It strikes me that there's another factor in play here: Do we as a society and as individuals care about working to prevent harm to others more at risk?
Our society tends to focus on the greatest good for the greatest number, especially of those we center - as opposed to preventing harm for those on the margins. We tend more so than other counties to be individualistic rather than focusing on the vulnerable.
From my point of view, people and government declaring this to already be endemic, dropping protections like masking or free tests, dropping funding, etc. are effectively saying to vulnerable people that "Your deaths are acceptable to us." Sometimes this is crass and obvious as a form of social homocide, other times it's more subtle as part of focusing on "normal" people and not thinking about others.
Granted that everyone will die someday, but for me a key question is whether society believes it is entitled to the deaths of those less fortunate so people can go to a movie?
This isn't a new issue, but rather one COVID has put into stark relief. COVID's effects have quite disproportionally harmed older people, poorer people, disabled people, minorities, etc. Declaring COVID "over" magnifies those harms.
First of all, as Katelyn said above, Denmark has a "high vaccination rate, ability to track the virus with comprehensive data, and wide safety net of universal healthcare coverage, paid time off, etc." We have none of those.
Also, it hasn't worked out well for Denmark. Here's from an article at Web MD:
"Since Denmark became the first major country to lift its remaining coronavirus restrictions at the beginning of February, it has recorded more COVID-19 cases per capita than most other places in the world."
"COVID-19 hospitalizations and deaths have jumped by nearly a third, signaling a warning to the U.S. and other countries that are now easing mask mandates, vaccine requirements, and limits for crowded spaces such as bars and nightclubs"
And lastly, that largely ignores the, I believe, fundamental ethical question I raised: What do we consider an acceptable level of harm and for whom?
Alan: "First of all, as Katelyn said above, Denmark has a "high vaccination rate, ability to track the virus with comprehensive data, and wide safety net of universal healthcare coverage, paid time off, etc." We have none of those."
MD: If you follow her writing closely, she pivots now that their strategy has proved a success. On Feb 7th she endorsed the lifting of all restrictions writing "Several countries, like Denmark and Sweden, are lifting all restrictions. And, I support this because their vaccination rates are high. During the Omicron wave, it was blaringly obvious that this high vaccination rate reduced burden on their healthcare systems." (no mention of the safety net) [1]
Two weeks later, with their cases rising, she wrote "Well, to no one’s surprise, cases continued to skyrocket. Interestingly, ICUs decreased but then plateaued and just recently began increasing. Denmark’s deaths continued to exponentially increase. In fact, just recently they reached a record-breaking high." (again, no mentioned of the safety net) [2]
Now, 3 months later, their strategy appears to have been appropriate. Denmark has suspended vaccinations, greatly reduced testing capacity, and doesn't talk about Covid anymore, and from what I gather they don't even seem to be concerned with Long Covid.
A "safety net" doesn't explain any of this. Being able to take time off work or get free healthcare are things they enjoyed while they were being challenged and chastised by Feigl-Ding and other experts forcing Denmark to rebuke them [3]. This sounds like a post-hoc justification to explain why predictions failed. Otherwise, they would have cited the safety net back in February to explain why this approach would work. Not to mention the same safety net applies to much of Europe so why does it only work in Denmark but not France or Germany? (Not to mention, why wasn't this cited as why Sweden's hands off approach would work back in April 2020?)
Alan: "Also, it hasn't worked out well for Denmark. Here's from an article at Web MD:"
MD: The article you cited was published on Feb 17th. With that mind in date, roll the mouse on the graph to Feb 17th and see what happened to cases since:
Alan: "And lastly, that largely ignores the, I believe, fundamental ethical question I raised: What do we consider an acceptable level of harm and for whom?"
MD: Agree this is a fundamental ethical question and requires a lot of nuance and openness to considering competing hypotheses.
We have spent an enormous amount of money already and have little to show for it. At the very least we should have dispassionate discussions on whether changes need to me made, while allowing for the possibility that countries doing less and having better results than us deserve some consideration.
Scrutiny in medicine can have a higher cost than disregard.
I'd remind you that Katelyn repeatedly comments on the high vaccination rates in Denmark as key to their overall success. The US isn't in the same situation.
Given that we aren't Denmark in so many ways, citing that effectively as a model for what we should do in the US seems off the point.
I'm unclear as to what you mean that "We have very little to show for it".
Your last comment leads me to suggest the following rephrasing, "Are our actions and policies further endangering people at risk? Are they increasing rather than decreasing inequality and the disperate effects of COVID based on those factors? Are we a society that cares about others?"
>"I'm unclear as to what you mean that "We have very little to show for it"."
The US spent more than any other country in the world on Covid (if you run as a function of GDP we still make top 10).
Yet we have per capita the most deaths, the most excess deaths, soaring inflation, a worker shortage, widening income gap, fewer staffed hospital beds than pre pandemic (I haven't re-run this calculation since early 2022 so may have changed?), massive educational loss for children predominately among the poor, minorities, and overall disadvantaged, etc.
So at a high level, it would seem to me that our money spent didn't have a good ROI.
1) The US has a very poor vaccination rate for a "developed" country. Ours is certainly far lower than Denmark's, for example. That strongly influenced outcomes such as per capita deaths and excess deaths that you cite.
2) Spending to try to increase the vaccination rate helps, but sadly doesn't determine it. You can lead a horse to water...
Here's an interesting article on the question of why things are so much worse in the US:
"Chief among the reasons is the country’s faltering effort to vaccinate its most vulnerable people at the levels achieved by more successful European countries."
So my question is how much worse would we be if less had been spent.
And the last paragraph of that article is my broader point:
“We’ve normalized a very high death toll in the U.S.,” said Anne Sosin, who studies health equity at Dartmouth. “If we want to declare the end of the pandemic right now, what we’re doing is normalizing a very high rate of death.”
STAT says smallpox vaccine is protective-but do we know for how many years? (for those of us who had that little circle of jabs as a kid). AND: Thank you Katelyn!!
Its reproduction rate is low because in general terms it requires close contact and is generally transmitted by direct transmission of bodily fluids or large droplets. This spread is especially noteworthy because it is spreading so broadly (no longer restricted to Africa), AND because lesions are being seen on body parts not considered normal in the past. The largest numbers appear to be in men who have sex with men, but people not in this group should be vigilant and careful to prevent spread.
Thank you as this is the balanced voice we need and wish this would get to all the different important entities that are involved. The headlines from many epidemiologists has been frightening to read as PCR tests are no longer free, masks are all but gone in Texas and our leaders are focused on other things, BUT we are so much more fortunate than so many countries and yet we ARE TERRIBLE at public health measures. It does not make sense. This has affected every aspect of our lives for the past three years how can we stop??? This virus has no boundaries so it should not be a Republican/Democrat issue, it is a human one. We can do this. I continue to contact my elected representatives to let them know this is important. In a sea of confusion you are a port in the storm and we are so grateful for your dedication.
I fear another “epidemic “ of hospitals going broke. Ours just had to lay off 105 people and not fill 76 positions while most every day we are at maximum capacity and sometimes boarding patients in the ED. I survived this cut, but who knows what fall will bring. We aren’t the only hospital system struggling, either.
I always like what you write but don't often tell you that. This interplay of science, political priorities, personal citizen fatigue, and our usual difficulty as semi-evolved chimpanzees has made this a big mess. How many deaths are okay? How much time on ventilators, how much long covid, how much cost...I feel that if there was a ravaging bear in the room, we would respond quickly and mostly accurately. This is different. Somebody coined the word "permademic," which is a real possibility. Anyway, thanks again and keep them coming.
I liked your observation about us being "semi-evolved chimpanzees.". Couldn't agree more and we disregard that at our peril. I've contended that the tragi-comedy of our species is that we're bright, but not bright enough! We're the best tool makers on the planet, but we don't often foresee the longterm outcome of use of such tools (think automobiles and computers for example.) Evolutionarily, it may be because we were mostly required to make accurate short term decisions, such as fight, flight, ignore, but we were less required to make medium term decisions (like store grain for the winter) and almost no requirement for long term planning. It's not that we can't do the latter, it's just our decision compass defaults to a short term generally. This is clearly seen in all our affairs and in the current pandemic. We tend toward being reactive rather than proactive. And almost no one is thinking about the pandemic landscape 20 years down the road.) There are two other interesting features in our evolutionary makeup that have bearing on our response to the pandemic. One is uncovered in Newcomb's Paradox: a basic faultline in our decision-making approaches. The other is the conceptual phenomena of shifting baselines, discussed recently in connection to wildfires and global warming, but with wide applications even to pandemics. Public health policy makers should acquaint themselves with these modifiers and perhaps throw in Dietrich Braess's discovery of the counter intuitive effects of over-articulating systems (including our pandemic responsive infrastructure.)
Love your work, thank you so much for all you do. I would love to know whether long covid or longer term issues due to covid (such as a new diabetes diagnosis) are even being considered as part of any broader public health conversations, especially for young children. I run a preschool, and I want to know if it makes sense to stop wearing masks indoors or outdoors, and when it makes sense to keep wearing them. It seems like these decisions aren't backed up sometimes by reason and I wish there was a more nuanced dialogue from the experts about covid risk (now and future health) for preschool-age children balanced against risks of wearing masks for years in early education programs.
This is a tangent to the topic at hand, but you referred to SARS-CoV-2 as a 'respiratory virus'. I was under the impression that we had learned that it was more of a vascular disease affecting the entire body, with typical entree via the respiratory system but that it would attach to anything with ACE2 receptors, which would also include epithelial cells anywhere throughout the body. Hence the risk of blot clots, strokes, heart problems, organ damage, etc. (I have no medical background so forgive the broad generalities and possible inaccuracies.)
Is that not consensus that this is different type of virus? I get frustrated when people refer to it as a respiratory virus as I think it lets them mentally put it in a category with bad colds and flu and thus discount its severity on individuals and the community.
One thing we know for sure is that it is primarily a respiratory virus but that it causes damage throughout the body, especially in heart, liver, and kidneys via inflammatory processes but also by transport through the vascular system. The Journal of Hepatology has an article from Chinese researchers who found cv19 viral particles in livers postmortem. https://doi.org/10.1016/j.jhep.2020.05.002
Also viral particles have been directly observed in kidney and heart tissues,
Not speaking as an expert, but what is the definition of 'respiratory virus?' That its typical mode of entry is thru the respiratory tract (which is true); that it most-typically infects the tissues of the respiratory tract (also, I believe, mostly true)? However, because ACE2 (an important tho not only target of the spike) operates in so many tissues, the impact can be exerted in many tissues. Among these is vascular endothelium (Circulation Research. 2021;128:1323–1326. DOI: 10.1161/CIRCRESAHA.121.318902) where it would have a proinflammatory effect by decreasing ACE2 availability.
Thanks for that clarification. Respiratory virus due to transmission/entry even if impact is much more systemic than less severe respiratory viruses. Got it.
Thanks for these elaborations. I appreciate all of you taking the time to write out your knowledge for us.
I do have a friend who works in a hematology clinic which has had an uptake of younger patients who have been throwing microclots since contracting Covid. It has been notably unusual for the clinic. I have no data though on numbers and percentage increase, just anecdotal observation. As a layperson, I had never heard of blood clots being a possible downstream effect of any other "respiratory" virus.
I've read that many people are getting reinfected, and more frequently. I think this changes things too. It's one thing to get a cold or flu every 2-3 years. But another to get sick with covid 3 times a year.
Yes, especially because of the increasing risk of long COVID from repeated infections. It's so many bites at the apple and will lead to significant morbidity and disability.
I hadn't thought of it that way, but that sounds quite plausible.
I remember how optimistic I was when the mRNA vaccines came out and heard how easy it would be to tweak for any new variants. Yet this isn't happening.
How much do we know at this point about reinfection? E.g., same vs. different strain; true reinfection vs. extended version of an initial infection; whether vax'd or not (and how long ago, and with how many doses); whether an actual 'infection' vs. 'being a carrier' who just happens to have picked up some viral particles (not sure that's actually a medical distinction)? Also - how does the probability of getting 'long' Covid change with each new infection (no doubt this depends on various factors)?
I have always felt we do, and did not track influenza deaths well, and never as robustly as we do for COVID. I think your comparison to a bad flu year is good, but I always question the numbers that we have for influenza. Having worked as an infection control practitioner, I know many community cases are just not reported, people get sick, ride it out at home, and go back to their lives. Yes, some people die, and it gets back to the question of dying from influenza or with influenza in patients with multiple co-morbidities.
Some of the lessons that we have learned from this pandemic, as others have stated, need to stay in place: funding of public health, reporting, stockpiles of pandemic materials (that are rotated so they are not outdated), better reporting, virology, etc.
This "clearly defined our end goal." It seems that the effectiveness of vaccines against infection changed the playing field. Before vaccines the goal was for a vaccine that could simply keep people out of the hospital and be at least 50% effective at that. The first vaccines worked almost too well at keeping people from getting infected so for many, the goal changed to "Keep from getting infected." I wonder that because the overwhelming number of deaths (in 2022 75% were 65 and over and 20% were 45-64) that we have already subconsciously as a nation have found a high death rate acceptable as the norm. That we will basically ignore deaths in 65 and over and simply look to under 65 as being acceptable as long as it stays under about 65,000 or so.
As you stated there are multiple groups (and of course individuals) each with a different goal. It seems to then make different groups look at each other as "crazy" which also makes it hard to see what an overall goal is.
And where one gets their information/lives plays such a huge role. We see cases increasing on in CA and in the NE in places that are well vaccinated, but because they were well vaccinated their were lower rates of infections. These places were also hard hit in 2020 so there is some left over trauma about hearing "cases are rising" that don't happen elsewhere. So case sensitivity differs geographically.
What I don't understand right now is:
(1) Why isn't more money being put into finding a nasal vaccine?
(2) Why isn't their more clarity from the government about yearly/how often we need vaccinations? We have people well over their 6 month booster not knowing what to do since vaccines are more for keeping people from getting very sick, not simply from getting infected
(3) Why isn't there more information/discussion about how long covid symptoms might last/more discussions on the percentage of people who have long lasting symptoms (Meaning % symptoms last 2 months vs % symptoms lasting 6+months)?
I think the issues of long covid hitting the country economically (Fewer people in the workforce and economic losses in the insurance industry) will have an great impact on what defines an end goal and where energy is put (both my media and government).
The NE was slammed by Omicron, despite comparatively high vaccination rates. Everyone that I know in the Boston-area who got Omicron were vaccinated and boosted. I think the notion that vaccine would keep someone from getting infected was long ago abandoned by realizing avoiding severe disease was the more realistic goal when community spread is so high. I hardly remember 2020 because Delta and Omicron, post vaccine, remain so prominent in my mind!
I do hope the nasal vaccines are here sooner than later. I suppose my poorly worded statement was why we weren't throwing more money (ala a mini operation warp speed) at this.
And I think the preventing infection vs preventing serious illness was really when the goal post problem started. While medical/scientific experts were pretty clear on the difference, I don't think the general public was. Part of that was having to push the effectiveness of the vaccine (including hey you can go out without a mask) in order to get more people vaccinated, but over time, when vaccines still worked exceptionally well on serious illness but not simply infection, some people took that as vaccines aren't working/OMG we are in trouble and so messaging got more mixed.
Long covid - I was shocked by the Bank of England estimates. Like most things, the greater the impact the more focus and money is put on an issue. It will be interesting to watch what the business community starts saying about long covid impacts and watch as they push for my answers.
I was shocked to read that Covid is currently the 3rd leading cause of US deaths this year. You wouldn't otherwise know that because of how political Covid continues to be. I don't how to solve the political problem, but I do know it increases the challenge in making good decisions and providing proper guidance. That challenge has been equal to the virus itself IMHO.
After doing everything we could to avoid this, my oldest caught it at school (he was the only remaining child masking in his class). When my husband went positive, we opted to ask for the antiviral since the supply issues seem to be resolved and he has risk factors. Our doc was very against it, though did call it in. I thought the use of antivirals would be welcomed, are there reasons to avoid the antivirals?
My layperson thought process is - we know not much about long covid, nothing about long term syndromes, and that even mild cases can raise the risk of clots, damage to organs, etc, so why would there be reason NOT to lower that viral load as quickly as possible, especially with cases where there are risk factors present?
I do know of the contraindications and side effects, it just seemed strange to hear her say she specifically would avoid it. To me it seems the unknowns and risks of covid would be far greater than those associated with the antiviral. Thank you for the link, I’ll be sure to read it!
Anecdotally, he did take the antiviral, and rapid is neg on day 3 and 4, we are pcr-ing today as well. He will remain masked for a full 10 days in our house (we mask in public anyway) and follow Katelyn's testing suggestions for post anti-viral, but I thought I would share. If he rebounds, I will update as well. I know that he is just 1 case.
May be your doctor was seeing a lot of Paxlovid rebounding which is something being studied and not understood (see Stephen Colbert for a high profile example).
In one of the larger private Covid 19 Physician groups there’s been a lot of doctors sharing examples of this phenom lately, so even if she wasn’t prescribing it herself, she may be seeing peers talking about it too. Katelyn wrote about it too on May 10th.
Just a thought of what might be giving her pause. (Or if your husband wasn’t that sick she might have not seen the benefit?). Like my pediatrician would only write for Tamiflu when children were very sick with the flu, and that was even back when the perceived efficacy was high for Tamiflu.
Thank you for your newsletters, which I forward to others regularly. Our local Coronavirus group has a question about this statement “Unfortunately, viruses mutate randomly. We don’t know the next move.” What is the science behind this? Many are of the belief that viruses mutate to be more transmissible and less severe. The Omicron variant has a lot of people convinced the danger of a more deadly variant is passed. Would love to hear more about this topic in your newsletter.
I think this means that it's to viruses' advantage to become more transmissible (selection pressure), but there is no pressure to become more--or less--virulent (pathogenic). By the time a virus has been transmitted from host A to host B, hours or days have passed. For example I think smallpox's virulence remained about the same throughout, and probably there are other examples. I also wonder (anyone know?) whether Omicron variants only SEEM to be less virulent because potential hosts (people) are becoming somewhat more immune from prior natural or vaccine-induced immunity. QUESTION: What happened with the flu pandemic of 1917+? Was that a combo of widespread natural immunity plus a virus that didn't happen to mutate much? (Asking as a non-expert...)
A study I saw yesterday specifically said more died during the omicron wave in Massachusetts than during delta. Early "data" suggesting omicron was less virulent probably contributed to the media statements about decreased virulence.
Obviously, some degree of immunity may mitigate some severity of the disease. This has been demonstrated in the fact that those vaccinated tended overall to experience less severe symptoms and outcomes in breakthrough cases than the unvaccinated. With omicron, prior immunity conferred solely by infection appeared to have little beneficial effect.
In the Spanish Flu we lacked any way to actually identify and sequence the virus. There's speculation that it, too, was a novel coronavirus outbreak rather than an influenza strain, but in those days, virtually any severe respiratory illness was "Influenza". The multiple waves seen over a 3 year period suggest there was mutation. Many cities failed to heed the warnings of areas infected before them, and didn't employ mitigation strategies in timely manner, and suffered the consequences of increased morbidity and mortality. We seem dead-set on repeating those lessons of history.
Note the reply below by Iver. Mutations do occur randomly in viruses. The successful mutations tend to increase the reproduction rate in the disease process (are more transmissible). It's not to the advantage of a virus to rapidly kill a new host, as this reduces the ability of a virus to propagate to more hosts. To that end, increased transmissivity and decreased virulence would go hand-in-hand, but there aren't too many functioning planning neurons in a virus, so a new random mutation could indeed cause more severe disease. Omicron was of particular concern because it had a LOT of substitutions/deletions and we didn't know how those would affect severity or evasion of immunity.
We have no idea if the potential for a more virulent variant remains (actually, we do: It is possible, but is it LIKELY?). I'm in the group that is not convinced we have seen COVID-19 run its course. Recently, Mike Osterholm, University of Minnesota, suggested that the difference between earlier variants and omicron and its subvariants could be allow one to consider omicron a new and novel coronavirus rather than a mere variant of earlier historical lineages. Think, SARS-CoV-3 or COVID-2022.
Finally, we almost always think of COVID-19 as a respiratory virus while there is evidence that its effect on other organs is significant and not related to a respiratory component other than respiratory transmission being the primary vector. Changes in virulence may still occur, and we've not had sufficient time to establish what those changes may be in multiple organ systems. An article in JAMA Open Network found people 18-65 were likely to see a 20% increase in respiratory and thrombotic events over the general population, and those 65-85 could expect a 25% increase. The lesson here is that consequences of COVID are not limited to the immediate acute phase. The potential long-term effects have to be considered as well, and increased mortality in the long-term phase isn't unlikely.
Thank you Katelyn for a balanced multi-perspective piece on the contributors to and implications of policy decisions. As well, individuals and families/social groups must make decisions based on evolving, imperfect data. The analyses that ought to inform such decisions aren't necessarily based on the everyday questions people have. Take for example questions of viral transmissibility. People think in terms of their own situation (including their perceived risk level) - e.g. for how long could a person who tested positive X days ago potentially transmit the virus if not wearing a mask, if wearing surgical vs. KN95 vs. N95 masks, if they were or were not vaccinated/boosted (and how long ago)? Could someone be a 'carrier' without being infected? How would they know? These highly detailed questions are more likely to be asked by people at high risk if they get infected, but may not much affect policy-making.
It strikes me that there's another factor in play here: Do we as a society and as individuals care about working to prevent harm to others more at risk?
Our society tends to focus on the greatest good for the greatest number, especially of those we center - as opposed to preventing harm for those on the margins. We tend more so than other counties to be individualistic rather than focusing on the vulnerable.
From my point of view, people and government declaring this to already be endemic, dropping protections like masking or free tests, dropping funding, etc. are effectively saying to vulnerable people that "Your deaths are acceptable to us." Sometimes this is crass and obvious as a form of social homocide, other times it's more subtle as part of focusing on "normal" people and not thinking about others.
Granted that everyone will die someday, but for me a key question is whether society believes it is entitled to the deaths of those less fortunate so people can go to a movie?
This isn't a new issue, but rather one COVID has put into stark relief. COVID's effects have quite disproportionally harmed older people, poorer people, disabled people, minorities, etc. Declaring COVID "over" magnifies those harms.
The counter to this is that the countries which stopped mass testing/masking/vaccine drives like Denmark and Sweden have faced zero repercussions.
I'm not sure how that's a counter.
First of all, as Katelyn said above, Denmark has a "high vaccination rate, ability to track the virus with comprehensive data, and wide safety net of universal healthcare coverage, paid time off, etc." We have none of those.
Also, it hasn't worked out well for Denmark. Here's from an article at Web MD:
"Since Denmark became the first major country to lift its remaining coronavirus restrictions at the beginning of February, it has recorded more COVID-19 cases per capita than most other places in the world."
"COVID-19 hospitalizations and deaths have jumped by nearly a third, signaling a warning to the U.S. and other countries that are now easing mask mandates, vaccine requirements, and limits for crowded spaces such as bars and nightclubs"
And lastly, that largely ignores the, I believe, fundamental ethical question I raised: What do we consider an acceptable level of harm and for whom?
Some feedback/replies:
Alan: "First of all, as Katelyn said above, Denmark has a "high vaccination rate, ability to track the virus with comprehensive data, and wide safety net of universal healthcare coverage, paid time off, etc." We have none of those."
MD: If you follow her writing closely, she pivots now that their strategy has proved a success. On Feb 7th she endorsed the lifting of all restrictions writing "Several countries, like Denmark and Sweden, are lifting all restrictions. And, I support this because their vaccination rates are high. During the Omicron wave, it was blaringly obvious that this high vaccination rate reduced burden on their healthcare systems." (no mention of the safety net) [1]
Two weeks later, with their cases rising, she wrote "Well, to no one’s surprise, cases continued to skyrocket. Interestingly, ICUs decreased but then plateaued and just recently began increasing. Denmark’s deaths continued to exponentially increase. In fact, just recently they reached a record-breaking high." (again, no mentioned of the safety net) [2]
Now, 3 months later, their strategy appears to have been appropriate. Denmark has suspended vaccinations, greatly reduced testing capacity, and doesn't talk about Covid anymore, and from what I gather they don't even seem to be concerned with Long Covid.
A "safety net" doesn't explain any of this. Being able to take time off work or get free healthcare are things they enjoyed while they were being challenged and chastised by Feigl-Ding and other experts forcing Denmark to rebuke them [3]. This sounds like a post-hoc justification to explain why predictions failed. Otherwise, they would have cited the safety net back in February to explain why this approach would work. Not to mention the same safety net applies to much of Europe so why does it only work in Denmark but not France or Germany? (Not to mention, why wasn't this cited as why Sweden's hands off approach would work back in April 2020?)
Alan: "Also, it hasn't worked out well for Denmark. Here's from an article at Web MD:"
MD: The article you cited was published on Feb 17th. With that mind in date, roll the mouse on the graph to Feb 17th and see what happened to cases since:
https://ourworldindata.org/coronavirus/country/denmark#what-is-the-daily-number-of-confirmed-cases
It clearly worked out just for them just fine.
Alan: "And lastly, that largely ignores the, I believe, fundamental ethical question I raised: What do we consider an acceptable level of harm and for whom?"
MD: Agree this is a fundamental ethical question and requires a lot of nuance and openness to considering competing hypotheses.
We have spent an enormous amount of money already and have little to show for it. At the very least we should have dispassionate discussions on whether changes need to me made, while allowing for the possibility that countries doing less and having better results than us deserve some consideration.
Scrutiny in medicine can have a higher cost than disregard.
__________________________
[1] https://yourlocalepidemiologist.substack.com/p/riding-the-waves-a-framework-for?s=r
[2] https://yourlocalepidemiologist.substack.com/p/two-week-recap-denmark-ba2-and-boosters?s=r
[3] https://en.ssi.dk/covid-19/typical-misinformation-regarding-danish-covid-numbers
Thanks for the updated info for Denmark.
I'd remind you that Katelyn repeatedly comments on the high vaccination rates in Denmark as key to their overall success. The US isn't in the same situation.
Given that we aren't Denmark in so many ways, citing that effectively as a model for what we should do in the US seems off the point.
I'm unclear as to what you mean that "We have very little to show for it".
Your last comment leads me to suggest the following rephrasing, "Are our actions and policies further endangering people at risk? Are they increasing rather than decreasing inequality and the disperate effects of COVID based on those factors? Are we a society that cares about others?"
I like your rephrasing. Can get behind that.
>"I'm unclear as to what you mean that "We have very little to show for it"."
The US spent more than any other country in the world on Covid (if you run as a function of GDP we still make top 10).
Yet we have per capita the most deaths, the most excess deaths, soaring inflation, a worker shortage, widening income gap, fewer staffed hospital beds than pre pandemic (I haven't re-run this calculation since early 2022 so may have changed?), massive educational loss for children predominately among the poor, minorities, and overall disadvantaged, etc.
So at a high level, it would seem to me that our money spent didn't have a good ROI.
A few things stand out to me there:
1) The US has a very poor vaccination rate for a "developed" country. Ours is certainly far lower than Denmark's, for example. That strongly influenced outcomes such as per capita deaths and excess deaths that you cite.
2) Spending to try to increase the vaccination rate helps, but sadly doesn't determine it. You can lead a horse to water...
Here's an interesting article on the question of why things are so much worse in the US:
https://www.nytimes.com/interactive/2022/02/01/science/covid-deaths-united-states.html
"Chief among the reasons is the country’s faltering effort to vaccinate its most vulnerable people at the levels achieved by more successful European countries."
So my question is how much worse would we be if less had been spent.
And the last paragraph of that article is my broader point:
“We’ve normalized a very high death toll in the U.S.,” said Anne Sosin, who studies health equity at Dartmouth. “If we want to declare the end of the pandemic right now, what we’re doing is normalizing a very high rate of death.”
Brilliant post! Now, if we could just get the two camps of scientists/ engineers to stop yelling at each other...
...it would help.
You are spot on that this is complicated!
can you please update us on Monkey Pox?
coming :)
STAT says smallpox vaccine is protective-but do we know for how many years? (for those of us who had that little circle of jabs as a kid). AND: Thank you Katelyn!!
Keep a weathereye on this one. It's a bit worrisome.
Its reproduction rate is low because in general terms it requires close contact and is generally transmitted by direct transmission of bodily fluids or large droplets. This spread is especially noteworthy because it is spreading so broadly (no longer restricted to Africa), AND because lesions are being seen on body parts not considered normal in the past. The largest numbers appear to be in men who have sex with men, but people not in this group should be vigilant and careful to prevent spread.
Thank you as this is the balanced voice we need and wish this would get to all the different important entities that are involved. The headlines from many epidemiologists has been frightening to read as PCR tests are no longer free, masks are all but gone in Texas and our leaders are focused on other things, BUT we are so much more fortunate than so many countries and yet we ARE TERRIBLE at public health measures. It does not make sense. This has affected every aspect of our lives for the past three years how can we stop??? This virus has no boundaries so it should not be a Republican/Democrat issue, it is a human one. We can do this. I continue to contact my elected representatives to let them know this is important. In a sea of confusion you are a port in the storm and we are so grateful for your dedication.
I fear another “epidemic “ of hospitals going broke. Ours just had to lay off 105 people and not fill 76 positions while most every day we are at maximum capacity and sometimes boarding patients in the ED. I survived this cut, but who knows what fall will bring. We aren’t the only hospital system struggling, either.
I always like what you write but don't often tell you that. This interplay of science, political priorities, personal citizen fatigue, and our usual difficulty as semi-evolved chimpanzees has made this a big mess. How many deaths are okay? How much time on ventilators, how much long covid, how much cost...I feel that if there was a ravaging bear in the room, we would respond quickly and mostly accurately. This is different. Somebody coined the word "permademic," which is a real possibility. Anyway, thanks again and keep them coming.
I liked your observation about us being "semi-evolved chimpanzees.". Couldn't agree more and we disregard that at our peril. I've contended that the tragi-comedy of our species is that we're bright, but not bright enough! We're the best tool makers on the planet, but we don't often foresee the longterm outcome of use of such tools (think automobiles and computers for example.) Evolutionarily, it may be because we were mostly required to make accurate short term decisions, such as fight, flight, ignore, but we were less required to make medium term decisions (like store grain for the winter) and almost no requirement for long term planning. It's not that we can't do the latter, it's just our decision compass defaults to a short term generally. This is clearly seen in all our affairs and in the current pandemic. We tend toward being reactive rather than proactive. And almost no one is thinking about the pandemic landscape 20 years down the road.) There are two other interesting features in our evolutionary makeup that have bearing on our response to the pandemic. One is uncovered in Newcomb's Paradox: a basic faultline in our decision-making approaches. The other is the conceptual phenomena of shifting baselines, discussed recently in connection to wildfires and global warming, but with wide applications even to pandemics. Public health policy makers should acquaint themselves with these modifiers and perhaps throw in Dietrich Braess's discovery of the counter intuitive effects of over-articulating systems (including our pandemic responsive infrastructure.)
Love your work, thank you so much for all you do. I would love to know whether long covid or longer term issues due to covid (such as a new diabetes diagnosis) are even being considered as part of any broader public health conversations, especially for young children. I run a preschool, and I want to know if it makes sense to stop wearing masks indoors or outdoors, and when it makes sense to keep wearing them. It seems like these decisions aren't backed up sometimes by reason and I wish there was a more nuanced dialogue from the experts about covid risk (now and future health) for preschool-age children balanced against risks of wearing masks for years in early education programs.
This is a tangent to the topic at hand, but you referred to SARS-CoV-2 as a 'respiratory virus'. I was under the impression that we had learned that it was more of a vascular disease affecting the entire body, with typical entree via the respiratory system but that it would attach to anything with ACE2 receptors, which would also include epithelial cells anywhere throughout the body. Hence the risk of blot clots, strokes, heart problems, organ damage, etc. (I have no medical background so forgive the broad generalities and possible inaccuracies.)
Is that not consensus that this is different type of virus? I get frustrated when people refer to it as a respiratory virus as I think it lets them mentally put it in a category with bad colds and flu and thus discount its severity on individuals and the community.
If that were true you’d see much higher demand and different patient profiles for vascular surgeons.
We aren’t seeing that. In fact in the most recent issue of Journal of Vascular Surgery, of the 37 articles, there’s not a single one mentioning Covid.
One thing we know for sure is that it is primarily a respiratory virus but that it causes damage throughout the body, especially in heart, liver, and kidneys via inflammatory processes but also by transport through the vascular system. The Journal of Hepatology has an article from Chinese researchers who found cv19 viral particles in livers postmortem. https://doi.org/10.1016/j.jhep.2020.05.002
Also viral particles have been directly observed in kidney and heart tissues,
Good point and worth noting. I wonder if the more general cardiovascular journals would be likelier to publish, for example in this week's Circulation (https://www.ahajournals.org/doi/epub/10.1161/CIRCULATIONAHA.122.059231) an editorial about the potential in post ("long") Covid
"Covid is a vascular disease"
"But Covid is not a vascular disease adding burden to vascular surgeons"
Got it.
Not speaking as an expert, but what is the definition of 'respiratory virus?' That its typical mode of entry is thru the respiratory tract (which is true); that it most-typically infects the tissues of the respiratory tract (also, I believe, mostly true)? However, because ACE2 (an important tho not only target of the spike) operates in so many tissues, the impact can be exerted in many tissues. Among these is vascular endothelium (Circulation Research. 2021;128:1323–1326. DOI: 10.1161/CIRCRESAHA.121.318902) where it would have a proinflammatory effect by decreasing ACE2 availability.
Thanks for that clarification. Respiratory virus due to transmission/entry even if impact is much more systemic than less severe respiratory viruses. Got it.
Thanks for these elaborations. I appreciate all of you taking the time to write out your knowledge for us.
I do have a friend who works in a hematology clinic which has had an uptake of younger patients who have been throwing microclots since contracting Covid. It has been notably unusual for the clinic. I have no data though on numbers and percentage increase, just anecdotal observation. As a layperson, I had never heard of blood clots being a possible downstream effect of any other "respiratory" virus.
I've read that many people are getting reinfected, and more frequently. I think this changes things too. It's one thing to get a cold or flu every 2-3 years. But another to get sick with covid 3 times a year.
Yes, especially because of the increasing risk of long COVID from repeated infections. It's so many bites at the apple and will lead to significant morbidity and disability.
I hadn't thought of it that way, but that sounds quite plausible.
I remember how optimistic I was when the mRNA vaccines came out and heard how easy it would be to tweak for any new variants. Yet this isn't happening.
How much do we know at this point about reinfection? E.g., same vs. different strain; true reinfection vs. extended version of an initial infection; whether vax'd or not (and how long ago, and with how many doses); whether an actual 'infection' vs. 'being a carrier' who just happens to have picked up some viral particles (not sure that's actually a medical distinction)? Also - how does the probability of getting 'long' Covid change with each new infection (no doubt this depends on various factors)?
I have always felt we do, and did not track influenza deaths well, and never as robustly as we do for COVID. I think your comparison to a bad flu year is good, but I always question the numbers that we have for influenza. Having worked as an infection control practitioner, I know many community cases are just not reported, people get sick, ride it out at home, and go back to their lives. Yes, some people die, and it gets back to the question of dying from influenza or with influenza in patients with multiple co-morbidities.
Some of the lessons that we have learned from this pandemic, as others have stated, need to stay in place: funding of public health, reporting, stockpiles of pandemic materials (that are rotated so they are not outdated), better reporting, virology, etc.
This "clearly defined our end goal." It seems that the effectiveness of vaccines against infection changed the playing field. Before vaccines the goal was for a vaccine that could simply keep people out of the hospital and be at least 50% effective at that. The first vaccines worked almost too well at keeping people from getting infected so for many, the goal changed to "Keep from getting infected." I wonder that because the overwhelming number of deaths (in 2022 75% were 65 and over and 20% were 45-64) that we have already subconsciously as a nation have found a high death rate acceptable as the norm. That we will basically ignore deaths in 65 and over and simply look to under 65 as being acceptable as long as it stays under about 65,000 or so.
As you stated there are multiple groups (and of course individuals) each with a different goal. It seems to then make different groups look at each other as "crazy" which also makes it hard to see what an overall goal is.
And where one gets their information/lives plays such a huge role. We see cases increasing on in CA and in the NE in places that are well vaccinated, but because they were well vaccinated their were lower rates of infections. These places were also hard hit in 2020 so there is some left over trauma about hearing "cases are rising" that don't happen elsewhere. So case sensitivity differs geographically.
What I don't understand right now is:
(1) Why isn't more money being put into finding a nasal vaccine?
(2) Why isn't their more clarity from the government about yearly/how often we need vaccinations? We have people well over their 6 month booster not knowing what to do since vaccines are more for keeping people from getting very sick, not simply from getting infected
(3) Why isn't there more information/discussion about how long covid symptoms might last/more discussions on the percentage of people who have long lasting symptoms (Meaning % symptoms last 2 months vs % symptoms lasting 6+months)?
I think the issues of long covid hitting the country economically (Fewer people in the workforce and economic losses in the insurance industry) will have an great impact on what defines an end goal and where energy is put (both my media and government).
The NE was slammed by Omicron, despite comparatively high vaccination rates. Everyone that I know in the Boston-area who got Omicron were vaccinated and boosted. I think the notion that vaccine would keep someone from getting infected was long ago abandoned by realizing avoiding severe disease was the more realistic goal when community spread is so high. I hardly remember 2020 because Delta and Omicron, post vaccine, remain so prominent in my mind!
I do hope the nasal vaccines are here sooner than later. I suppose my poorly worded statement was why we weren't throwing more money (ala a mini operation warp speed) at this.
And I think the preventing infection vs preventing serious illness was really when the goal post problem started. While medical/scientific experts were pretty clear on the difference, I don't think the general public was. Part of that was having to push the effectiveness of the vaccine (including hey you can go out without a mask) in order to get more people vaccinated, but over time, when vaccines still worked exceptionally well on serious illness but not simply infection, some people took that as vaccines aren't working/OMG we are in trouble and so messaging got more mixed.
Long covid - I was shocked by the Bank of England estimates. Like most things, the greater the impact the more focus and money is put on an issue. It will be interesting to watch what the business community starts saying about long covid impacts and watch as they push for my answers.
I was shocked to read that Covid is currently the 3rd leading cause of US deaths this year. You wouldn't otherwise know that because of how political Covid continues to be. I don't how to solve the political problem, but I do know it increases the challenge in making good decisions and providing proper guidance. That challenge has been equal to the virus itself IMHO.
After doing everything we could to avoid this, my oldest caught it at school (he was the only remaining child masking in his class). When my husband went positive, we opted to ask for the antiviral since the supply issues seem to be resolved and he has risk factors. Our doc was very against it, though did call it in. I thought the use of antivirals would be welcomed, are there reasons to avoid the antivirals?
My layperson thought process is - we know not much about long covid, nothing about long term syndromes, and that even mild cases can raise the risk of clots, damage to organs, etc, so why would there be reason NOT to lower that viral load as quickly as possible, especially with cases where there are risk factors present?
I do know of the contraindications and side effects, it just seemed strange to hear her say she specifically would avoid it. To me it seems the unknowns and risks of covid would be far greater than those associated with the antiviral. Thank you for the link, I’ll be sure to read it!
Anecdotally, he did take the antiviral, and rapid is neg on day 3 and 4, we are pcr-ing today as well. He will remain masked for a full 10 days in our house (we mask in public anyway) and follow Katelyn's testing suggestions for post anti-viral, but I thought I would share. If he rebounds, I will update as well. I know that he is just 1 case.
May be your doctor was seeing a lot of Paxlovid rebounding which is something being studied and not understood (see Stephen Colbert for a high profile example).
She actually said it was the first prescription she’d written for it. So, may be from others writing it?
In one of the larger private Covid 19 Physician groups there’s been a lot of doctors sharing examples of this phenom lately, so even if she wasn’t prescribing it herself, she may be seeing peers talking about it too. Katelyn wrote about it too on May 10th.
Just a thought of what might be giving her pause. (Or if your husband wasn’t that sick she might have not seen the benefit?). Like my pediatrician would only write for Tamiflu when children were very sick with the flu, and that was even back when the perceived efficacy was high for Tamiflu.
Thank you for your newsletters, which I forward to others regularly. Our local Coronavirus group has a question about this statement “Unfortunately, viruses mutate randomly. We don’t know the next move.” What is the science behind this? Many are of the belief that viruses mutate to be more transmissible and less severe. The Omicron variant has a lot of people convinced the danger of a more deadly variant is passed. Would love to hear more about this topic in your newsletter.
I think this means that it's to viruses' advantage to become more transmissible (selection pressure), but there is no pressure to become more--or less--virulent (pathogenic). By the time a virus has been transmitted from host A to host B, hours or days have passed. For example I think smallpox's virulence remained about the same throughout, and probably there are other examples. I also wonder (anyone know?) whether Omicron variants only SEEM to be less virulent because potential hosts (people) are becoming somewhat more immune from prior natural or vaccine-induced immunity. QUESTION: What happened with the flu pandemic of 1917+? Was that a combo of widespread natural immunity plus a virus that didn't happen to mutate much? (Asking as a non-expert...)
A study I saw yesterday specifically said more died during the omicron wave in Massachusetts than during delta. Early "data" suggesting omicron was less virulent probably contributed to the media statements about decreased virulence.
Obviously, some degree of immunity may mitigate some severity of the disease. This has been demonstrated in the fact that those vaccinated tended overall to experience less severe symptoms and outcomes in breakthrough cases than the unvaccinated. With omicron, prior immunity conferred solely by infection appeared to have little beneficial effect.
In the Spanish Flu we lacked any way to actually identify and sequence the virus. There's speculation that it, too, was a novel coronavirus outbreak rather than an influenza strain, but in those days, virtually any severe respiratory illness was "Influenza". The multiple waves seen over a 3 year period suggest there was mutation. Many cities failed to heed the warnings of areas infected before them, and didn't employ mitigation strategies in timely manner, and suffered the consequences of increased morbidity and mortality. We seem dead-set on repeating those lessons of history.
Note the reply below by Iver. Mutations do occur randomly in viruses. The successful mutations tend to increase the reproduction rate in the disease process (are more transmissible). It's not to the advantage of a virus to rapidly kill a new host, as this reduces the ability of a virus to propagate to more hosts. To that end, increased transmissivity and decreased virulence would go hand-in-hand, but there aren't too many functioning planning neurons in a virus, so a new random mutation could indeed cause more severe disease. Omicron was of particular concern because it had a LOT of substitutions/deletions and we didn't know how those would affect severity or evasion of immunity.
We have no idea if the potential for a more virulent variant remains (actually, we do: It is possible, but is it LIKELY?). I'm in the group that is not convinced we have seen COVID-19 run its course. Recently, Mike Osterholm, University of Minnesota, suggested that the difference between earlier variants and omicron and its subvariants could be allow one to consider omicron a new and novel coronavirus rather than a mere variant of earlier historical lineages. Think, SARS-CoV-3 or COVID-2022.
Finally, we almost always think of COVID-19 as a respiratory virus while there is evidence that its effect on other organs is significant and not related to a respiratory component other than respiratory transmission being the primary vector. Changes in virulence may still occur, and we've not had sufficient time to establish what those changes may be in multiple organ systems. An article in JAMA Open Network found people 18-65 were likely to see a 20% increase in respiratory and thrombotic events over the general population, and those 65-85 could expect a 25% increase. The lesson here is that consequences of COVID are not limited to the immediate acute phase. The potential long-term effects have to be considered as well, and increased mortality in the long-term phase isn't unlikely.
Thank you Katelyn for a balanced multi-perspective piece on the contributors to and implications of policy decisions. As well, individuals and families/social groups must make decisions based on evolving, imperfect data. The analyses that ought to inform such decisions aren't necessarily based on the everyday questions people have. Take for example questions of viral transmissibility. People think in terms of their own situation (including their perceived risk level) - e.g. for how long could a person who tested positive X days ago potentially transmit the virus if not wearing a mask, if wearing surgical vs. KN95 vs. N95 masks, if they were or were not vaccinated/boosted (and how long ago)? Could someone be a 'carrier' without being infected? How would they know? These highly detailed questions are more likely to be asked by people at high risk if they get infected, but may not much affect policy-making.