The tale of two COVIDs: New Zealand and Hong Kong.

Compare cases and deaths. It's two very different stories

Both have kept COVID at bay with public health COVID zero-styled approaches.
Both finally saw Omicron break through.
Cases shot up in parallel.
Now for the bad news: Hong Kong now leads the world in deaths per capita.
In New Zealand, there is barely a blip in deaths per capita.
There are many differences here, like density. Hong Kong is a lot smaller in size than New Zealand but larger in population (7.5M vs 5M)
The crucial difference though is vaccination
It's not that Hong Kong doesn't have vaccines, it's just not the right ones w the right targeting
Hong Kong has higher vaccination rates than most of the world. At least 82% have 1 dose, 70% have 2 doses, 23% have 3 doses
This doesn't match New Zealand: 84%, 78%, 48% but it isn't far
The overall rate isn't the issue. It's which vaccines and who did or didn't get them.
Hong Kong has more who are elderly and fewer who are vaccinated than in New Zealand. It's the elderly who die from COVID.
As Omicron spread in HK, vaccine hesitancy has led to vaccination rates among those aged 70-79 and 80-plus to be just 63.1% and 34.2%…
Meanwhile in New Zealand, vaccination rates in the elderly are over 95%…
The immune wall also depends on which vaccines used. Inactivated whole virus vaccines like coronavac in HK are just not as effective as mRNA (or viral vector) in NZ. Neither has more substantial infection-derived immunity to compensate.
We need better metrics to capture the immune wall, the buffers that keep death and overwhelming outbreaks at bay. It needs to include not just how many were vaccinated but who, with which vaccines, supplemented by what levels of infection-derived immunity

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More from @InfectiousDz

Mar 2
When systems falter, TB, especially MDR TB, finds a home. This happened as the Soviet Union fell. In Ukraine 1 in 4 new TB infections and most recurrent TB is MDR (Multidrug resistant). Further disruptions now will only fuel spread further spread.
MDR TB occurs when the 2 most important first line drugs - rifampin and isoniazid - stop working. Much of MDR TB in Ukraine is actually pre-XDR or XDR (resistant to 2nd line fluoroquinolone and certain injectable meds). In Kharkiv most were XDR or pre-XDR
TB is as biologic as societal. Resistance was fueled by disruptions and gaps in system over last decades, inpatient-focused care lasting months, stigma, lack of HIV integration, difficulty tracing patients, lack of supplies (advanced resistance testing).…
Read 6 tweets
Jan 2
We can't pretend our way out of an epidemic. Paxlovid has tremendous promise. Problem is, there are more cases in one day than Paxlovid courses expected during this surge.
We need ethical means of allotting these courses for maximal benefit. Otherwise, it's 1st come, 1st served🧵
Headlines say the US bought 10 million courses. These won't arrive until July. The total allotted in January and December will be fewer than the almost 500,000 cases the US is recording a day

This is what the US has sent to each state and territory:…
NY State reported 85K new cases yesterday. NY state currently has 3,180 courses, that's not for one day, that's total currently allotted. full stop.

DC reports over 2000/day on average. It has 40 doses allotted.
Read 11 tweets
Jan 2
The criteria for prescription of Paxlovid are starkly different in different geographic areas and between public and private health systems.

This is a huge equity issue.

First come, first service apparently.
Paxlovid will run out soon.
NY State guidelines allow for Paxlovid for vaccinated individuals under 65 and 2 risk factors

NY City public health system only has the med for
immunocompromised or over 65, unvaccinated, with risk factors

This prioritizes those with private doctors and private pharmacies
The US state of Maryland has 960 courses. The guidelines would mean with almost 9000 cases a day that there would be enough eligible persons to use up the supply in one day.
Read 6 tweets
Jan 1
The movies get viral hemorrhagic fevers wrong

The granddaddy of all - Ebola - is often mistaken for malaria, sometimes cholera or the flu

It spread for months in West Africa undiagnosed before one salient symptom was noticed - hiccups - by someone who knew Ebola
Ebola starts off mild
It's just a sudden fever. "It must be malaria"
Symptoms are "dry" - maybe a cough, headache, fatigue
Wet symptoms may take a week to develop - lots of watery diarrhea, vomiting.
Viral loads climb with illness and virus spreads more easily with wet symptoms
Most Ebola patients do not have heavy bleeding and never like the movies
Heavy bleeding with miscarriage or delivery, exposing midwives and other attendants, is common
Bruising or bleeding with IV's also happens
Bleeding zombies in the movies, not so much…
Read 4 tweets
Dec 9, 2021
For those not working in epidemiology:

Omicron isn't Pac Man

It's not chasing down the few with no past infection or vaccination

Most have been infected or vaccinated in South Africa and worldwide

To spread this fast, this variant has been infecting those with some immunity
This changes how we quantify its risk.
It is a bit of the tortoise and the hare.

Variants that quickly infect in naive populations are like the hare. High R0

Variants that keep chugging along despite immunity may be the tortoise. High Immune Escape

Tortoise can win in the end
A bit of terminology
R0: # 2ndary infections per initial infection in a naive population
Intrinsic R0 no longer alone determines spread as the world is no longer naive to COVID

Rt or Reffective describes 2ndary infections in real time in an outbreak w/immunity, behavior change
Read 5 tweets
Sep 29, 2021
In August, an 80 year old man woke up to find a bat on his neck. Bat tested positive for rabies. The man reportedly refused the vaccine. He died of rabies. First death in Illinois from rabies since 1954.…
So far this year, 30 bats have tested positive for rabies in Illinois. More than 1,000 bats are tested for rabies each year in Illinois due to a possible exposure. Approximately 3% of tested bats are positive for rabies.
So what is post-exposure prophylaxis for rabies?
- Clean wound with soap and water (or povidine-iodine)
- Immunoglobulin if never vaccinated for rabies
- 4 doses (immediately, then days 3, 7, 14) Image
Read 16 tweets

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