COVID news 7/29/22

(and a Monkeypox update)

Hi all,

I am including a few articles on monkeypox this week as the WHO declared monkeypox a “public health emergency of international concern” (PHEIC) on July 23rd, which is the WHO’s highest alarm. San Francisco has also declared monkeypox a local public health emergency. So far, 98% of cases have been found in men who have sex with men, but anyone who has prolonged skin-to-skin contact with an infected person or contact with an infected person's linens (sheets and towels) can get monkeypox. The smallpox vaccine Jynneos can protect people against monkeypox if they are vaccinated within 3 days of exposure and vaccinations are being offered to high risk individuals.

This week, a study from Portugal shows that an infection with the BA.5 variant of SARS-CoV-2 is more than 3x as likely to cause hospitalization as BA.2 infection in vaccinated people, confirming the Danish report from last week that showed that BA.5 is 65% more likely to cause hospitalization probably because of BA.5's increased virulence. Fortunately, the absolute numbers of hospitalizations are lower than in previous SARS-CoV-2 waves because we continue to build our "immunity wall" from vaccinations and prior infections.

BA.5 is more infectious and more immune evasive than any prior variant.  Many people are positive on rapid antigen tests for longer, and are therefore infectious to others longer, with BA.5.  In fact, one in four people is still positive on rapid antigen test on day 8 with BA.5. We should be isolating for at least 10 days with BA.5 instead of the 5 day recommendation from the CDC.  The CDC recommendations should evolve along with the evolving virus, but they haven't yet.

Two new studies show that prior BA.1 and BA.2 infections may protect against BA.5.  This is in direct contradiction to other studies showing that BA.1 and BA.2 infections would not protect against a reinfection with BA.5.  Immunity is very complex and is different for each individual depending on prior COVID infections, vaccines, prior viruses the body has seen, mutations in the latest SARS-CoV-2 virus variant and other factors. 

Children age 6 to 11 who are vaccinated against SARS-CoV-2 with the original mRNA vaccines also produce antibodies against Omicron.  Unfortunately, only 30% of kids aged 5 to 11 years old and only 3% of younger children ages 6 months to 5 years have been vaccinated against COVID.  Many parents still plan not to vaccinate their children according to the KFF.  We need better messaging for parents on why vaccinating their children against SARS-CoV-2 can protect them and others in the family as children often bring the infection to the home.

Evusheld is a pre-exposure prophylactic drug containing 2 long lasting monoclonal antibodies that can shield immunocompromised people against getting COVID infections before they are exposed.  We need to try to get more immunocompromised people information on how to get Evusheld.  Many immunocompromised people do not make good antibodies against the virus after vaccination because of their immune system issues and therefore they are prone to getting protracted COVID infections that may lead to new variants of the virus.  Evusheld could help them to avoid both severe disease and prolonged chronic SARS-CoV-2 infections. 

Finally, in opposition to the FDA's latest recommendation, I believe that all adults including those under age 50 should be able to get a 2nd booster (dose 4) now. Most people got their 1st booster last November or December and we know that antibody levels wane over several months.  The FDA has decided that adults under age 50 should wait until "September" when the new bivalent vaccines (mRNA to both the original Wuhan virus and to BA.5) are available. It would be surprising if Pfizer and Moderna can get these new bivalent vaccines ready, mass produced and into people's arms by September.  That is only about 4 to 6 weeks away. I agree with Drs. Bob Wachter, Fauci, Ashish Jha, and Eric Topol that the U.S. should allow anyone under age 50 to get the 2nd booster (dose 4) of the original mRNA vaccines now if they desire.  We know that immunity wanes anywhere from 2 to 5 months later and these folks can get the bivalent booster after several months if they so choose.

I will be taking a week off from the COVID newsletter next week. So, unless there is exceptional breaking news, my next newsletter will come out on August 12, 2022.

Have a good weekend,

Ruth Ann Crystal MD
Twitter: https://twitter.com/CatchTheBaby

Important science news: DeepMind AI can predict how almost all proteins fold 

• AlphaFold reveals the structure of the protein universe https://buff.ly/3zBjpiN

Monkeypox news:

7/25/22 NEJM: Monkeypox Virus Infection in Humans across 16 Countries — April–June 2022  https://buff.ly/3b48QLH

• 528 monkeypox (MPX) infections in 16 countries

• 98% of the persons with MPX were gay or bisexual men, 41% had HIV.

• Sexually transmitted in 95%.

• In this case series, 95% of the persons presented with a rash (with 64% having <10 lesions), 73% had anogenital lesions, and 41% had mucosal lesions (with 54 having a single genital lesion). 

• Common systemic features preceding the rash included fever, lethargy, myalgia and headache; lymphadenopathy was also common. 

• Concomitant sexually transmitted infections noted in 29%. 

• Median incubation period was 7 days (range, 3 to 20). 

• Semen was positive for MPX virus in 29 of the 32 persons tested.

• 13% were hospitalized for pain management, superinfection; pharyngitis limiting oral intake.

7/23/22 WHO chief declares monkeypox a global emergency https://buff.ly/3PXWfbT

• WHO declares monkeypox (MPX) “public health emergency of international concern” (PHEIC), the WHO’s highest alarm.

• >16,000 cases in 75 countries, 5 deaths

• "WHO’s assessment is that the risk of monkeypox is moderate globally and in all regions, except in the European region where we assess the risk as high".

7/26/22 Palo Alto Online: Monkeypox is spreading in the Bay Area. Stanford wastewater data shows the region's hot spots. https://buff.ly/3PFyZPV

• London Breed’s article: Monkeypox: What a Local Health Emergency Means https://buff.ly/3Bkzj2q

_________________________

Tongue-in-cheek Timeline of COVID: "No one could have foreseen this."

COVID News: 

     World             

United States

United States:

7/26/22 CDC reports BA.5 is now 82% of cases in US

NY Times: US reported cases (probably 5x this because of home testing):

US Wastewater from CDC: https://covid.cdc.gov/covid-data-tracker/#wastewater-surveillance

Note the high levels reported in many more places now.

Wastewater SCAN (Bay Area): https://soe-wbe-pilot.wl.r.appspot.com/charts

Australia: BA.5 is causing record hospitalizations and a significant rise in deaths

Australia deaths:

New Zealand deaths:

Japan’s cases!

7/28/22 NY Times: Biden Administration Plans to Offer Updated Booster Shots in September https://buff.ly/3PJNJNX

• With reformulated shots from Pfizer and Moderna on the horizon, the F.D.A. has decided that Americans under 50 should wait to receive second boosters.

7/29/22 I agree with Drs. Bob Wachter, Fauci and Ashish Jha and Eric Topol. We should offer a 2nd booster (dose 4) to people under age 50 now.  The new bivalent vaccines won’t be out until sometime in September possibly, and many people won’t receive them until November or later depending on the vaccine roll out.

Give the 2nd boosters (dose 4) now if people want them.  They received their 1st dose booster (dose 3) last November and December and immunity wanes. It’s been 8 months for many.

7/28/22 NY Magazine: BA.5 Shows COVID Is Evolving Fast. Why Aren’t We Fighting Back? https://buff.ly/3vougdD

• Dr. Eric Topol on BA.5, next-gen vaccines, and America’s maddening capitulation to the virus.

7/28/22 Economist: Paxlovid appears to be reaching the Americans who need it least https://buff.ly/3zimCSY

• The vaxxed take Pax.

7/27/22 via Eric Topol MD: 

• 5 studies all show a reduction of mortality for a 2nd booster (vs 1st booster), in people ranging from age 50+ to 80+, summarized in the table below. All during Omicron and subvariants.

• Tens of millions of vaccine doses in the US are about to expire in the US and will be wasted.

• 2nd booster doses should be made available to all age <50 who want added protection now.

728/22 PLOS: Risk of severe COVID-19 infection among adults with prior exposure to children https://buff.ly/3zj8R6q

• In a large, real-world population, exposure to young children (< 5 years old) was strongly associated with less severe COVID-19 illness, after balancing known COVID-19 risk factors. 

• Endemic coronavirus cross-immunity from exposure to non-SARS-CoV-2 coronaviruses may play a role in protection against severe COVID-19.

7/28/22 MedRxiV: Risk of BA.5 infection in individuals exposed to prior SARS-CoV-2 variants https://buff.ly/3cQ174w

• In Portugal, a country with a highly vaccinated population (>98% of the nation have gotten ≥ 2 doses), prior infection with Omicron BA.1 and BA.2 protected well vs BA.5 breakthrough infections.

7/27/22 PLOS: Smoking is associated with increased risk of cardiovascular events, disease severity, and mortality among patients hospitalized for SARS-CoV-2 infections https://buff.ly/3zzRorY

• Patients who reported smoking or vaping prior to COVID-19 hospitalization were more likely to experience severe complications, including death, than nonsmokers.

7/26/22 Nature: How long is COVID infectious? What scientists know so far https://buff.ly/3oA9i7M

• “There is not data to support 5 days or anything shorter than ten days [of isolation].”

• Barczak’s research shows that 25% of people with Omicron could still be infectious after eight days.

• Isolating for 10 days is best for Omicron.

• If taking Paxlovid, check for rebound if symptoms return.

7/26/22 White House vaccine summit recommended nasal boosters for mucosal immunity and pan-coronavirus vaccines to fight future variants.

7/26/22 MedRxiV: SARS-CoV-2 BA.5 vaccine breakthrough risk and severity compared with BA.2: a case-case and cohort study using Electronic Health Records in Portugal https://buff.ly/3Bf1OhX

• Portugal report 

• BA.5 has >3x risk of hospitalization than BA.2, post-vaccination and booster.

• BA.5 has significantly increased risk of reinfection. 

• VE against hospitalization reduced from 93% (BA.2) to 77% (BA.5)

This is consistent with the study from Denmark showing 65% increased risk of hospitalization with BA.5.

7/26/22 LA Times: COVID outbreaks hit TSA, American and Southwest airlines at Los Angeles LAX airport  https://buff.ly/3PSubGI

• At least 400 confirmed cases.

7/26/22 Annals of Internal Medicine: Update Alert 8: Masks for Prevention of Respiratory Virus Infections, Including SARS-CoV-2, in Health Care and Community Settings  https://www.acpjournals.org/doi/10.7326/L22-0272

7/26/22 Science: SARS-CoV-2 mRNA vaccination elicits robust antibody responses in children https://buff.ly/3vgE2ON

• 6 to 11 year old children

• Robust antibody immune response that an mRNA vaccine induces in children, including "highly preserved omicron-specific functional immunity".

7/22/22 KFF: COVID-19 Vaccination Rates Among Children Under 5 Have Peaked and Are Decreasing Just Weeks Into Their Eligibility https://buff.ly/3RVTLfM

• Only 30% of children age 5-11 and 3% for age 6 months to 5 years have been vaccinated.

7/26/22 KFF: More Than Four In Ten Parents Of Children Under 5 Eligible For The Vaccine Say They Will "Definitely Not" Vaccinate Their Child For COVID-19  https://buff.ly/3BkX0aP

7/26/22 Arxiv: Increasing ventilation reduces SARS-CoV-2 airborne transmission in schools: a retrospective cohort study in Italy's Marche region https://buff.ly/3cacdRi

• 10,000 classrooms, of which 316 were equipped with mechanical ventilation.

• Ventilation ranging from 10 to 14 L s-1 student-1 reduced the likelihood of infection for students by 80% compared with a classroom with only natural ventilation. 

7/25/22 JAMA: Preventive Medication for COVID-19 Infection https://buff.ly/3OsZG9i

• Evusheld is a combo of 2 long acting monoclonal antibodies- Tixagevimab and Cilgavimab.

• Evusheld is used in immunocompromised people to prevent COVID infections.

• “Hundreds of thousands of [Evusheld] doses sit on shelves in hospitals and infusion centers across the country.”

7/25/22 Nature: Symptoms and risk factors for long COVID in non-hospitalized adults  https://buff.ly/3PY0HHD

• Comprehensive assessment of symptoms from a large Long Covid non-hospitalized cohort w/ matched controls

• Increased risk with younger age

• Largest hazard ratios: loss of smell, hair loss, reduced libido, ejaculation difficulty

7/25/22 STAT: White House to launch effort to develop next generation of Covid vaccines https://buff.ly/3PVHoym

1. Nasal vaccines that could create antibodies at the mucosal surfaces in the nose and elsewhere where viruses enter the body, thereby preventing transmission. 

2. Vaccines against a broader array of coronavirus strains.

7/24/22 "It's the virus, stupid" by Eric Topol MD https://buff.ly/3vicV5R

• Why are so many infections and reinfections, and a rise in hospitalizations and deaths (albeit not to the extreme levels as Omicron BA.1 in most places or anywhere close) happening with immunity walls (from vaccination, boosters, infections, and their combinations) that have been built to a varying extent around the world?

• As the virus evolved, it has progressively pierced through the first 2 lines of defense, as recently shown with innate immunity interferons inhibited by Omicron, and particularly with BA.5, and the impaired neutralizing antibody response to BA.5 from prior vaccinations/boosters or infections.

7/23/22 (Northwestern): Treatment of Long COVID with Paxlovid (nirmatrelvir/ritonavir) and tocilizumab in a patient with rheumatoid arthritis and SARS-CoV-2 antigen persistence: a case report https://buff.ly/3vCaQCb

• Persistent SARS-CoV-2 antigen in the throat of a patient with autoimmune disease.

• Nirmatrelvir/ritonavir should be considered in the treatment of PASC in patients who have SARS-CoV-2 antigen persistence, though care must be taken to monitor the patient for symptom resurgence or viral reactivation. 

• In addition, the IL-6 inhibitor tocilizumab may ameliorate PASC symptoms in patients with persistent headache, fatigue, and brain fog.

7/22/22 Interferon resistance of emerging SARS-CoV-2 variants | Proceedings of the National Academy of Sciences https://buff.ly/3J3IeH8

• The immune response resistance that's been occurring w/ evolution of #SARSCoV2 variants is not just about neutralizing antibodies. It's also involving our innate immunity, blocking interferon, our 1st line of defense vs Covid infections.

7/21/22 Lancet: Finite neutralization breadth of omicron after repeated vaccination https://buff.ly/3cGfKXS

• Is there a plateau of breadth of neutralization with vaccines vs Omicron BA.1? Perhaps in some people with hybrid immunity but not in those without prior infections

7/22/22 JAMA Pediatrics: Post–COVID-19 Conditions (PASC, Long COVID) Among Children 90 Days After SARS-CoV-2 Infection https://buff.ly/3PAWCcC

• Long COVID only "slightly higher" than the rates vs matched children without Covid, more seen in hospitalized and older kids.

7/20/22 Covid-19 Complication MIS-C Among Children Fades in Latest Wave of Virus  https://buff.ly/3PULFCw

7/25/22 Second coronavirus booster shots for people under 50 on hold amid drive to speed up new vaccine  https://buff.ly/3z2UdQH

• Officials are hoping vaccine makers – Moderna and Pfizer and its German partner, BioNTech – are able to make the updated shots available as soon as early to mid-September instead of later in the fall.

7/27/22 JAMA: Effectiveness Associated With Vaccination After COVID-19 Recovery in Preventing Reinfection https://buff.ly/3zfKzua

• March 2020 to December 2021

• Vaccination after recovery from COVID-19 was associated with substantial benefit, reducing risk of reinfection by approximately half during periods when wild type, Alpha, and Delta strains of SARS-CoV-2 were predominant.