Lunchtime pandemic reading.
Standard disclaimer: this is a roundup of informative pieces I've read that interest me on the severity of the crisis and how to manage it. I am not a qualified medical expert in ANY sense; at best I am reasonably well-read laity. ALWAYS prioritize advice from qualified healthcare experts over some person on Facebook.
This is also available as an email newsletter at https://lunchtimepandemic.substack.com if you prefer the update in your inbox.
You are welcome to share this.
---
I had a discussion with a friend this morning who was asking under what circumstances visiting for the holidays could be made safe, or at least safer. Based on our current knowledge and science, it goes like this:
1. Anyone considering visiting should get tested, along with the holiday hosts. Any positive tests, and that person and their househould should not attend.
2. Isolate for 5 days prior to the test to make sure the test result is reliable.
3. When visiting, wear a mask at all time. DO NOT REMOVE YOUR MASK FOR ANY REASON.
4. Do not stay overnight.
5. Do not serve food or drink. Meet, exchange gifts, stay a while to talk, but do nothing that requires removing your mask.
6. Do not use mass transit (airplanes, trains, etc.) - drive in your own vehicle.
7. Do not attend if you need to make any stops along the way. Do not stop for gas, the restroom, etc. - from door to door, make sure you don't get out of your car.
8. Adhere to generally accepted practices: hand washing, spending as little time in enclosed air spaces as possible, distancing, and universal mask wearing.
9. Thoroughly vent and clean restrooms after each use.
If you strictly adhere to all 9 steps, a visit for the holidays should be safe for you and whoever is hosting. If you are hosting, every guest following these steps should be safe as well.
---
Allergic reaction. "UK regulators have issued a warning that people who have a history of "significant" allergic reactions should not currently receive the Pfizer/BioNTech Covid-19 vaccine after two NHS staff members who had the jab suffered allergic reactions.
The workers were given the Pfizer/BioNTech vaccine on Tuesday - the first day of the NHS mass vaccination programme - and then suffered an allergic reaction.
The NHS in England said all trusts involved with the vaccination programme had been informed.
The Medicines and Healthcare products Regulatory Agency (MHRA) has given precautionary advice to NHS trusts that anyone who has a history of "significant" allergic reactions to medicines, food or vaccines should not receive the vaccine.
Professor Stephen Powis, the national medical director for the NHS in England, said: "As is common with new vaccines the MHRA have advised on a precautionary basis that people with a significant history of allergic reactions do not receive this vaccination after two people with a history of significant allergic reactions responded adversely yesterday.
"Both are recovering well."
It is understood both staff members have a significant history of allergic reactions - to the extent where they need to carry an adrenaline auto injector with them."
Source: https://www.telegraph.co.uk/global-health/science-and-disease/coronavirus-news-vaccine-pfizer-nhs-oxford-covid-uk-cases/
Commentary: This is an important piece, not because of the reaction, but because of what isn't said: the denominator. How many people received the vaccine? 2 people out of 10 would be a serious problem. 2 people out of 10,000,000 would not be. Denominator blindness makes rare events seem more common, because we can mentally conceptualize 2 people and our brains hold about 150 people (Dunbar's number) so we'll always tend to see small numbers as much bigger. It's very difficult for us to conceptualize people beyond settings we've seen them in - stadiums, etc.
Keep this in mind as you read coverage of adverse reactions to the vaccines. Without a denominator, we have no idea what proportion of people experienced an issue, and thus we may judge a risk to be higher than it actually is.
---
More data on Moderna's vaccine. "At the 100-μg dose, mRNA-1273 produced high levels of binding and neutralizing antibodies that declined slightly over time, as expected, but they remained elevated in all participants 3 months after the booster vaccination. Binding antibody responses to the spike receptor–binding domain were assessed by enzyme-linked immunosorbent assay. At the day 119 time point, the geometric mean titer (GMT) was 235,228 (95% confidence interval [CI], 177,236 to 312,195) in participants 18 to 55 years of age, 151,761 (95% CI, 88,571 to 260,033) in those 56 to 70 years of age, and 157,946 (95% CI, 94,345 to 264,420) in those 71 years of age or older (Figure 1).
At day 119, the binding and neutralizing GMTs exceeded the median GMTs in a panel of 41 controls who were convalescing from Covid-19, with a median of 34 days since diagnosis (range, 23 to 54).2 No serious adverse events were noted in the trial, no prespecified trial-halting rules were met, and no new adverse events that were considered by the investigators to be related to the vaccine occurred after day 57.
Although correlates of protection against SARS-CoV-2 infection in humans are not yet established, these results show that despite a slight expected decline in titers of binding and neutralizing antibodies, mRNA-1273 has the potential to provide durable humoral immunity. Natural infection produces variable antibody longevity3,4 and may induce robust memory B-cell responses despite low plasma neutralizing activity.4,5 Although the memory cellular response to mRNA-1273 is not yet defined, this vaccine elicited primary CD4 type 1 helper T responses 43 days after the first vaccination,2 and studies of vaccine-induced B cells are ongoing. Longitudinal vaccine responses are critically important, and a follow-up analysis to assess safety and immunogenicity in the participants for a period of 13 months is ongoing. Our findings provide support for the use of a 100-μg dose of mRNA-1273 in an ongoing phase 3 trial, which has recently shown a 94.5% efficacy rate in an interim analysis."
Source: https://www.nejm.org/doi/full/10.1056/NEJMc2032195
Commentary: This is excellent news for Moderna's vaccine - showing high immune effect almost 4 months after vaccination.
---
School infections. "We analysed data on confirmed COVID-19 cases and outbreaks in educational settings in England following the reopening of mainly early years settings and primary schools as the first national lockdown was eased. The number of events (cases, coprimary cases, and outbreaks) reported in this period was low, with an estimated 1·1 events (95% CI 0·75–1·4) per 1000 settings per month in early years settings, 6·5 events (5·3–7·9) per 1000 settings per month in primary schools, and 4·5 (2·7–7·1) events per 1000 settings per month in secondary schools, although the proportion of case introductions that resulted in outbreaks ranged from 26% (95% CI 18–36) to 40% (25–57) depending on the setting. The number of outbreaks in educational settings was strongly associated with regional COVID-19 incidence, with the risk of an outbreak increasing by 72% (28–130) for every five cases per 100 000 increase in community incidence (p<0·0001). Staff members were more likely to be affected than students.
Taken together with literature evidence, our findings emphasise a need to improve awareness and infection control measures for staff members both within and outside the educational setting. The strong correlation between COVID-19 outbreaks and regional incidence and the proportion of cases in school settings ultimately resulting in outbreaks also highlight the importance of controlling the disease in the community to protect staff and students in educational settings."
Source: https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30882-3/fulltext
Commentary: Fundamentally, school outbreaks are concurrent with outbreaks in the community. Thus, if COVID-19 prevalence is high in your community, your schools should not be open. It is possible to reopen schools as long as the community itself is safe; this should provide added incentive to parents in affected communities to do their part in getting outbreaks under control by enforcing universal mask-wearing.
---
Common sense travel restrictions. "Countries are at different stages of COVID-19 epidemics, and many have implemented policies to minimise the risk of importing cases via international travel. Such policies include border closures, flight suspensions, and quarantine and self-isolation on international arrivals. Searching PubMed and medRxiv using the search term (“covid” OR “coronavirus” OR “SARS-CoV-2”) AND (“travel” OR “restrictions” OR “flight” OR “flights” OR “border”) for articles published in any language from Jan 1 to July 10, 2020, returned 118 and 84 studies, respectively, of which 39 were relevant to our study. These studies either concentrated in detail on the risk of importation to specific countries or used a single epidemiological or travel dataset to estimate risk. Most of them focused on the risk of COVID-19 introduction from China or other countries that had cases early in 2020. No study combined country-specific travel data, prevalence estimates, and incidence estimates to assess the global risk of importation relative to current local transmission within countries.
Our study considers the risk of case importation across 162 countries, in the context of local epidemic growth rates. Producing estimates on a global scale allows the complex relationship between the prevalence of COVID-19, traveller volume, and incidence locally to be combined, producing a simple, digestible metric. This allows decision makers to determine where travel restriction policies make large contributions to slowing local transmission, and where they have very little overall effect.
In many countries, imported cases would make a relatively small contribution to local transmission, so travel restrictions would have very little effect on epidemics. Countries where travel restrictions would have a large effect on local transmission are those with strong travel links to countries with high COVID-19 prevalence or countries that have successfully managed to control their local outbreaks."
Source: https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(20)30263-2/fulltext
Commentary: It makes logical sense that blanket travel restrictions would not change the trajectory of COVID-19 significantly in a locale, whereas targeted restrictions from sources of high infection would. For example, no one should be admitting travelers from the United States of America - the country is simply too high risk. On the other hand, accepting travelers from Australia would be perfectly fine.
---
Isolation works when incentivized. "Anne Wyllie, associate research scientist in epidemiology at Yale School of Medicine (New Haven, Connecticut, USA) welcomed the effort. “Mass testing offers an opportunity to reset where you are in the pandemic”, she told The Lancet Microbe. “You can identify cases and hotspots and start the process of contact tracing; it means you have a good shot at breaking chains of transmission”. But she stressed the importance of supportive measures. Slovakia offers accommodation for those who cannot easily self-isolate in their homes. It also compensates workers who have to take time off after a positive test result. This is an important incentive, especially given the possibility of false positives. Testing 3·6 million people with a test with a specificity of 99·7%, for example, would result in 10 800 individuals being wrongly advised to self-isolate."
Source: https://www.thelancet.com/journals/lanmic/article/PIIS2666-5247(20)30205-6/fulltext
Commentary: Countries where quarantines and isolation have been most effective are those places where isolation has been out of the home and isolated individuals are compensated by the government for their time. This reduces incentives to break isolation substantially, and is a general best practice all countries should consider adopting. Encourage your elected officials wherever you live to legislate for this.
---
A reminder of the simple daily habits we should all be taking.
1. Wash/sanitize your hands every time you are in or out of your home for any reason. Consider also spraying the bottoms of your shoes with a general disinfectant (alcohol/bleach/peroxide) when you return home. Remember that cleaners are NEVER to be ingested or injected. If you come in physical contact with others, wash your clothing upon returning home.
2. Always wear a mask when out of your home and if going to a high-risk area, wear goggles. Respirators are back in stock at online retailers, too. When going indoors to a place that isn't your home, wear the best protective mask available to you.
3. Stay home as much as possible. Minimize your contact with others and maintain physical distance of at LEAST 6 feet / 2 meters, preferably more. Avoid indoor places as much as you can; indoor spaces spread the disease through aerosols and distance is less effective at mitigating your risks.
4. Get your personal finances in order now. Cut all unnecessary costs.
5. Replenish your supplies as you use them. Avoid reducing your stores to pre-pandemic levels in case an outbreak causes unexpected supply chain disruptions.
6. Ventilate your home as frequently as weather and circumstances permit, except when you share close airspaces with other residences (like a window less than a meter away from a neighboring window).
---
Common misinformation debunked!
There is no genomic evidence at all that COVID-19 arrived before 2020 in the United States and therefore no hidden herd immunity:
Source:
There is no evidence SARS-CoV-2 was engineered, nor that it escaped a lab somewhere.
Source: https://www.washingtonpost.com/world/2020/01/29/experts-debunk-fringe-theory-linking-chinas-coronavirus-weapons-research/
Source: https://www.nature.com/articles/s41591-020-0820-9
Source: https://www.nationalgeographic.com/science/2020/05/anthony-fauci-no-scientific-evidence-the-coronavirus-was-made-in-a-chinese-lab-cvd/
There is no evidence a flu shot increases your COVID-19 risk.
Source: https://www.factcheck.org/2020/04/no-evidence-that-flu-shot-increases-risk-of-covid-19/
Source: https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa626/5842161
---
A common request I'm asked is who I follow. Here's a public Twitter list of many of the sources I read.
https://twitter.com/i/lists/1260956929205112834
This list is biased by design. It is limited to authors who predominantly post in the English language. It is heavily biased towards individual researchers and away from institutions. It is biased towards those who publish or share research, data, papers, etc. I have made an attempt to follow researchers from different countries, and also to make the list reasonably gender-balanced, because multiple, diverse perspectives on research data are essential.
This is also available as an email newsletter at https://lunchtimepandemic.substack.com if you prefer the update in your inbox.