Memorial Day weekend is a good reason not to worry about reporting cases or deaths. FDA declines to respond with making it easier to get treatments we have in ample supply, or to update the vaccines. Congress refuses to fund anything at all, really.
Doesn’t sound like a state of emergency to me. Yet in California, we still have one, and we decline to respond to when we might end the ‘state of emergency.’ In New York, health officials make it clear that if it were up to them, we’d have these pandemic restrictions forever here as well.
Don’t leave it up to them. Respond.
Executive Summary
- Paxlvoid and Fluvoxamine remain hard to get.
- Time is not a flat circle, that’s a dumb expression, but history rhymes.
- Covid-19 is a good excuse to work on curing aging, let’s do that.
Let’s run the numbers.
The Numbers
Predictions
Last week I somehow once again forgot about a holiday, in this case Memorial Day, because I don’t think in those terms naturally and it still boggles my brain that it matters. But in terms of ‘why this prediction was stupid’ that’s why.
Assignment for readers: Next time a holiday is coming up and I forget about it, whoever notices first should write a comment in the Substack version that says ‘you forgot to take into account the upcoming holiday!’ and whoever does scores points. Note that if I don’t explicitly mention the holiday I’m probably forgetting about it.
Prediction from last week: 700,000 cases (+9%) and 2,725 deaths (+15%)
Results: 566k cases (-12%) and 1,994 deaths (-15%)
Prediction for next week: 675,000 cases (+19%) and 2,400 deaths (+20%)
As usual with a holiday drop like this, one must hedge between ‘it was the holiday and will be even higher than trend next week’ and ‘it wasn’t entirely the holiday, this was a real drop.’ Even if I’d remembered the holiday my prediction would have come in high. Is it possible cases have peaked for real? Definitely possible, but the decline in deaths now makes zero underlying sense outside of the holiday, so I’m guessing we’re looking mostly at a large holiday effect.
Deaths
Ah, Memorial Day, yet another holiday. Silly me.
Cases
Vaccine Discussion Offer
Chise, who has provided good information several times, says their DMs are open for anyone with vaccine-related questions or even want someone to listen because you are unsure. A fine public service, if you need it please use this resource or pass it along to someone else who needs it.
Variants
Trevor Bedford thread confirming BA.4/5 will likely outcompete BA.1.2.12, confirmation at least a lot of that is immune escape, and the note that a BA.1-based vaccine update would be helpful but a BA.4 or BA.5-based update would be much better at this point.
Big Time Surge Story
How is the other half not living? It’s calling another big time surge. The note here is specific to San Francisco but the logic is universal. Everywhere will have their turns.
The framing here seems like the ‘friendly’ version of paternalistic public health. Are you trying to stay well? If so, time to step up your game. If not, then that’s fine too says your grandmother, don’t try to stay well and be home for dinner.
On some level I find that fair, because the whole point is that it is not worth trying to stay well, if stay well means avoid infection, which is slightly unfair but all right, fine, sure. Permanently avoiding infection is for most people not a good plan, and if you did need to have that as your plan then yes it’s time to step up your game and pull out that P100.
The contrast between Bob’s two graphs is interesting. In the first one, we have less than half as many cases now as at the start and less than a fifth of the peak. In the second, we have more patients needing care now than we did before and over a third of the peak. This implies a lot of cases are not being reported, and that this is not mostly reflective of lower severity unless most patients under care are ‘with’ rather than ‘for’ Covid (because math).
Similarly, on the question of whether the unvaccinated should be worried right now, Matt Yglesias points out the graph versus NYTimes story differential here.
Let My People Go
There are no standards. There are no criteria. There is only emergency.
Defendant inquires about never. He asks if never works for you.
Meanwhile CDC continues to recommend the full ten days quarantine period for children under the age of two, because they are unvaccinated and couldn’t mask. Words, I have none. Maddening lack of connection with the physical realities of life.
Link to the referenced article here. Both are fine but I prefer the thread.
The amount of willful ignorance, of selective faith in the facts that fit whatever narrative supports restrictions today, the not caring about costs, would have been stunning two years ago. Now it’s completely unsurprising, although the ‘I never talk to anyone with the view that we shouldn’t take lots of pointless public health measures’ still packs a punch.
The juxtaposition of ‘we don’t know the long term effects of Covid so we need to destroy life indefinitely’ and ‘we don’t know the long term impact of child masking but eventually there will be studies and we’ll know’ could not be more clear.
And of course, there is nothing the kinds of restrictions we are talking about could meaningfully do over the medium term to prevent infections, even if everyone did cooperate, but hey, it’s not as completely insane as putting kids through live shooter drills.
FDA Delenda Est: Approved Treatments Edition
Tyler Cowen reminds us that Paxlovid remains remarkably hard for regular people to get and that this (OF COURSE!) is largely the FDA’s fault since they could allow pharmacists to prescribe it themselves. Quoting in full:
Pharmacists still cannot prescribe the medication themselves, a step that would cut the time it takes patients to secure the drug.
The Food and Drug Administration “is looking at this and thinking about it,” Dr. Jha said. “Whether they’re going to make a change, when and how, etc., is totally in their wheelhouse.”
Many patients are still handling the sometimes-cumbersome steps on their own: locating a virus test, then securing a Paxlovid prescription from a health provider, then finding a pharmacy that carries the pill, all within days of first showing symptoms.
Dr. Jha described being frustrated by physician colleagues who have told him they still limit Paxlovid to patients 65 years and older.
Tyler: But no they still will not do this. I repeat myself, but you need to keep in mind the only time panel members have resigned from the FDA is when the Biden administration pushed through the booster shots. Here is the full NYT article, via Rich Berger.
Then everyone goes around wondering why so few people are using Paxlovid. And this is what is ‘in their wheelhouse.’
Then there’s Fluvoxamine, WSJ asks why the FDA said no to prescribing it for Covid, which I covered two weeks ago. I mentioned then that I wasn’t concerned about that because it was mostly ignorable – you could still get Fluvoxamine if you cared enough, and if you didn’t care enough you were never going to get it. In practice, however, doctors are remarkably reluctant to write that kind of off-label prescription and there are numerous reasons why almost no one will end up taking it without the approval.
So once again, I can only conclude the FDA has reached the same conclusion as the top comment on Tyler’s post.
CDC Delenda Est
Remember when Trump complained that the problem was that we had all these cases because was did all those tests? Well…
…yeah.
The quote is from this Kelsey Piper post about Monkeypox, including that we’re still doing the whole ‘downplay the situation so people don’t panic’ thing, which is going into my list of Monkeypox links that I will use if I write a post that I sincerely hope I never write.
And on another note on Monkeypox, it’s worth pointing out that history is rhyming again, oh no:
Think of the Children
In Other News
The new reality of Covid, summarized.
The reality of what’s going to happen early in the next pandemic.
Nope. Can’t say we have.
Fund Anti-Aging Research
The beatings will continue until morale and/or survivability improve.
Aging is bad. It leads to being old, which leads to all sorts of bad things like loss of one’s various facilities and also it kills you. We should get to work on that. However, aging is not considered a disease, so attempts to treat or cure it don’t count. Most people have rationalized that the thing that slowly destroys and kills every single human is ‘natural’ and fine actually, using a variety of time-honored rationalizations. Even on the voyages of the USS Enterprise they risk the ship to save an innocent old person’s life then give that person a stern lecture about not wanting to then die on schedule.
So yeah, this battle’s been a tough one. Lost a lot of good men. All of them, actually.
However, aging is also the primary risk factor for Covid-19, so perhaps we can market our anti-aging solution as a Covid-19 treatment?
Covid-19 is far more likely to kill you if you’re old. One reason is that aged immune systems struggle to cope with infections and recover from them. So why not try drugs that make bodies young again? That’s the bold idea now being explored in clinical trials around the world, which are testing drugs that reverse the impacts of age on the body, rejuvenate the immune system and clear out aged, worn-out cells.
This does not appear to be satire. Now that Covid-19 is around suddenly we have this bold idea to solve the problem, which is to cure aging by making people younger. And no, there is no hint of noticing that maybe we should have been trying to do this anyway? Cause you know what age is a risk factor for almost exactly the same amount as for death from Covid?
Other than violence, accidents, drug overdoses and infant mortality?
Death. It increases risk for death.
Imagine if this was true not in the pandemic.
Most of the cells in our body divide up to a certain point. Once they reach this limit, they should die and be cleared away by the immune system. But that’s not always the case—some cells linger on. These cells no longer divide, and some instead churn out a toxic brew of chemicals that trigger damaging inflammation in the surrounding area and beyond.
Cells that do this are called “senescent,” and they accumulate across our organs as we age. They’ve been linked to an ever-growing number of age-related diseases, including diabetes, heart disease, osteoporosis, cataracts, Alzheimer’s—the list goes on. They also appear to play an important role in coronavirus infections.
Yes. Please do work on that. Thank you. I will totally pretend not to notice the skulls, except by the skulls I mean look at everyone who ever lived because they are skulls now, they are dead, I am going out on a limb and saying I do not like this.
We might come out ahead from this pandemic yet.
One More Note About That Long Covid Study
As I said on Twitter, every now and then they still manage to surprise me.
Whether or not this is something otherwise worth taking seriously, if the mean age in your study is 71 years old that’s an important point when deciding how to use the results of that study.
The Future
This was another light week for Covid news, and what news there is seems like it is largely repeating itself. If this continues, my current plan is to emphasize other things and also to start doing post-mortem analysis on prior posts, ideally starting back at the beginning – pulling out evergreen things to create reference posts, analyzing mistakes and things I got wrong, that kind of thing.
For now, I intend to keep doing the weekly posts as a public service – I keep an eye on things so you don’t have to.
Planned next post is a review of Talent, by Tyler Cowen and Daniel Gross. There’s a ton of specific detail there to talk about so it’s getting long, but I want it out there in the next few days one way or another. I had another thing planned for this week, but turned out I’d already written a version of it back in 2010, so no need to write it again.
Don't Worry About the Vase 
Regarding the NYC “public health high level employee”. It’s ambiguous, but thread specifically does not say “Doctor”.
In which case the headline should read “Bureaucrat given broad sweeping new powers and sense of importance reluctant to give them up”.
It other news, water is wet.
“I also brought up that 20% of NYC had covid in the past two weeks.” (From the Daniela Jampel tweets.)
Wait, what? What’s the reason to think this? It’s plausible that 20% of NYC had it in a two-week period in January (when unrecorded cases are included), but it doesn’t seem plausible to be the case in the last two weeks.
I do not believe that it is the case, but I can’t rule out that a very large number of people had very mild cases. I have no idea why he thinks this. I do find the reaction to the claim interesting…
“This person was telling me, over and over again, that it was so interesting talking to me because she hadn’t met a single other person with my views.”
Obligatory adjunct hypothesis: this is not an accurate report of the size of the selection bias. The speaker has — through some mixture of dismissal, forgetting and compartmentalization — been successfully defending the belief “there is no legitimate opposition” and was reporting that she *couldn’t recall* meeting a “person” (as opposed to an ignoramus) with this view. If the meeting with the tweeter was not somehow unusually significant, it’s, say, 40% that a week later a question along the lines of “have you met anyone who opposes [restriction]?” would be met with “no” (even though she might be able to recall the tweeter if you ask the right questions, it’s not available for the first query).
Loosely related to living forever: https://rootsofprogress.org/img/armstrong-1999-fig-1.png
Where I work, the biggest problem right now is CDC close contact guidelines. My employer has agreed to follow CDC guidelines in our health & safety protocol. This is absolutely killing us. One infection takes out an entire group of people for a week or more. We are catching cases because of testing! No one has come to work symptomatic! Everyone is not only vaxxed, but boosted! I wish we could stop being dumb and use common sense, but managers need a sign to tap to pass off responsibility.
The pandemic will not be “over” in my book until people don’t have to isolate just because they spent 15 minutes near someone who later developed symptoms (or tested positive).
Are you at all at the ’14 minute conversation’ phase?
I believe what you’re describing is much stricter than the CDC guidelines. My understanding is that *if you’re vaccinated* (or if you tested positive for covid in the previous 90 days) then the CDC does not recommend anything beyond testing for close contacts. My employer’s policy following a close contact who lives outside your household is to test daily (they give you a set of antigen tests) and come to work as long as you’re negative and symptom-free.
https://www.cdc.gov/coronavirus/2019-ncov/your-health/quarantine-isolation.html
Without going into too much detail, the problem is that some people have jobs they can’t do while wearing masks, and the CDC recommends wearing a mask for 10 days following the contact.
But once again this case was caught because someone woke up with symptoms and took a test. The purpose of surveillance testing is to detect asymptomatic or pre-symptomatic infections. We have not caught one of those in the year and a half we’ve been testing, despite people developing symptoms shortly after. Not with PCR tests, and not with the current antigen tests.
I have been trying to get them to switch to a “no testing; stay the F home if you’re sick” policy for months to no avail. Some people still need the security blanket of mass testing, though.
And over here is Canada still not letting the unvaccinated fly or take trains, still firing them or putting them on leave without pay even if they work from home, and now trying to seize more firearms from its law-abiding populace.
All the while my office requires masks, but cloth masks only.
I flew from Canada to the US and back recently, the contrast between the airports was wild. The most memorable part was that the way checking my vaccination status worked. Security guy asks for my vaccination docs, I show him the papers I printed off which are basically just a QR code on government letterhead, guy asks me to hold it a little closer, guy *visually inspects* the QR code, waves me through.
I know it’s all security theatre, but I was at least expecting it to be better staged.
Related to making a difference with paxlovid, just yesterday an Israeli group published a study of paxlovid in actual clinical use. It’s important because (a) it’s on a heavily vaxed population (the paxlovid clincal study was only on unvaccinated), (b) it’s during the reign of Omicron (the paxlovid study was during Delta), and (c) it’s actual combat usage seeing what real doctors and real patients do in practice (as opposed to a highly controlled study).
I wrote an explainer about it. The general results are:
(1) Age 65+: dramatic positive effect on reducing hospitalization and death rates.
(2) Age 40-64: no particular effect either way.
À propos your comments on aging research (with which I agree in general, but then I’m older and need it more): it really looks like paxlovid took the risk rate in older people down to the rate in younger people.
Beyond that, it did not go. Though that in itself is enough.
Thanks, W.E. Paxlovid in the Wild is a concise writeup of the Israeli group’s key findings. I will get more traction sharing that link with Busy Physician Friends, compared to sharing the paper itself.
John Gorka’s got you covered, musically speaking.
The source, of course, is Hillel. Gorka’s been doing a lot of “1-song concerts” at his home during the pandemic. Really good stuff, at least by my taste.
Of potential interest to New Yorkers: a population survey aiming at measuring the true incidence of COVID-19 (beyond the official cases), and how many people know about or received paxlovid.
Summary: There’s a lot more COVID-19 than we think. More than half of people who’ve had it don’t know about paxlovid. Only 15% got paxlovid. Family size, presence of children under 18, and lower education were risk factors; income and borough of residence were not.
OK, so I guess this is the source of that claim that 20% of New Yorkers got COVID in two weeks in April/May. But something isn’t right about it.
Out of their sample, 11% (117 out of 1030) reported testing positive *at a health care or testing provider* (with another 11% classified as probable/possible cases based on home tests, or contacts and symptoms). It also says “The estimate of 1.5 million infections is about 31-fold higher than the 49,253 cases in the official NYC case counts”, with the 1.5 million estimated assuming 22% incidence. 49,253 as a two-week official case count is plausible based on other statistics I can find.
But, presumably, tests done at a health care provider make it into the official statistics! If 11% of New Yorkers tested positive at a health care provider, that would make for some 900 thousand cases, far above the official statistics. And the study shows an undercount by a factor of ~2, not 31.
So either less than 10% of the positive tests at healthcare providers make it into the official statistics, or this sample is very unrepresentative, or something else is very wrong with this study.
First, congratulations for actually reading the paper. That’s rare, and I appreciate it.
Second, this is an early preprint, and like you I suspect many aspects will get sanded down during peer review. I mean, if you can find this sort of thing in a few minutes, imagine what the referees will do. (At least, when I was a referee digging & checking is what I did.)
Third, I think it’s most important to take their conclusions not in detail, but very broadly: (a) there’s a lot more COVID-19 than in the official numbers, and (b) paxlovid is being way underutilized.
I’m more than happy to watch people who know what they’re doing argue over the specific numbers. It would not surprise me at all to find that many fewer positives get reported by healthcare providers than we’d like.
Anti-aging as a Covid treatment is the most “You gave me a TIME MACHINE? FOR MY SLEEP DISORDER?” thing I have ever seen in real life.
Hi Zvi, I want to apologize/ acknowledge my ‘inappropriate posts’*. As my only defense I’ll say that without some guidelines, I’m apt to perhaps post what comes into my head while reading…
So it would be nice if you had guidelines, but until then I’m going to assume the guidelines are like on Peter Woit’s “Not Even Wrong” blog. which are…
quote:
Informed comments relevant to the posting are very welcome and strongly encouraged. Comments that just add noise and/or hostility are not. Off-topic comments better be interesting… In addition, remember that this is not a general physics discussion board, or a place for people to promote their favorite ideas about fundamental physics. Your email address will not be published. Required fields are marked *
unquote:
*inappropriate posts are any posts taken down by you.
I don’t know what is happening to your posts, but it’s not me taking them down – I have taken down exactly one thing total, otherwise it’s purely completely-obvious-spam, because people have mostly been good and I haven’t needed strict guidelines. I did once have to issue some warnings.
And yeah, my rules are similar in spirit, plus a rule about keeping politics to the minimum required for the topic at hand and avoiding political advocacy.
No, you also took down the posts of that insane “I want everyone on both sides of the Ukraine war to die, and hell, anyone who argues with me can die too” ranting guy.
Oh yeah, that’s right. That one too, so a total of twice I’ve had to do it. I forgot about that guy. In hindsight seems like it wasn’t such a hard call after all.
Huh? OK… I guess It’s possible I’m losing my mind, or having dreams about your newsletter? But wasn’t there a comment saying that Kristen Fortney was a good person doing good work, and you even responded, ‘good to know she is a good person’.
And then comments about upcoming holidays in June? Juneteenth and Flag day.
Weird.
I remember the comments about holidays, and the Fortney thing too, you are not losing your mind about that. But I didn’t delete them, so that’s… pretty weird and spooky actually. I mean, I’m not super sad they’re gone but I didn’t delete them, at least not on purpose and I don’t see how I could have done it by accident so strange.
So, yeah. What the hell is going on?
Today the FDA’s external advisory committee VRBPAC met to discuss the Novavax vaccine, a more traditional protein-based vaccine. I went through it all, so you don’t have to.
They gave it the thumbs up, despite some glitches. The ball is now in the CDC’s court.
Today Moderna announced the readout of their trial for a bispecific classic + Omicron vaccine. I wrote a (very brief) explainer on it, given the somewhat sparse news.
Bottom line: If we take them at their word that the final technical documents will say what they claim, then they’ve demonstrated very significant and strong superiority over the classic vaccine for all of Alpha, Beta, Gamma, Delta, and Omicron variants.
They intend to file with the FDA for this as their leading candidate.
However, the FDA wants to meet on 2022-Jun-28 to decide what strains should go into such a thing in the first place. If the FDA says pretty much anything other than what’s in this trial, then that’s a Very Big Problem: there will not be time for manufacturing before fall, let alone to run another trial.
I really don’t know what to say about that, other than that I really don’t like it. This looks almost like a sure thing, and I dislike leaving sure things untaken.