Coronavirus: What questions do you have?

[cwbullet]

Georgia had a new record yesterday. I thought we were coming out of this. There are similar second spikes to this time. Hospitalizations are climbing in many states. The good news is that there is a general downtrend that I think will continue as long as we do not get stupid.

 

[bronicabill]

The spousal unit just got a call from her doctor telling her she has COVID and needs monoclonal antibody treatment... which we cannot find available anywhere! There are plenty of clinics around that offer it, including all local hospitals, but the Alabama Dept of Public Health is only sending 6 treatments per week to each facility, and therefore the waiting list is VERY long!

She is a diabetic, plus she has asthma and pneumonia so is high risk... and she cannot get the meds she needs. This seriously sucks!!!

 

[Marc_G]

The spousal unit just got a call from her doctor telling her she has COVID and needs monoclonal antibody treatment... which we cannot find available anywhere! There are plenty of clinics around that offer it, including all local hospitals, but the Alabama Dept of Public Health is only sending 6 treatments per week to each facility, and therefore the waiting list is VERY long!

She is a diabetic, plus she has asthma and pneumonia so is high risk... and she cannot get the meds she needs. This seriously sucks!!!

I'm not close to the monoclonal treatment stuff but I did see this in my feed today:

COVID Omicron News: NIH says only 1 monoclonal antibody treatment effective against omicron

Updated guidelines from the NIH COVID Treatment Panel say Regeneron and Eli Lilly's treatments have been shown to fail against omicron.

abc7ny.com

 

[Marc_G]

Chuck, I meant to ask in my prior note, have you heard much about monoclonal treatments and Omicron?

 

[OverTheTop]

Looks like omicron has peaked down here. Just waiting for hospitalisations to peak.

These eight charts suggest Australia may have reached its Omicron peak, with one state ahead of the rest

The evidence is firming up that at least one state — New South Wales — has reached its hospitalisation peak for this wave of the pandemic.

www.abc.net.au

 

[cwbullet]

Chuck, I meant to ask in my prior note, have you heard much about monoclonal treatments and Omicron?

Results are mixed. I am not willing to say that most failed to work. Sotrovimab is effective and the rest are either less effective or ineffective.

 

[cwbullet]

The numbers are in a clear decline but as they drop, the BA.2 variant raises it head from the ashes.

New COVID variant detected in at least 40 different countries

WEST PALM BEACH, Fla. (WPEC) — As omicron cases fall across some parts of the United States, international health officials are now warning about a new variant. "BA. 2" is a sub-variant of omicron and has been labeled “variant under investigation" by health officials in the United Kingdom who...

cbs12.com

Will it be a variant of concern? Only the maker knows!

The new subvariant is believed to come from Omicron and accounted for 20% of all Covid cases in Denmark in late December. By the second week of January, its share had risen to about 45% of the total. It is beating out Omnicron in some locations. Some areas have dubbed it the “stealth Omicron” because it seems to evade identification better than Omicron.

Three observations on BA.2:

1. I believe it will be no different in hospitalization and death. I expect the mild lineage to be similar.
2. PCR will be less effective at detecting the virus. A deletion caused a change that alters part of what we look for when testing for COVID.
3. Vaccines may be less effective against the subvariant. It has similar changes to Omicron and these changes may be similar or slightly worse than its sister.

Now it is time to wait and watch.

 

[cwbullet]

I do want to stress that what I said above is a little bit of an educated guess. Protect yourself.

BA.1 or Omicron has 60 mutations and BA.2 or Son of Omicron has about 85 mutations. Early data indicates it might be more transmissible, but only time will tell. Most countries in Europe saw a rapid increase in infection as BA.1 decreased and BA.2 out competed to take over. We could have already experienced this change or acceleration of infections in the US and just did not know it.

There is no indication of increased fatalities or hospitalization.

Can I catch BA.2 after having BA.1 or am I immune after having the prior infection?

Isn't that the million-dollar question? Ask back in 2-4 weeks and I will have an answer but right now, only the magic eight ball knows the answer.

Also, BA.2 is not new..... We have known about it for at least a month....

Scientists find ‘stealth’ version of Omicron that may be harder to track

Variant lacks feature that allows probable cases to be distinguished among positive PCR tests

www.theguardian.com

 

[Sooner Boomer]

Chuck, have you heard about any use (or any trials) of ACE-2 inhibitors/blockers? I used to have high blood pressure, so I'm somewhat familiar with these drugs.

The "spike" protein attaches itself to the cell wall at ACE-2 (angiotensin converting enzyme) sites, and is able to enter the cell there. ACE-2 sites are found throughout the lining of the lungs, throat, and nose (and a bunch of other places). Binding of the virus to the ACE-2 sites in the heart may be responsible for the damage seen there.

 

[cwbullet]

Chuck, have you heard about any use (or any trials) of ACE-2 inhibitors/blockers? I used to have high blood pressure, so I'm somewhat familiar with these drugs.

The "spike" protein attaches itself to the cell wall at ACE-2 (angiotensin converting enzyme) sites, and is able to enter the cell there. ACE-2 sites are found throughout the lining of the lungs, throat, and nose (and a bunch of other places). Binding of the virus to the ACE-2 sites in the heart may be responsible for the damage seen there.

Yes. I want to stress that there is limited research as a treatment for COVID. I absolutely would not rush to the doctor to get a prescription, nor would I stop the drugs for unless a medical provider says they are no longer needed. Further research my change my opinion, but this si what I have right now.

Initially, there were two camps in medicine in response to ACE inhibitors and ARBs (Angiotensin Receptor Blockers). One side felt that blocking the receptor might increase infections and the other might help prevent infections. If you know the drugs and the virus, that seems unlikely and the research appears to reduce the likelihood of either. There was even a small group that felt that controlling angiotensin might control the vascular compromise as the disease progresses.

What do we know?

1. ACE Inhibitors and ARBs are clearly safe and may be helpful in COVID infections. I would not start one to treat it, but it is one more reason to take for other conditions one if your lack a contra-indication.
2. ACE inhibitors and ARBs appear to lower the risk for COVID for the patient and maybe the household. I am not sure but I think this might be independent of behavior but who knows. More research is needed but this is positive and supports continuing the medication but I would not ask for ti for this reason alone.
3. ACE Inhibitors and ARBs in the absence of hypotension may improve outcomes in hospitalized patients. This could be do to multiple mechanisms.
4. ACE Inhibitors and ARBs do nto appear to increase infections and they might reduce them. More research needs to be done to look at behavior.

Their are a few that show some benefit in Here are two and an editorial:

1. https://advances.massgeneral.org/research-and-innovation/journal.aspx?id=1991
2. https://heart.bmj.com/content/106/19/1503
3. https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(21)00303-5/fulltext

I found a bunch in my limited search.

 

[Cl(VII)]

Chuck, are you seeing many people testing positive on PCR after they are fully recovered? I know this has been reported on, but I don't have a feel for is that 1% of people and it just grabs attention, or is it rather common. If you are seeing this kind of thing, how long do these post-infection positives typically last?

 

[cwbullet]

Chuck, are you seeing many people testing positive on PCR after they are fully recovered? I know this has been reported on, but I don't have a feel for is that 1% of people and it just grabs attention, or is it rather common. If you are seeing this kind of thing, how long do these post-infection positives typically last?

That is not necessarily a false positive. It is rare and more common in patients that are immunocompromised. Remember the PCR tests for viral RNA genes so a true false positive is rare.

I have seen folks sloth virus for 60-90 days after a positive. I am not sure if those are still infectious.

 

[cwbullet]

I had the day off to help my wife. I only thought of COVID once and that was sitting in the car watching some idiot wear their mask like a chin bib. That really works.

 

[Reinhard]

Three observations on BA.2:

1. I believe it will be no different in hospitalization and death. I expect the mild lineage to be similar.
2. PCR will be less effective at detecting the virus. A deletion caused a change that alters part of what we look for when testing for COVID.
3. Vaccines may be less effective against the subvariant. It has similar changes to Omicron and these changes may be similar or slightly worse than its sister.

As I understand it, the issue from your second point does not make it harder to find the virus, but it removes a marker that allowed to infer the Omicron variant in PCR assays (S-gene dropout). One practical implication is that it makes it harder to decide wether a patient should receive certain monoclonal antibodies that are effective against Delta but not a good use of limited resources against Omicron.

In case anybody is interested:
(Please take with a grain of salt, I'm not an expert, just interested)
PCR tests are targeting parts of the virus genome, instead of analyzing the whole genome like gene sequencing. Those targets are only detected when an exact match is found. If the target is mutated, it can escape detection.
To ensure infections are not missed in case of mutations, manufacturers usually select multiple targets and at least one target that resides in a stable region that is unlikely to mutate. One example is the N-gene (for the nucleocapsid). The N-gene of SARS-COV-2 is still quite similar to other bat-associated betacoronaviruses like the original SARS-COV-1.
Other genes like the S-gene (for the spike protein) are more likely to mutate. If such a mutation affects a target, S-gene target failure (also called S-gene target dropout) happens. So when a PCR test doesn't find one of its targets but confirms the presence of other targets, this is an indication for a different variant.
This is how the Alpha variant was initially noticed in the UK, before it was confirmed by sequencing. Apparently, the UK just happened to use a test widely that was affected by the S-gene dropout. The UK also sequences a lot more than most other countries.

Like Alpha, Omicron subtype BA.1 has a deletion on the S-gene at 69-70 that causes S-gene dropout on certain PCR tests. This deletion is not present on the wild type, Delta and Omicron subtype BA.2. Therefore Delta and Omicron BA.2 can't be distinguished with those PCR tests, but I guess one could create specialized PCR tests for that purpose. Sequencing also works regardless of variant, but is not as widely available.

Further reading:
About PCR target selection
Manufacturer information of a variant selective test

Reinhard

 

[cwbullet]

As I understand it, the issue from your second point does not make it harder to find the virus, but it removes a marker that allowed to infer the Omicron variant in PCR assays (S-gene dropout). One practical implication is that it makes it harder to decide wether a patient should receive certain monoclonal antibodies that are effective against Delta but not a good use of limited resources against Omicron.

In case anybody is interested:
(Please take with a grain of salt, I'm not an expert, just interested)
PCR tests are targeting parts of the virus genome, instead of analyzing the whole genome like gene sequencing. Those targets are only detected when an exact match is found. If the target is mutated, it can escape detection.
To ensure infections are not missed in case of mutations, manufacturers usually select multiple targets and at least one target that resides in a stable region that is unlikely to mutate. One example is the N-gene (for the nucleocapsid). The N-gene of SARS-COV-2 is still quite similar to other bat-associated betacoronaviruses like the original SARS-COV-1.
Other genes like the S-gene (for the spike protein) are more likely to mutate. If such a mutation affects a target, S-gene target failure (also called S-gene target dropout) happens. So when a PCR test doesn't find one of its targets but confirms the presence of other targets, this is an indication for a different variant.
This is how the Alpha variant was initially noticed in the UK, before it was confirmed by sequencing. Apparently, the UK just happened to use a test widely that was affected by the S-gene dropout. The UK also sequences a lot more than most other countries.

Like Alpha, Omicron subtype BA.1 has a deletion on the S-gene at 69-70 that causes S-gene dropout on certain PCR tests. This deletion is not present on the wild type, Delta and Omicron subtype BA.2. Therefore Delta and Omicron BA.2 can't be distinguished with those PCR tests, but I guess one could create specialized PCR tests for that purpose. Sequencing also works regardless of variant, but is not as widely available.

Further reading:
About PCR target selection
Manufacturer information of a variant selective test

Reinhard

That is correct. The S gene is one thing the PCR tests for. It makes it hard to identify.

 

[cwbullet]

Does the vaccine help against Omicron?

Yes. Having 2 shots is less effective than 3 (boosted), but it is still superior to being unvaccinated.

Association Between 3 Doses of mRNA COVID-19 Vaccine and Symptomatic Infection Caused by Omicron and Delta Variants

This case-control study uses data from the Centers for Disease Control and Prevention Increasing Community Access to Testing platform to estimate the association between receipt of 3 doses of Pfizer-BioNTech BNT162b2 or Moderna mRNA-1273 vaccine, compared with 2 doses or unvaccinated, and...

jamanetwork.com

 

[cwbullet]

Association Between 3 Doses of mRNA COVID-19 Vaccine and Symptomatic Infection Caused by Omicron and Delta Variants

This case-control study uses data from the Centers for Disease Control and Prevention Increasing Community Access to Testing platform to estimate the association between receipt of 3 doses of Pfizer-BioNTech BNT162b2 or Moderna mRNA-1273 vaccine, compared with 2 doses or unvaccinated, and...

jamanetwork.com

Vaccination and boosting reduce infections over those that are unvaccinated or less vaccinated. The protection is less with Omicron but still significant.

 

[WoShuGui]

Association Between 3 Doses of mRNA COVID-19 Vaccine and Symptomatic Infection Caused by Omicron and Delta Variants

This case-control study uses data from the Centers for Disease Control and Prevention Increasing Community Access to Testing platform to estimate the association between receipt of 3 doses of Pfizer-BioNTech BNT162b2 or Moderna mRNA-1273 vaccine, compared with 2 doses or unvaccinated, and...

jamanetwork.com

Thanks. A good reminder of why to get the booster.

 

[cwbullet]

Masking in daycare will reduce program closure:

Kids Masking Up Prevented Daycares From Closing Up

Fewer COVID-related closures for centers where kids masked early and often

www.medpagetoday.com

In the first 2-3 years of life, face visualization is important for children to learn communication. This study does not comment on that. Then again, if they can't go to school or pre-school, they can't learn.

 

[Rob Campbell]

Here's some encouraging news. Omicron appears to be well on the decline in Florida. The 7 day average new cases dropped below 30k. It hasn't been that low in a month. If this trend continues, COVID may become endemic and manageable like the flu by spring.

 

[cwbullet]

Here's some encouraging news. Omicron appears to be well on the decline in Florida. The 7 day average new cases dropped below 30k. It hasn't been that low in a month. If this trend continues, COVID may become endemic and manageable like the flu by spring.
View attachment 501949

Yes. It plateaued in GA but it not dropping yet. My prior thoughts were premature.

The toughest thing about the military is being tasked to deploy folks. I have had to choose folks to deploys in support of COVID for 2 years. It comes with telling a service member they are deploying and telling their patients that their doc or nurse is not available. We do not have excess so any deployment creates a hole somewhere.

 

[NateB]

We do not have excess so any deployment creates a hole somewhere.

That is always frustrating. We lost an EMT for several months while she was called up for guard duty to provide care and vaccines for some of the Afghan refugees. It's is important work, but also created a hole in our system.

My sister had a friend in a similar situation, she's a flight nurse for the air guard, but when she was deployed somewhere for a need, it just created a hole at the hospital she works at full time.

I'm not really sure how one goes about these situations. There's no good answer and a small pool of people to fill a specific and needed set of skills.

 

[cwbullet]

What do you mean by research does not account for behavior changes?

I could have clarified this more. We know that vaccination tends to increase risk-taking. People think they cannot get COVID so they mask less and gather more. Most research does not look at behavior like this.

 

[cwbullet]

Numbers are decreasing in GA as with most states. We are a long way from the bottom, but the numbers are improving. Also, Moderna was approved.

 

[cwbullet]

I saw a 60 Minutes episode about the success of a COVID treatment in the military hospitals. What can you tell me about it?

I do not have all of the data, but I can say the treatment is very successful. I was a part of the episode. Don't worry, you will not see me or my ugly mug on TV. I left that for the physicians who are more regularly on the front lines of COVID.

I can tell you that the research shows a combined treatment of proning, medications (varied), and a dialysis-like filter. Some facilities have reported over 90% success in patients surviving serious infections. My facility has had similar results. I hope this is enough of an answer.

Two Patients With Severe COVID Pneumonia Treated With the Seraph-100 Microbind Affinity Blood Filter - PubMed

We present 2 patients with rapidly escalating oxygen requirements from severe acute respiratory syndrome coronavirus 2 infection (COVID-19) treated with the Seraph100 Microbind Affinity Blood Filter under Emergency Use Authorization from the US Federal Drug Administration. The Seraph100 is an...

pubmed.ncbi.nlm.nih.gov

This is the filter I am referring to and appeared on 60 Minutes. You can find article after article that shows success.

 

[kuririn]

Two questions:
1. My limited understanding of the SARS outbreak in '05 is that it petered out because the virus mutated into a less virulent strain . In fact a vaccine was developed but never put into production because it was not needed. Why haven't we seen the same happening with the covid virus? And could it peter out and disappear with future mutations?
2. We obviously weren't prepared for this. What changes can we implement to mitigate the economic and social impacts of a future pandemic. What can we do to be better prepared?

 

[John Kemker]

Chuck, I recently received an advertisement from CVS stating that the CDC has recommended a second booster for those who have had COVID-19. Is this reliable information? Should I seek a second booster since I've tested positive and am now asymptomatic?

 

[cwbullet]

Two questions:
1. My limited understanding of the SARS outbreak in '05 is that it petered out because the virus mutated into a less virulent strain. In fact, a vaccine was developed but never put into production because it was not needed. Why haven't we seen the same happening with the covid virus? And could it peter out and disappear with future mutations?

The conjecture is that is mutated into a less virulent strain. We limited to no evidence to back that. It was definitely less infectious and more deadly than COVID. I suspect that we just contained it and because of its less infectious nature, we are more successful. Ask 100 experts and you might get just as many opinon. The future of COVID depends on which why. the mutations turn. Most likely, it will become less virulent and just go away. It could also do the opposite.

2. We obviously weren't prepared for this. What changes can we implement to mitigate the economic and social impacts of a future pandemic? What can we do to be better prepared?

The medical community is better prepared with contingency plans. Our plans allow us to institute testing and treatments in novel ways. I have unique training and we were able to stand up testing and treating in 7 days. Most facilities took a little longer. Most have maintained lessions learned and can do this again.

We need to train more nursing and medical staff. We currently have lost them too fast and training programs have been slow to respond.

 

[cwbullet]

Chuck, I recently received an advertisement from CVS stating that the CDC has recommended a second booster for those who have had COVID-19. Is this reliable information? Should I seek a second booster since I've tested positive and am now asymptomatic?

No official word, but planning is on the way.

4th COVID-19 shot: Who will need another booster soon

Here’s what we know about who needs that extra protection now, and what we might expect next.

www.newsnationnow.com

I suspect it will come in the coming weeks.

 

[NateB]

The medical community is better prepared with contingency plans. Our plans allow us to institute testing and treatments in novel ways. I have unique training and we were able to stand up testing and treating in 7 days. Most facilities took a little longer. Most have maintained lessions learned and can do this again.

Our health system was quick to adjust to the surge in patients by adding beds and floating non-clinical staff back to clinical roles. They opened testing centers and covid treatment offices quickly. Much of that was pre-planned of course, but it more or less went well and as planned. We were fortunate that 6 story tower was alresdy under construction in 2019 and contractors were able to work to get floors open as demand grew.

The supply chain problem was a big issue. Our warehouse supply couldn't be restocked fast enough. Some orders were canceled and others delayed. We had vent circuits for our transport vents intercepted and shifted to FEMA along with about 6 months worth of manufacturing. We were able to improvise, but it wasn't ideal. Some drugs were backorder, but pharmacy was able to supply us with close alternatives in the same class or other concentrations.

Earlier on, it was frustrating keeping up with rapidly changing protocols. 0nce a best practices were established, the care we are expected to give became more routine. Staff burnout is rough. We are shifted around from normal roles to other duties and everyone has been working incredibly long hours on complicated cases.

I feel like we were well prepared in some areas and adapted and overcame in others. I'm concerned the supply problems with low reserve stock and single suppliers for essential equipment and drugs will persist. I might be pessimistic, but we didn't seem to learn from natural disasters and factory fires shuttering drug supplies.