Delta Variants — More Science, Less Fiction | Dispatch #19
“A fish doesn’t know what water is, until its beached.” — Marshall McLuhan
August 9th, 2021
I was really hoping that my last Dispatch #18, Response Ability, was my final one. After all, vaccines were on the rise and the big third wave was on the downslope and science seemed to be moving a bit faster than nature’s retort. Wishful thinking. As the Delta variant (Variant B.1.617.2) storms through nations, cities, counties, weddings and households, it’s worth noting a few critical elements here. First of all, pandemics are not video games — we cannot will them away with technology, media or magic. They are nature’s responses to something; what, we may never know, however I imagine that it’s as simple as being out of balance.
To put this in perspective: if your car tire is low on air and you don’t tend to it, the entire car drives differently (and you may not really know it). Yet, when the low tire slowly gets too low, the car doesn’t turn well. If you make a hard right turn, you may lose traction and get into an accident. Was it an accident? Or was it something that could have been imputed given you were aware of the low tire, cared about the low tire and understood the probable consequences of inaction to filling that tire.
All this to say, here we are. This pandemic is not going away and more to the Delta point, we are all likely going to get this virus. All the data shows that those that are vaccinated fare much, much better than those that are not vaccinated. The unvaccinated are gambling with their lives, even the younger ones.
Despite the recent rise in cases, the death rate has remained low and while there is always a lag in cases and deaths, we may not (hopefully) see a rise in deaths due to the vaccine penetration.
Should we wear a mask? Should we cancel schools, weddings, events? Should we impose lockdowns? I will attempt to give you a framework for how to answer these very personal questions — and the key question for you is this: what is your risk tolerance?
My goal is to distill the latest science, as we know it, and create a framework so that you can make informed decisions about your life. I fully acknowledge the fast pace of new data and science and with these dispatches hope to unpack with intellectual honesty and intellectual humility.
Science is the method for attempting to find truth through systematic experimentation and empirical probability — and science is always changing. This is why it is critical to distinguish between quality science and pseudoscience. My goal in this dispatch is to animate the best and most accurate science.
The cold hard reality is that we are likely at the one third mark of this entire public health meets post-truthers rodeo. For those vaccinated, you are in a much safer place and despite variant setbacks, progress is being made. The biggest news will be when we have a treatment; until then there is a social and moral imperative to get the whole world vaccinated. We are not isolated; in fact, we’re the opposite, interconnected, dependent and social.
For those of you who desire to see my daily posts, please follow me on LinkedIN as this is where I share my daily readings and musings on Covid.
Lastly, there are models I trust that indicate that Delta, as contagious as it is, will have a difficult time finding new hosts by early Oct and could quickly disappear as it did in the U.K. More info on all of that and more below.
If you’re going to wear masks, get KN95 or N95 — they are much more effective.
Let’s get to it.
STATE OF PLAY
Develop Countries are getting it done. It’s time to focus on the rest of the world.
Here in the US: For some perspective: below is January, April and August -the darker colors indicate more severe risk — this is a Delta backslide!
WAIT, WHAT
“We can either have a free society, or we can have a biomedical security state,” Mr. DeSantis said this week in Panama City, Fla. “And I can tell you: Florida, we’re a free state. People are going to be free to choose to make their own decisions.”
Or said another way, Delta is going to be a nasty wave for the unvaccinated and the healthcare system — and worse is that absent a national strategy, the South is going to cause national problems by potentially spawning new, nastier variants; thereby-imposing their “free choices” upon those of us who will now have restricted choices. Ugh.
The South is getting clobbered — The New Orleans Jazz and Heritage Festival scheduled to take place October 8–17 was just cancelled. Choices have consequences. Bummer!
In science we say that correlation does not equal causation, but the vaccine hesitancy by county illustration below and the graph above does challenge this assumption — and it does beg the question: if resources are constrained, how should the medical profession triage two people with the exact same illness when one of them actively flouted the medical professions recommendations? A moral Gordian knot.
To put this Delta wave in perspective, it’s looks like a lot like the third wave.
To give you a bit of hope, the Institute for Health Metrics and Evaluation sees these possible projections.
TRANSMISSION
In the space of about six weeks the Delta variant (B.1.617.2) went from accounting for around 10 percent of all COVID-19 cases in the United States, to a stunning 83 percent of new cases.
If you’re vaccinated
You can still get Delta and probably will. As you can see in the graph below, Delta is as contagious as chickenpox and smallpox.
In Iceland, despite having the second highest vaccination rate in the world at 79% with at least one dose, they also have one of the most rapid Delta infection spikes in the world.
I posted this commentary on LinkedIn last week…
1. Everyone is likely to get it.
2. The vaccinated people are safer than the non-vaccinated.
3. The unvaccinated people are not as safe as vaccinated
4. If you have lots of other illnesses, you’re less safe than if you’re perfectly healthy.
5. There is always a risk for the healthy, vaccinated person, but that risk is very, very small.
…. and was gobsmacked at the anti-vaxxer response. There is clearly a psychological virus that has yet to be named infecting large swaths of otherwise reasonable people.
From a trusted source: “I was talking to some senior researchers at Moderna. Their thesis: the highly contagious Delta variant will infect a very large portion of the US population between now and the end of September. Then, by October, COVID infections will decline substantially and perhaps crash for lack of new hosts. In other words, high levels of seroprevalence in the US population, combined with ongoing booster shots, will effectively bring the pandemic to an end, allowing an almost total return to normalcy by 2022.”
BOTTOM LINE: The risk of severe disease or death reduced 10-fold or greater in vaccinated and the risk of infection reduced 3-fold in vaccinated. Just be smart and know that there is a high likelihood we are all going to get Delta.
Also: I believe the delta variant will likely burn itself out by the end of October almost everywhere in the US according to many models; of course in areas with low vaccination rates, it’s anyone’s guess how long it lasts.
I’m not sure how to think about this headline: Over half the deer tested in Michigan have been exposed to SARS-CoV-2. I guess the first question I have is, why test deer and the more profound question is what other animals have Covid that we don’t know about. This is a biological phenomenon, not a human one.
PERSONAL RISK TOLERANCE: RISK MATRIX
Here is an email exchange I had with a friend.
Hi Jordan,
I hope you’re having a fabulous Friday. I’m reaching out personally and professionally on the topic of Delta and wonder: This is the personal ask for a colleague who has already rescheduled his wedding once.
If you were getting married in Chicago in late November, which scenario do you think is most likely/what would you do based on your understanding of Delta/the 4th wave?
Cancel now and go to the Court House?
Move forward with a limited (50-ish) invite list?
Continue as planned (200+ invites)?
My answer:
This is a very nuanced question. But the short version for both host and guests debating a gathering is: a) it depends less on the risk of getting delta than on your risk tolerance for getting infected; b) if a group of vaccinated, healthy people who aren’t worried about breakthrough infection want to go to a wedding, OK; and c) if you are someone who isn’t at risk for severe disease and isn’t worried about the hassles of a “vaccinated COVID infection,” who cares?
I’m not sure if this gives you enough info, but it’s really hard to answer this as it’s a deeply personal question about risk tolerance and the guest list.
The most important thing about risk profiles here is the level of vaccine penetration in your community and the case rate. So, dig into the CovidActNow site to learn about your communities vaccination rates and case rates. Also, take some time to think about your risk tolerance.
I know a woman who was absolutely freaked out about getting Covid. Her strategy was not isolation, rather it was testing. She tested hundreds of people who came to her house each week, believing that testing was a fool-proof strategy. You guessed it, she has Covid and hopefully will be fine. (yes, it begs the question of why she had some many visitors.). The point here is try to step outside of yourself and look at your behaviors in the context of your risk tolerance. You might start to resemble the woman I referenced.
VACCINES & BOOSTERS
Vaccines work, they are not perfect. So far, they are proving highly effective and very safe — despite the fake news machine. Before you start mixing and matching vaccines, it may be sensible to check your immune status first (see Immunity).
For those who are immunocompromised, boosters are expected within weeks. Israel is already offering a third dose of Pfizer to this community and Germany is doing this same and offering a second J&J or AstraZeneca.
A recent study showed that the Pfizer vaccine is 96.7% effective against severe disease (although this study did not distinguish different variants). Public Health England published a study that shows that two doses of Pfizer are 96% protective against hospitalization with Delta and 88% effective against symptomatic disease.
This study from Singapore shows that not only do vaccines stop you from getting sick with Delta, but they also clear your viral load much faster. Encouraging and we have much more to learn.
BOOSTERS
There is much debate about boosters — the most compelling article came out August 6th in Nature. The overarching themes are that boosters are a good idea for those immunocompromised and at-risk groups while new data suggest that immunity from the original vaccines does wane over time — which makes boosters more a compelling strategy.
On 29 July, Israel announced plans to give people aged over 60 a third dose of the Pfizer–BioNTech vaccine. The United Kingdom has drawn up tentative plans to offer vaccines to those over 50, as well as other high-risk groups, from September.
- If you had J&J or Astra Zeneca, get either Pfizer or Moderna booster when they are available.
A large mix-and-match booster trial in the United Kingdom is set to deliver valuable insights into the efficacy of different vaccines given as a third dose.
and…The World Health Organization is calling for a moratorium on booster shots until at least the end of September, WHO Director-General Tedros Adhanom Ghebreyesus said during a news briefing in Geneva on Wednesday.
The CDC graphic below shows the clear benefit of the current vaccines for the alpha version of covid but also illustrates the non-trivial benefit against Delta (the little red triangles).
And to make a much finer point on this topic, the WSJ shows hospitalization rates of vaccinated states vs. unvaccinated states.
Known Adverse Reactions To Vaccine
Cardiac adverse events with vaccines are very rare — yet there are reported cases of pericarditis and myocarditis. In this August 6th JAMA study, those that were diagnosed were admitted to the hospital and were discharged after a median of 2 days. There were no readmissions or deaths. Net net: the risk is worth the benefit.
IMMUNITY
People who are not vaccinated but did get Covid, also have natural immunity. LabCorp has a test you can get ($10 for the virtual consultation and insurance pays for the test) to understand the level of your immunity (semi-quantitative spike protein titer). The good news is that SARS-CoV-2 infection results in long (>9mo study length) immune memory of all its structural proteins. Most of the pre-pandemic control population also had a measurable response to other human coronaviruses, suggesting that immunity to this class of virus is extremely long term.
There is some hope that by studying Uber Antibodies from recovered people, we may be able to develop better therapeutics.
The above quote, of course, doesn’t take into account new variants….so we have that going for us.
From the Scientific American article, The Crucial Vaccine Benefit We’re Not Talking about Enough (worth a read):
“”The Delta variant of the coronavirus, now dominant in the U.S. and many other countries, may induce a viral load that is 1,000 times higher than the level that was typically associated with the ancestral lineage of the virus in early 2020. This higher viral load makes Delta infections more contagious, which has led to a greater number of breakthrough cases, albeit many mild or asymptomatic. But the mRNA-based vaccines still provide strong protection, with efficacy against symptomatic infection in the range of 80 to 90 percent. And the ability of these vaccines to substantially reduce viral load in breakthrough cases could be a valuable tool in containing spread of the Delta variant.”
STURGIS, South Dakota.
August 8th. Day One of Ten — likely a real-time super-spreader event.
INFODEMIC
The WHO defines infodemic as an overabundance of information-some accurate and some not — that makes it harder for people to find trustworthy sources and reliable guidance when needed. Does it make you wonder how reliant many people have become on social media? It’s not lost on me that the groups spreading egregious information are highly organized and profit via advertising. These people can change their names and campaigns while consciously seeking vulnerable populations.
MEDICATION
There are still no great medications on the horizon, although this is the ideal scenario. There is some early, preliminary data on fluvoxamine, a generic medicine used for mental health that appears to show some benefit; yet more research is needed. The preliminary rationale is that it confers some anti-inflammatory effects by reducing production of cytokines.
Ivermectin data is not looking promising despite much enthusiasm.
From the reputable Cochrane review:
“We found no evidence to support the use of ivermectin for treating or preventing COVID‐19 infection. Overall, the reliable evidence available does not support the use of ivermectin for treatment or prevention of COVID‐19 outside of well‐designed randomized trials.”
TESTING
Here are some rapid at-home tests for COVID-19 that perform well when testing people with cold symptoms. Inventory is a moving target, of course.
I recommend having these at home before you need them. As the wave increases, they will be more difficult to get.
Binax now (antigen test): Amazon & Walgreens
Lucira (LAMP methodology, a NAAT or “molecular” test like PCR):
Nurx offers Bianax and Luceria
KIDS
According to the American Academy of Pediatrics, “at this time, it appears that severe illness due to COVID-19 is uncommon among children.” However, they also sent a letter dated August 5th to the FDA stating, “The FDA should strongly consider authorizing these vaccines for children ages 5–11 years based on data from the initial enrolled cohort, which are already available, while continuing to follow safety data from the expanded cohort in the post-market setting. This approach would not slow down the time to authorization of these critically needed vaccines in the 5–11-year age group.”
The best way to protect kids who are currently too young to get vaccinated is for everyone else in the household who is eligible to get the shots. If you live in Vermont with low circulating disease and an 80 percent vaccination rate, it’s not the same calculus as if you’re living in New Orleans and hospitals are overflowing.
Many experts agree that the overall benefits of in-person learning outweigh the risks, but for families with kids under 12 who are unvaccinated, decisions about what to do for the upcoming school year may be more complicated.
A recent Lancet study of 258K children showed that the most common symptom was headache and fatigue.
Here are complete statistics on kids in the US. While case rates are going up and the news is making it seem that “younger” people are getting very ill from Covid, it’s important to reconcile that when the media says “younger” they mean people not over 70. Yes, more cases of twenty and thirty year olds are getting ill, but the preponderance of them are likely saddled with other co-morbid conditions. Regarding the dread of mortality, the statistics below show that a child dying of Covid is extremely rare!
- Among states reporting, children were 0.00%-0.26% of all COVID-19 deaths, and 7 states reported zero child deaths.
- In states reporting, 0.00%-0.03% of all child COVID-19 cases resulted in death
Vaccines are being studied for kids under 12 and it is not clear when and whether vaccine developers will publish data on their trials. Both Pfizer and Moderna have launched pediatric studies and we might expect them to seek emergency authorization within six months.
The Centers for Disease Control and Prevention shared updated guidance that fully vaccinated individuals in counties with “substantial or high transmission” should resume wearing masks indoors. Additionally, the CDC now recommends that all teachers, staff, and students in K-12 schools wear masks indoors — even if they’re vaccinated.
Emily Oster
My colleague and bestselling author on kids and parenting, Emily Oster, states
“What should you expect?
First, there is about a 50% chance they’ll be totally asymptomatic (based on various things, including this French study). If they do have symptoms, in the vast majority of cases, those will be mild and short term. Last week, The Lancet published this excellent study on about 1700 symptomatic COVID-19 cases in children. The most common symptoms were headache and fatigue, and the average duration of symptoms was 6 days, with 75% of children having symptoms for a week or less. “
To put things in perspective, the risk of a child dying of covid-19 is roughly the same as them dying of influenza — the more proximate concern is symptoms that linger beyond eight weeks.
Basically, if you think you or your child just has a cold, get your child and family tested asap.
Here is the Aug 4th update from the CDC which recommends universal indoor masking for all students, staff, teachers, and visitors to K-12 schools, regardless of vaccination status.
The American Academy of Pediatrics has put out this great resource/checklist for how to think about youth participation in sports.
LONG COVID: Adults and Kids
It’s real. There are two initiatives I find compelling, Survivor Corps and a new initiative launched by the National Institutes of Health, the RECOVER project.
Their objective is to find treatments for people with lingering COVID-19 symptoms and ascertain the biology and pathology. There are already many hypotheses, including a persistent low level of virus, a “ghost” of the virus where lingering fragments cause harm or most likely an autoimmune response. The latter is consistent with why some fully vaccinated people may still get long Covid.
An April study by the United Kingdom’s Office for National Statistics found that 9.8 percent of 2-to-11-year-olds and 13 percent of 12-to-16-year-olds infected with the coronavirus reported continuing symptoms five weeks later. After 12 weeks, rates remained significant: 7.4 percent in the younger group and 8.2 percent in the older group.
In another U.K. study, 4.4 percent of 1,734 children had symptoms more than four weeks post-Covid, over four times as high as the percentage with symptoms four weeks after non-Covid illnesses like flu. About 2 percent of Covid patients had symptoms after eight weeks.
FINALLY
Here is a great chart from my good friend Bob Wachter at UCSF. He is a must- follow on Twitter.
IN CLOSING
We are entering the phase of the forever pandemic that will wax and wane based on the global community efforts to vaccinate the world and develop medications that work. So long as developing countries have low vaccination rates, variants will emerge. This is the tire with low air analogy I made earlier. We cannot, a priori, know how this ends with so much imbalance on earth. I won’t get into my thoughts on what the imbalances are that likely stimulated this pandemic here, but I do look for the silver linings for our future. We are spending more time with family, learning to work from home, commuting and polluting less, moving to rural areas and stimulating local economies, recalibrating our consumptive tendencies, realizing the corrosive effects of ultra processed foods and their negative impact on our health, and a renewed spirit of collaboration in the scientific community, to name a few.
The goal of the CDC’s updated guidance is to reduce the likelihood that fully vaccinated people become infected and transmit the disease to unvaccinated people, while the virus is surging across the country. If you are fully vaccinated and live in a county with high vaccine coverage, you should feel safe in most environments, and if your county does not have high vaccination rates, consider taking extra precautions .
This still begs the big question: at what point do the vaccinated people continue to protect the unvaccinated people who do not want to be protected? This is the moral and ethical elephant-in-the-room question. The counter-factual question would be: do the unvaccinated people take any measures to protect the vaccinated people?
Unvaccinated people frame this as their “choice,” yet the choice that they make constrains the choices of the community — and how do we reconcile one person’s “freedom of choice” when it constrains their fellow citizens’ “choices”?
There are some people who just aren’t afraid of Covid and the real challenge is to educate them with compassion as making them feel defensive for their passionately held opinion isn’t productive.
Some final words of wisdom:
Pay attention.
Look for patterns.
Be aware of the things going on around you.
Be open to new ideas.
Avoid large indoor gatherings.
Wear masks at indoor venues, preferably a KN95.Get comfortable with the idea that there is still a high likelihood you will get Delta.
This is Dr. Jordan Shlain, signing off for now.
This dispatch was created on August 8th and is the 19th in an ongoing series.
P.S. We all have a collective responsibility to produce simple, clear and honest messages underpinned by trust, credibility, humility and self-efficacy.
Please help me raise awareness for EatReal. CEO Nora LaTorre is available if you would like to collaborate.
