COVID again.

[dreamshark]

I haven't posted about COVID for awhile, partly because everyone is sick of the topic but mostly because it seemed pretty clear how the game was going to play out. But just as we were rounding third base and heading for home plate, the delta variant arrived. There were concerning mutations before, but this one is a game-changer. In fact, it has me wondering exactly how much a virus has to mutate before we stop calling it a "variant" and give it a new major release number.

This isn't just a little more drift towards increased virulence - the symptoms are different and everything we've learned so far about how to protect ourselves from infection is called into question. People are catching it outdoors now, something that was actually pretty rare with the OG virus. There are now documented cases of people being infected by passing an infected person in the mall. The chances of household spread have jumped from a surprisingly anemic 25% to 90%. A crew of airplane cleaners was reportedly infected - is it actually spreading through surface contact now? Do masks even work any more? 

I've been trying to process the new information and figure out what it actually means. How should I change my behavior? Does it make a difference if I make that evaluation based on my own personal welfare or the general welfare of society? And is this the worst twist that COVID could have taken, or is it not as bad as it sounds?

THE BAD NEWS 

• In Provincetown, MA (one of the most vaccinated states in the country) almost 900 people got infected over Fourth of July. 75% of them were fully vaccinated. Remember when we thought 50 people was a big infection cluster? 
• Anecdotal reports from hospitals around the country strongly suggest that the delta variant makes people sicker. Younger people (including an increasing number of children) are ending up in intensive care. And they get sicker faster - average time from onset to hospitalization is shorter, and from initial hospitalization to ICU. 
• The R0 of this variant is tentatively estimated at 5-9, which is approaching the virulence of chicken pox. Chicken pox virus wafts on the wind. Do you know what percentage of adults in the US have had chicken pox?  95%. Think about that. Pretty much every unvaccinated person is going to get this. Sources who are still describing the delta variant as "twice as contagious" need to get with the program. More like 3 or 4 times. 
• There are clearly way more breakthrough infections with Delta than the government wants to admit. Data from Israel, where they seem to be more committed to distributing actual facts than the US health care establishment, has found that the Pfizer vaccine is just 39% effective at preventing infection now that delta is the dominant variant there. This compares to about 90% effective with the original virus. That is a stunning decline. 
• And vaccinated people who get infected can spread the virus, which rarely happened with the earlier variants. That's what really changes the whole social calculus. Now vaccinated people can infect other vaccinated people. 

THE GOOD NEWS

• The vaccines really are effective at preventing serious illness and deaths, even the J&J vaccine. Only 3% of people coming into hospitals with COVID now have been fully vaccinated. And I think that includes the population that was hospitalized for reasons unrelated to COVID and just turned out to have it when they were routinely tested. 
• Vaccination rates are finally going up in states like Missouri, Alabama, and Arkansas. A lot. Nationwide, it's up 26% from 3 weeks ago. In Alabama and Arkansas the vaccination rate has doubled. I suppose it's only a matter of time before even Florida Man takes notice of what is going on and rethinks things. 
• It looks like India and the UK have peaked out and are headed back down again. I've analyzed these graphs before and noted that the time from the top of a steep peak back down to baseline is usually 6-8 weeks, pretty much independent of mitigation steps. It's usually pretty symmetrical - 6 weeks up and 6 weeks back down. It will be interesting to see if the pattern holds, especially with 2 countries in such different situations vaccination-wise. 
• It's not really as communicable as chicken pox. There's an overlap between the highest R0 estimates for COVID (5-9.5) and the lowest estimates for chickenpox (8.5-12). It's moving up into the hideously contagious category, but probably not quite that contagious. Yet.

SO WHAT SHOULD I DO?
My first reaction was to start masking up and avoiding crowds again, hoping that this spike will peak and crash within a couple of months. That's a revision of my initial strategy of just trying to ride out the pandemic without getting infected.  

But maybe that's not the right strategy anymore. If everybody is going to catch it, maybe now is as good a time as any. I'm relatively freshly vaccinated and in good health. A mild case of delta variant on top of a recent mRNA vaccination might just put the cherry on the top of lifetime immunity to this virus. 

It's highly unlikely that the SARS-2 virus is going to kill me now, or even make me very sick. But there's still Long COVID to worry about. There's not enough known about that, but it doesn't sound like having a mild case makes you any less likely to have lingering symptoms. So maybe the best approach is to hunker down and wait it out until there's a booster shot available, especially one tailored to the variants. 

And why exactly is the government urging people to mask up and take precautions rather than just get vaccinated and let it play out from there? What do they think the end game is? Are they counting on the whole thing burning itself out in another 6 months? Another year? Or are they assuming that there will eventually be a booster that could protect the entire population? 

Comments

[redbird]

At a guess, they're urging us to mask up and take precautions because children still can't be vaccinated, and even if every adult who isn't vaccinated changes their minds, vaccinating that many people will take weeks if not months.

If everyone is going to get Covid sooner or later, we may be back to "flatten the curve" territory, because there aren't significantly more medical workers or hospital beds than 18 months ago, there may not even be as many (because of doctors and nurses who died or were disabled by the virus, or are too burned out by what they've been through since this started.

On the other hand, chicken pox may be a relevant comparison for another reason: best is not to get it, but if you're going to get it, you're better off catching it when you're five than when you're in your 20s or 30s.

[dreamshark]

All good points.

[quadong]

I remain unclear on the breakthrough infections. On NPR last week, a guest pointed out that PCR tests can return a positive result if you have a single virus on the swab. These are reported as "infections", when a more accurate assessment would be "some virus landed here and were all killed by the immune system (not an infection)". All PCR tests automatically distinguish between a single virus and many viruses, but the distinction is typically not reported and they are all called "positive".

Do vaccinated people really get *infections* at any significant rate? i.e. where the virus is substantially multiplying in their body before being fought off? Or do they just have a lot of virus landing on them because unvaccinated people are shedding prodigious amounts of it?

[dreamshark]

Yes, this virus really brings into focus how inadequate our traditional medical terminology is. What DO we mean by "infection?" Does "asymptomatic infection" actually make sense? Can you be infected but not sick? That's not a distinction that anybody ever made in the past when assessing the effectiveness of a vaccine. The reason we started doing it with SARS-2 was because it turned out that a significant number of people seemed to be passing on the virus to other people without being sickened by it themselves. So it became important to come up with a term that captured that. We seem to have settled on "infected" vs "symptomatically ill."

But then, just as the medical establishment was reluctantly admitting that asymptomatic infection was playing a significant role in the spread of the disease, we have a new question. Are vaccinated-infected people as contagious as unvaccinated-infected people? With the original virus it kind of looked like the answer to that was no, although it was hard to be sure because breakthrough infections were so rare.

But with the delta variant, it's looking like there are WAY more people with breakthrough infections, some symptomatic and some not. Medical authorities initially clung to the idea that vaccinated people were not a factor in spreading the virus, but that's clearly no longer true. That's why the CDC went into a tailspin with the discovery that vaccinated-infected people were probably just as infectious as unvaccinated-infected.

From a public health standpoint, the most important piece of information is still "Who can spread the virus?" For hospital planning, it's also important to know how many people are likely to need serious medical intervention, but the first order of business is to keep the virus from spreading. So we should probably use the term "infected" to mean that a person has enough virus in their system that they can spread it to someone else. And with the delta variant, that seems to be the case for most or all of the people who test positive.

We may eventually need a different term for people who have been exposed to sufficient amounts of the virus to develop some immunity to it but not enough to become spreaders.

[lydamorehouse]

The Delta variant freaks me out. I've been masking in public spaces again. per the CDC, but it feels very much like I'm the only one. Sometimes I will see staff masking at food service places, but not uniformly?

I kind of just want to hide for another six months, but I just started to enjoy people again????

[dreamshark]

I guess it depends on your long-term goal (which is the thing I can't quite figure out for myself).

If everybody is going to get it eventually, the best strategy is probably to get vaccinated and then go about your business until you eventually get infected. Most likely it will be mild or asymptomatic and then you will have increased immunity, possibly all the immunity you will ever need for the SARS-2 virus.

If there is going to be another booster shot (ideally one that is enhanced to cover all known variants) you can go back into hiding and wait for that.

Or you can go back into hiding and hope that the whole thing blows over on its own like the Spanish Flu did. I think this is really a variation on option #2, except you'd be waiting for natural herd immunity rather than another vaccine.

Why do you think the CDC wants us to mask?
ETA: let me rephrase that. I don't mean why do you think that is what the CDC wants. You think that because that's what they said, sort of. I mean why is the CDC saying that?

[lydamorehouse]

Having read several articles in the New York Times about places that are seeing a resurgence (or new surge, if you will,) of the Delta variant, the reason is simple: to save the hospitals from being overwhelmed. Sure, we might all get it, but it's best if it's not all at once.

Hospitals and staff are collapsing under the exponential growth of this one.

[dreamshark]

Right, what they used to call "flattening the curve." That makes sense, especially in places like Florida and L.A. where the hospitals are back in crisis mode now, or approaching it.