Thread by @ASlavitt

COVID Update: We are experiencing a significant wave of case growth.

We may be getting clues as to what endemic COVID looks like. If so, it feels different from other endemic diseases in some important ways. 1/

Endemic is this word that’s been bandied about a lot. For the purpose of this discussion, let’s just assume “endemic” means “steady state.”

In other words, what will COVID look like when it no longer surprises us? 2/

As a result, we won’t know whether we’re actually in an endemic until we’ve been there for a while.

Whether we’re at that point depends on whether major new variants emerge. Putting that aside, what we’re seeing in May 2020 gives us some clues. 3/

First, what are we observing?

-We are seeing a slew of Omicron BA variations driving spikes in South Africa— 5-6 months after Omicron was first spotted there
-Cases in the US are in fact spiking, the degree to which we can’t be sure

4/

More…

-Each of the variants teach us new things. So far each variant of Omicron appears to have a lower % of people hospitalized & hospitalizations are less severe
-Prior Omicron infection is less & less effective at protecting against new versions as time goes on

5/

More…

-Vaccines help & boosters help even more and are a multiple times better than prior infection
-But current vaccines are less effective at preventing infection as time goes on
-It’s too early to see the impact on death rates but layered immunity so far appears effective 6/

To be clear, in the US, we are seeing high levels of outbreaks. The number reported is growing at high double digits. The number of unreported/at home is much higher.

Data from several sports leagues which do constant testing show we may actually be experiencing prevalence 7/

If those are the facts as best we know them, if today represents a steady state scenario, what does it imply about what an endemic would look like? 8/

The big questions are:
1- how frequently will we experience waves?
2- how severe will COVID be?
3- will vaccines work & how often will vaccines need to be updated?
4- what should be our approach to tests, therapies, boosters & other measures?

Here goes… 9/

1- How frequently will we experience a COVID wave?

If you had to answer that question now, you would have to say every 4-6 months.

2-3x as often as the flu?
Not quite a constantly circulating common cold?

I hope this is wrong. But it’s what we have for now. 10/

2- How severe will COVID be?

If the future is driven by linear progression of Omicron, severity appears to be continually declining along with stronger T-cell or memory B-cell immunity. 11/

As FDA Commissioner Rob Califf said on @inthebubblepod this week, vaccines reduce deaths by 90% & oral therapies reduce those who get infected by another 90%. In effect, very few people should die from COVID if we use the tools.

Listen—

12/

podcasts.apple.com/us/podcast/in-…

Less severe doesn’t mean not deadly.

Not everyone gets vaccinated, and even fewer get boosted.

And people with chronic conditions or who are older— even if vaccinated— are at risk of dying from the virus.

And as we sit here today, we still have kids 0-5 unvaccinated. 13/

3- Will vaccines work & how frequently will they be updated?

The vaccine developed for the wild type virus is less & less suited to prevent infections in Omicron.

While we don’t have data yet, the Omicron-specific booster or bivalent is going to be a better answer. 14/

If we care about infections— and the existence of long-COVID, the under-vaccination of the public, and the number of older & frail people in nursing homes alone suggests we should— then we need to update the vaccines. 15/

4- what should be our approach to tests, therapies, boosters & other measures?

This may be the most important question. What do we do in a world like this? 16/

With COVID a near-constant presence that takes people out for 7-10 days at a time from work or school…

With people contracting COVID 0-2x/year…

With 200,000 mostly unvaccinated & at risk communities dying in a normal year… 17/

This creates needs for:
-Very fast surveillance & waste water
-ubiquitous rapid test & treatment
capabilities
-full force efforts at boosters— 1/year for most; 2/year for those at risk
-nuanced masking policies for different times
-complete ventilation/filtration upgrades 18/

There’s no telling when a whole new variant comes & changes everything again. That can upset everything.

But if that happens we will be talking about even more frequent spread & more updated vaccines & tools.

This suggests we need to head the same direction at a minimum. 19/

With other variants, we would be adding fuller hospitals & the need for more aggressive measures on top of the scenario laid out here.

But realistically, it’s hard to see major public health measures in the current view of a steady state scenario. 20/

As it is, it feels like getting comfort with lots of new cases, low public health measures & a reliance on science & the use of it are what we might need to get used to. 21/

Protecting yourself from illness is tricky in this scenario even if it becomes a predictable pattern— particularly for people at higher risk.

Still less & less severity as time goes on would be a nice path if we stick to it. /end