Category: Medicine

Where are the Variant Specific Boosters?

I wasn’t shocked at the failures of the CDC and the FDA. I am shocked that our government still can’t get its act together in the third year of the pandemic. Consider how lucky, yes lucky, we have been. Here’s Eric Topol:

…the original vaccines were targeted to the Wuhan ancestral strain’s spike protein from 2019. The spike protein, no less the rest of the original SARS-CoV-2 structure, is almost unrecognizable now in the form of the Omicron strain (see antigenic drift from prior post). While there’s naturally been much focus on the extraordinary number of mutations in the receptor binding domain and the rest of the spike protein, over 50 mutations are spread out throughout Omicron, making the prior major variants of concern (Alpha, Beta, Gamma, Delta) lightweights with respect to changes in structure that are not just linear or uni-dimensional. Each mutation can interact with others (epistasis); any mutation or combination of mutations has the potential to change the 3D structure of the virus. In this sense, Omicron is an overwhelming reboot of the ancestral strain.

Omicron is very different from the Wuhan ancestral strain and it’s only a matter of luck that the vaccines continue to work and that Omicron is likely less severe than Delta. Don’t tell me that viruses evolve to be less severe over time–that isn’t correct in theory or practice. The most one might say is that a very deadly virus may be difficult to transmit but that only closes off a small part of the evolutionary design-space. There is plenty of room for transmission and lethality to both increase. So the vaccines continue to work well. We got lucky. But for how long will our luck last? Do we really have to wait for a more transmissible, more deadly, more vaccine escaping variant before we act?

Where are the variant-specific boosters? The FDA has said they would approve them quickly, without new efficacy trials so I don’t think the problem is primarily regulatory. Why not catch-up to the virus and maybe even get a jump ahead with pan-coronavirus vaccines?

More generally, in our February 2021 paper in Science my co-authors and I argued that we were still leaving trillion dollar bills on the sidewalk by not investing in more vaccine capacity. I am sorry to say that we were right. Why the failure to invest more broadly?

Mostly I blame American lethargy. After 9/11 the country was angry and united and we had troops in Afghanistan within a matter of weeks and we had taken over the country in a matter of months. For better or worse, we acted quickly and with resolve. Yet, when the virus was killing at 9/11 levels every day the public never reached the same level of anger or resolve. Even now Congress has spent trillions on unemployment insurance, business protection, money for schools and stimulus but has not passed the American Pandemic Preparedness Plan, a pretty decent, mostly science-based investment plan.

80,000 hours ranks research and investment against Global Catastrophic Biologic Risk (GCBR) as among the most pressing and yet tractable problems to work on and yet they estimate that quality-adjusted only about a billion dollars is being spent on these risks. Moreover, COVID doesn’t even count as a GCBR, i.e. 80000 hours at least recognizes that things could be much worse.

I understand that future people don’t vote but even so I expected a little bit more foresight.

How to elect Republicans

In New York, racial minorities are automatically eligible for scarce COVID-19 therapeutics, regardless of age or underlying conditions. In Utah, “Latinx ethnicity” counts for more points than “congestive heart failure” in a patient’s “COVID-19 risk score”—the state’s framework for allocating monoclonal antibodies. And in Minnesota, health officials have devised their own “ethical framework” that prioritizes black 18-year-olds over white 64-year-olds—even though the latter are at much higher risk of severe disease.

These schemes have sparked widespread condemnation of the state governments implementing them. But the idea to use race to determine drug eligibility wasn’t hatched in local health departments; it came directly from the federal Food and Drug Administration.

Here is the full story, I am very willing to issue a correction if it turns out anything posted from this is wrong.

Whither Australian liberty and rule of law?

According to a person close to the tournament with direct knowledge of the sequence of events, Djokovic followed every step of the country’s visa process properly. Moreover, the person said, Djokovic’s medical exemption was granted with all identifying information redacted, ruling out the possibility of favoritism for the tennis star.

But in the view of the person close to the Open, Australian authorities “did an about-face” on Djokovic’s status after his disclosure of being granted a medical exemption to covid vaccination requirements sparked outrage in Melbourne and throughout the country from citizens who have been subject to exceedingly strict protocols for nearly two years.

“He did everything correctly,” the person said. “But the goal posts have been changed — for him.”

Here is more from the very pro-vaccine Washington Post.  Has the culture there become so worn down from internal restrictions that they are so resentful?  Over ninety percent of the Australian public is vaccinated, and omicron is spreading there in any case.  Maybe there was some minor problem in the visa application, but so often there is — should the result really be such last minute political grandstanding?  It would have been easy enough to inform him in advance that maybe he would not be admitted into the country, right?  Is his case now really going to receive a fair hearing?

The mental health benefits of vaccines

We estimate that COVID-19 vaccination reduces anxiety and depression symptoms by nearly 30%. Nearly all the benefits are private benefits, and we find little evidence of spillover effects, that is, increases in community vaccination rates are not associated with improved anxiety or depression symptoms among the unvaccinated. We find that COVID-19 vaccination is associated with larger reductions in anxiety or depression symptoms among individuals with lower education levels, who rent their housing, who are not able to telework, and who have children in their household. The economic benefit of reductions in anxiety and depression are approximately $350 billion. Our results highlight an important, but understudied, secondary benefit of COVID-19 vaccinations.

Here is the NBER working paper by Virat Agrawal, Jonathan H. Cantor, Jeeraj Sood, and Christopher M. Whaley.

Some simple game theory of Omicron

Let’s say that everyone is totally reckless, and they go to Christmas Eve “Omicron parties.”  A week or two from now the virus has cleared their systems and I, who stay at home and blog, can then go out and frolic.  Even if they stay sick, or if they die, they are removed as sources of potential infections for others (see below for new variants, possibly from the immunocompromised).

If I know that is happening, I find it easy to stay at home for a week.  I look forward to my pending freedom.  In other words, right now my behavior becomes safer.  I engage in intertemporal substitution.

Alternately, let’s say that quite a few people decide to behave more safely.  They stay at home and avoid the Omicron parties, and furthermore they go about with a mask in Whole Foods and don’t go to bars at all.  The Omicron pandemic, instead of being over in two weeks, can run on for months, depending on the exact numbers of course.  There is a ready stock of “not yet infected with Omicron” potential victims to keep the virus circulating.  And that means ongoing risk for me.

Returning to my decision calculus, I can wait a week but I cannot stay at home for a month or two.  So I know I am going to go out, and I expect I am going to get Omicron.  So I might as well go out now.  My behavior becomes riskier.

Get the picture?  If one set of people behave more safely, another set takes more risks.  And vice versa.

This is one reason why moral exhortation, or for that matter policy interventions, may be less than effective in our current moment.

It is also a reason why telling people “don’t worry about it!” doesn’t fully translate at the collective level either.

Of course you can modify these scenarios with reinfection risk, new variants, and other factors.

ProPublica on the FDA and Rapid Tests

Lydia DePillis has written the best piece on the FDA that I have ever read in a mainstream news publication. It gets everything right and yes it frankly verifies everything that I have been saying about the FDA and rapid tests for the last year and a half. I wish it had been written earlier but I suppose that illustrates how difficult it is to radically change people’s mindset from the FDA as protector to the FDA as threat. The sub head is:

Irene Bosch developed a quick, inexpensive COVID-19 test in early 2020. The Harvard-trained scientist already had a factory set up. But she was stymied by an FDA process experts say made no sense.

The piece recounts how cheap, rapid tests could have been approved in March of 2020! Here’s the opening bit:

When COVID-19 started sweeping across America in the spring of 2020, Irene Bosch knew she was in a unique position to help.

The Harvard-trained scientist had just developed quick, inexpensive tests for several tropical diseases, and her method could be adapted for the novel coronavirus. So Bosch and the company she had co-founded two years earlier seemed well-suited to address an enormous testing shortage.

E25Bio — named after the massive red brick building at MIT that houses the lab where Bosch worked — already had support from the National Institutes of Health, along with a consortium of investors led by MIT.

Within a few weeks, Bosch and her colleagues had a test that would detect coronavirus in 15 minutes and produce a red line on a little chemical strip. The factory where they were planning to make tests for dengue fever could quickly retool to produce at least 100,000 COVID-19 tests per week, she said, priced at less than $10 apiece, or cheaper at a higher scale.

“We are excited about what E25Bio is capable of shipping in a short amount of time: a test that is significantly cheaper, more affordable, and available at-home,” said firm founder Vinod Khosla. (Disclosure: Khosla’s daughter Anu Khosla is on ProPublica’s board.)

On March 21 — when the U.S. had recorded only a few hundred COVID-19 deaths  Bosch submitted the test for emergency authorization, a process the Food and Drug Administration uses to expedite tests and treatments.

You know how the story ends but really READ the WHOLE THING.

The Slow Rollout of Rapid Tests

I thought the Biden administration would at least make original pandemic errors. But no, its been making all the same errors. Slow on vaccines, slow on rapid testing and slow on new drugs, and far too little investment. Still after a year and half of shouting it from the rooftops we are getting some rapid tests. Josh Gans has an interesting reminder focusing on Canada that this has been an example of expert failure not just US failure. 

Rapid test advocates such as myself have suddenly moved from fringe crazies who were told they didn’t understand the science to we need them and we need them now.

Several cases in point:

  • The CDC now says that unvaccinated students exposed to Covid can “test to stay.” That is, rather than sending all the students in a class (or a school!) home when one tests positive for Covid, they test the students instead and so long as they are negative, they stay.
  • The US Government is going to order 500 million rapid tests and distribute them free to the public … by mail!

It is hard to appreciate what a sea change this is in terms of attitude. A year ago, when we tried to roll out rapid tests — that had already been purchased and were sitting in their millions in warehouses in Canada — to Canadian workplaces, we were told that those tests had to be administered by health care professionals in PPE in secure and sanitised environments with all manner of precautions taken that really took the “rapid” out of rapid testing let alone exploding the costs to businesses who wanted to keep their workers safe. This was because they required those long-swabs etc. Eventually, short swabs were permitted. Then self-swabbing supervised in the workplace. Then swabbing at home while on a virtual call with a professional for that supervision with the swabs being picked up and then taken for safe disposal. Finally, we got to self-administered, at-home screening without supervision and you could pop your negative swan in the bin. A year after we had been told that you needed a full-court medical professional press to do this, our kids in Ontario were sent home with 5 rapid tests to use over the holidays. Only a couple of weeks ago, the Ontario government’s advisory board, the Ontario Science Table, finally endorsed the use of rapid tests in this way.

Freddie on worry porn

Bogost’s piece is an absolute classic, maybe the classic, in a particularly strange form of worry porn that progressives have become addicted to in the past half-decade. It’s this thing where they insist that they don’t want something to happen, but they describe it so lustily, imagine it so vividly, fixate on it so relentlessly, that it’s abundantly clear that a deep part of them wants it to happen. This was a constant experience in the Trump era – liberals would imagine that Trump was about to dissolve Congress and declare himself emperor, they’d ostensibly be opposed to such a thing, but they were so immensely invested in the seriousness and accuracy of such predictions that they’d clearly prefer for it to happen. I wrote about Chris Hayes and his bitter yearning for Trump last week, and he’s a good example, someone who ruminates on Trump and the dystopian future he might bring about with such palpable emotional pathology that it’s clear that, on some level, he needs it to happen, so that he can say “I was right.” And so with Bogost here; that level of anxious catastrophizing always carries with it the quiet, throbbing need for the bad dream to come true. Covid is already bad, very bad. I am always so confused that so many people seem desperately to want it to be worse.

Here is the full essay.

Earlier data on Texas abortion restrictions

Between 2011 and 2014, Texas enacted three pieces of legislation that significantly reduced funding for family planning services and increased restrictions on abortion clinic operations. Together this legislation creates cross-county variation in access to abortion and family planning services, which we leverage to understand the impact of family planning and abortion clinic access on abortions, births, and contraceptive purchases. In response to these policies, abortions to Texas residents fell 20.5%and births rose 2.6% in counties that no longer had an abortion provider within 50 miles. Changes in the family planning market induced a 1.5% increase in births for counties that no longer had a publicly funded family planning clinic within 25 miles. Meanwhile, responses of retail purchases of condoms and emergency contraceptives to both abortion and family planning service changes were minimal.

That is an NBER paper from 2017 by Stefanie Fischer and Corey White.

Will this Australian polity prove sustainable?

And what would Lysander Spooner say?:

South Australian Premier Steven Marshall said the two-week rule for vaccinated close contacts was under constant review.

And:

When Shaun Ferguson was browsing the plants at a local nursery last Tuesday afternoon, he never thought it would land him in two weeks quarantine in a medi-hotel.

That night he received the text message that no one wants to receive.

“At about 11.30 that night I got a text message from SA Health saying that I’d been to a potential exposure site for the Omicron strain,” Mr Ferguson said…

There were three other people on the bus with him, including a woman who had also visited the pet and plant shop in Glengowrie.

“She said, ‘I never go anywhere, I’m fully vaccinated … I just decided I’d go there and get this cat brush and now look what happens. I’m in quarantine,'” Mr Ferguson said.

There is much more to the story, and for the pointer I thank A.

How Many Lives has Vaccination Saved?

A Commonwealth Fund study:

The U.S. vaccination program campaign has profoundly altered the trajectory of the COVID-19 pandemic, preventing nearly 1.1 million deaths. Even with only about 60 percent of Americans vaccinated to date, the nation has dodged a massive wave of COVID-19 deaths that would have started as the Delta variant took hold in August 2021. Because of Delta’s rapid and nationwide spread, deaths due to COVID-19 would have far exceeded all previous peaks.

Our estimates suggest that in 2021 alone, the vaccination program prevented a potentially catastrophic flood of patients requiring hospitalization. It is difficult to imagine how hospitals would have coped had they been faced with 10 million people sick enough to require admission. The U.S. has 919,000 licensed hospital beds and typically accommodates about 36 million hospitalizations each year.3 Even the 2.6 million COVID-related hospitalizations that occurred during 2021 placed an enormous strain on hospitals, with many staff lost not only to the virus but also to exhaustion and burnout. Faced with such unprecedented demand, U.S. hospitals operating under crisis standards of care would likely have had no choice but to turn away tens of thousands or even hundreds of thousands of individuals.

The methodology is somewhat unclear so take this with a grain of salt–many future studies will look at this question–but one million lives saved is not outside the realm of the possible. One million lives saved at a $7 million value of statistical life is a 7 trillion dollar savings. Keep this number in mind when evaluating pandemic investment.

Photo Credit: Lindsay Bonanno