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  • Dr. Bow Tie

COVID-19: Breaking Our Public Health Promises To Ourselves

A few weeks ago I shared maps of the CDC's "Community Levels" (the newer, politically-driven, toned-down version of the map to make it seem like the pandemic is less rampant than it is) versus the "Community Transmission Levels" (the initial map which indicated how fast COVID-19 was spreading, which can still be used to get ahead of surges). We also discussed wastewater measurements of COVID-19 to predict surges.


After the Delta and Omicron surges last fall and winter, the CDC rolled out these kinder, gentler, Community Levels as part of allowing large corporations to shrug off other protective measures and demand workers come back sooner. The promise was that mask mandates could finally be dropped, with the "encouragement" to restore mandates if (when) transmission/community levels rose back to high levels.


Well, we're there. We have actually been there for some time now, but so far only a handful of counties have restored any type of mask mandate indoors (e.g. Philadelphia, Los Angeles, to name two).

We have multiple variants circulating right now. In addition to OG Omicron, we have BA.2, BA.4, and BA.5; BA.2.75 is starting to show up in more countries (likely including ours).


There has been A LOT of information making its way around, some of it true and some not. What do we know?


DO THE VACCINES STILL WORK?

Yes! They still do what they were intended to do, which is reduce severe disease and hospitalizations. Some of the variants do escape the vaccines especially if it's been several months since your last vaccination, but some protection is still better than none! This now applies to anyone not yet vaccinated, children getting their primary vaccine series, and if you're over 50 or immunocompromised, the second booster (fourth mRNA shot, or third shot if you took J&J).


IS THERE ANY INFECTION-MEDIATED IMMUNITY?

There is SOME protection against reinfection if you get infected with one of these variants, but it is not perfect. We have seen reinfection within weeks, so just because you got over your infection does not mean you can abandon mitigation measures. This is also happening in children, who do not create as much infection-mediated immunity according to a paper to which I'll link (and to which I linked in a previous post). Remember, infection-mediated immunity is NOT substitution for vaccination (less stable and more chance of longer-lasting lung, heart, and brain damage even with mild infections). Get your vaccines!


SO WHAT VARIANTS ARE MOST PREVALENT?

BA.2.75 (Centaurus) is starting to show up in more and more countries. How dangerous it is and how contagious it is remain to be seen. In addition to vaccine-mediated immunity, recent data came out to show that we do have effective monoclonal antibodies (regdanivimab, tixagevimab, and our old friend sotrovimab). Be sure to talk to your doctor to see if you qualify for treatment!


BA.4 and BA.5 are unfortunately a bit better at escaping infection-mediated immunity and vaccine-mediated immunity, but vaccines still provide some degree of protection (especially against severe disease, hospitalization, and death), including for children! In addition, if you do get infected, bebtelovimab is effective against these variants. BA.5 especially seems to be spreading quite rapidly and while the infection may not always merit hospitalization, it does not seem to feel all that "mild" to most people. Remember, "mild" mostly just means avoiding the hospital or the need for supplemental oxygen. Some will have more severe infections (especially if not vaccinated), and others will have persistent symptoms (more and more Long COVID is showing up in medical settings as we get further along).


Pandemic fatigue has set in hard among many people. People are tired of having to think about COVID-19, vaccines, maskingAnti-vaccine commentators continue to try to claim that "vaccines don't work!" (nirvana fallacy), but that is nothing new. However, more folks are beginning to claim that mitigation measures are useless (demonstrably false), or that we don't need them anymore because we have medications to treat COVID-19 (prevention is always preferable to treatment). There is a small faction of doctors claiming that they will "never return to masking" (some even in healthcare settings, which goes against the evidence we have gathered over the past two years). Unfortunately, there is a guaranteed spotlight with these "hot takes" and contrarian physicians, many of whom have not treated COVID patients, are finding sizable platforms amid all the pandemic fatigue.


Even some genuine vaccine experts are susceptible to pandemic fatigue. Dr. Paul Offit, who I've quoted frequently, was featured in an op-ed by Leana Wen, an emergency physician who has been frustrating in her minimizations of mitigation measures (I swear, I didn't mean to alliterate there but now that it's there I'm gonna leave it). Offit has joined some others in saying "we can't keep masking forever" and "we have to accept mild illness as a part of life with COVID-19." He's not technically incorrect, but he and Wen seem to toss aside those for whom it may not be mild - and how increasingly contagious the new variants are, especially among our most vulnerable (the elderly, the very young, and the immunocompromised, though even previously healthy folks can also be heavily affected). This leads to a downplaying of systemic mitigation measures such as improved ventilation and time off for illness when symptomatic.


Now, I don't want fearmonger - this is not the worst it's been. Hospitalizations and severe cases are less than at peak Omicron, thankfully - at least in Buffalo, where I live. That is not the case everywhere. I am still seeing new inpatient cases every week, sometimes prolonged hospitalizations forced to stay because the lung damage does not allow them to breathe adequately without heavy amounts of oxygen. I am also receiving messages or seeing announcements from SO MANY of my friends and colleagues who, despite taking precautions for so long, finally caught an infection or re-infection.


As I write this, my wife (who is usually on the couch next to me working on her own stuff) is isolating in our spare bedroom because she developed symptoms yesterday and tested positive this morning (the day before posting). I am asymptomatic, negative, and have a full week on service ahead of me, so I will be testing every day for the next week (or at least until my wife tests negative). We do not have children or elderly relatives to care for, so isolation is relatively straightforward for us, but my patients are still vulnerable and I have continued to wear KN95 masks indoors and try to stick to outdoor activities for their sake. That said, we have both relaxed our guard a bit over the last couple of weeks, with frequent testing, and this was the risk we took - and it got us.


This is going to continue happening, so we need to keep the danger level as low as we can. We need to remember the on-ramps, the guidelines we initially talked about as mandates were withdrawn: When transmission and levels are high, we SHOULD go back to indoor mask mandates. We should never have stopped frequent, regular testing (even when asymptomatic or presymptomatic, because that's often when it spreads!). Breakthrough infections WILL happen, but we should work to minimize them and, more importantly, their more serious effects.


In the meantime, on an individual level, please be wary as you go through your day, because transmission levels ARE high. If you're indoors with multiple people (especially strangers), especially in crowds, wear a well-fitting KF94 or KN95 mask (one-way protection is something, but two-way protection is much better). PLEASE get vaccinated, get your children vaccinated, and if you're over 50 or have any immunocompromise, get your second booster!


COVID is not over. We cannot afford to act like it is. As always, I welcome your questions.


Kids susceptible to re-infection: https://www.nature.com/articles/s41467-022-30649-1

Monoclonal antibodies vs. BA.2.75: https://www.biorxiv.org/content/10.1101/2022.07.14.500041v1

Neutralization Escape by BA.4 and BA.5: https://www.nejm.org/doi/full/10.1056/NEJMc2206576

Boosters Work Against BA.4 and BA.5 (small study): https://www.nejm.org/doi/pdf/10.1056/NEJMc2206725


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