, but from what I can find, rebound viral shedding of the type suffered by Dr. Fauci and President Biden are actually common and probably the rule.
This not withstanding, on yesterday's JAMA Covid update, the recommendation to proscribe Paxlovid, for those over 50 was strong. But I return to the problem, that data on how to do that safely is sparse. I can well understand the reluctance of prescribers to prescribe this drug without a moments thought.
So those are my observations on actually seeing this infection up close.
Where do we go from here? This is were it gets even murkier. I feel they are good reasons for significant concern. My biggest concern is co-infections this winter. The next is the rapid, and uncertain evolution of this virus, especially its immune evasion, both natural and by vaccination. At this time I am convinced both are highly significant and of great concern. The antigenic drift is so fast we will never be able to modify and produce vaccines fast enough to keep pace. Even if we could, is it really practical to immunize the whole population every three months, to say nothing of the cost? The hope is a universal Sars vaccine. If this is possible and could be made available that probably would end the pandemic, until that point I see no end to this, just an evolving pandemic that will continue to bring unpleasant surprise. It would seem any prospect of a universal vaccine is three years away at least.
The next concern is data showing that long Covid affects are larger percentage of individuals the more often they have a symptomatic case. Long Covid by the most reliable estimates seem to affect about one in eight individuals contracting Covid. This has enormous economic implications. There was recent paper showing a small increase in heart attack and stroke in survivors over 50. There was a small silver lining here, showing that full vaccination reduced this risk of stroke and heart attack, by a small but significant margin. These issues alone show that we can not advise individuals not to avoid infection and symptomatic people to isolate themselves. Also public health have not done enough to inform people that there is a 48 to 72 hour gap from symptoms to the home antigen test turning positive and that they are highly infectious during this period. So the advice should be it isolate for 72 hours if you have any upper, or lower respiratory infection and have at least two negative antigen tests. Again this issue has significant economic impact.
The final issue is this current winter and co-infections, especially influenza. We know that co-infection with Covid and influenza is bad. Lock down and isolation has also reduced the spread of all other respiratory viruses and resulted in a lowering of herd immunity to these infections. Australia has had a bad influenza season in this year's southern winter. So I think it is vitally important everyone gets influenza vaccination starting next next month, or when this year's influenza vaccine becomes available. Also follow guidelines for the uptake of any new polyvalent Covid vaccines, that become available. It is uncertain when this will be. Projections are anywhere from the end of next month to the end of December.
I wish I had better news, but that is the way I see it. People are done with Covid, but Covid is not done with us!
