Daniel R. Howard, MD, PA

My Thoughts on Covid-19
World: 177,470,902 cases worldwide, with 3,839,934 deaths . Number of cases world-wide is dropping off sharply now, as are deaths. There continue to be some hotspots, such as India, which is improving significantly at this point, and Nepal, which seems to be about two weeks past its peak. Cases continue to rise very steeply in South Africa and Namibia, which is very concerning. Although most nearby countries aren’t reporting increases in cases, this is probably due to very limited testing in most sub-Saharan African countries. For example, Ghana is reporting very few cases, but hospitalizations for Covid-19 have increased to the rate that there is nearly 100% hospital occupancy, so they probably have a severe unreported outbreak. In addition, Kenya has sharply rising Covid-19 death rates despite only a minimal increase in reported cases. I remain extremely concerned about Africa being the next India.
South America, especially Brazil, but also Argentina, Peru, and Venezuela continues to experience very high levels of infection without either increases or decreases.
US: 34,351,185 cases. 615,717 total deaths Equivalent to losing the entire population of the City of Baltimore in a little over a year
Both cases and deaths continue to drop off very steeply as vaccination rates climb. This is primarily due to vaccination.
US Vaccines: 53.2 % of the entire population has gotten at least one vaccine, and 44.4 % of the population is now fully vaccinated, with a much higher percent of those over the age of 18 vaccinated. There are differences in the reported vaccination rates depending on whether everyone is counted, or only those over age 18. There are major regional disparities, with 12 states having ove 70% of adults vaccinated, but several well under 50% of adults.
MD: 461,392 known total cases since the beginning of the pandemic.
9472 total deaths so far.
We are at 194 Covid-19 patients hospitalized statewide, down about 100 from last week, and the lowest it has been since early March, and the rate is declining quite rapidly.. 54 of those hospitalized are in the ICU’s across the state, the lowest rate since March 26th, and declining as well.
State-wide 7-day positivity rate 0.82%, which is extremely good news.
MD Vaccines: 72.2 % of those over the age of 18 have received at least one vaccine, and 52.6 % of those are fully vaccinated.
GENERAL: Although most news is generally good, there are still some very serious concerns, primarily concerning the variants. The nomenclature has been changed; the Indian variant is now called the Delta virus; it was previously referred to as B.1.617.2. B.117, the UK variant, is now called Alpha.
The Delta virus is predominant in India, and has now become the dominant virus in Great Britain. Great Britain, which has done a great job of vaccinating, has noted more than a doubling of its Covid-19 cases in the past two weeks. The Delta Virus now accounts for almost 10% of all Covid-19 cases in the United States.
It’s not clear if the Delta variant makes people sicker than the standard viruses and other variants, but information from India suggests that this is the case. Data from a study in Scotland also indicated a doubling of the hospitalization rate for the Delta virus compared to the B.117 (now called the Alpha virus)
The Delta variant appears to be at least 40 - 60% more transmissible than the prior Alpha, which was already much more transmissible than prior virus strains, and appears to be less susceptible to vaccination. Resistance to Delta is poor after one Pfizer vaccine, providing only 33% protection, but quite good after a second one, giving around 88% protection, again indicating the importance of getting fully vaccinated. There is no data on the Johnson and Johnson vaccine, but protection with the AstraZenica vaccine against this variant is probably around 72% based on one study, which is concerning because the J&J vaccine is made with a similar technology.
The Reproductive rate in the United States has taken a sharp upward turn in the past week, which really concerns me. It was 0.8 one week ago, now is 0.9. I will be following this number very closely!
To refresh everyone’s memory, the R is the number of people that each infected person is, on the average, likely to infect. If it is greater than 1, the epidemic will grow, and if less than one, it will die out. This change is likely due to both the opening up process, and the spread of variants with a higher reproductive number (B117, now called alpha, and Delta).
The reproductive rate is primarily dependent on three things: inherent characteristics of the virus, number of vaccinated individuals, and human behavior (such as masking and distancing). The R0 (the reproductive number for the virus before vaccinations and masking, etc., was believed to be about 3.5. The R0 for the Delta variant is suspected to be much higher, estimated to be between 5 and 7.
This means it is much more likely to be transmitted, and a much much higher level of vaccination, probably over 90%, is needed to reach herd immunity.
Assuming the Delta variant does take over in the US, which I believe it will, I unfortunately predict we will have another outbreak in the early winter. This outbreak will likely affect primarily unvaccinated people; but I do worry about vaccinated elderly patients and those with immunosuppressive disorders, which may not mount as vigorous of an immune response, as well as those who have received the J&J vaccine, although there isn’t much data on these issues at this point. I hope I am wrong about this, but I don’t think we are over this yet.

COVID-19

What is going on in the world?

World: 84,472,867 cases worldwide 1,837,442 deaths so far. These numbers are likely to double before the Pandemic is brought to some degree of control.

US: 20,619,032 cases. That means 6% of the population are known to have Covid-19 at some point. The real number of infections is certainly much higher than that, as many cases are not picked up.
356,450 deaths. That means that 0.1%, or one in 1000 Americans have already died from Covid-19, with many more deaths to come.
There were 2476 Covid-19 deaths in our nation yesterday.

Covid-19 Vaccines

About 2.5 million doses were administered by January 1st. This is well below the anticipated 20 million by that date. In contrast, Israel has already immunized 10% of it’s population. The vaccine rollout has been a disaster in my opinion, with the Federal government dumping the vaccine distribution on under-funded, unprepared Health Department that have not performed this function in the past. It is really critical to get as many people immunized as quickly as possible to minimize hospital overload and deaths.
The good news, and it is really very good news, is that there have been few serious reactions to the vaccine.

The New Variant Virus

The new virus variant, B117, which spreads about twice as fast as the usual Covid-19 virus, is very widespread in Britain, and some countries in Europe. It probably accounts for the two-fold increase in spread of infection noted in Switzerland.

This variant has now been found in Switzerland, Australia, Belgium, The Netherlands, Brazil, Denmark, Italy, France, Spain, Sweden, Japan, Singapore, Canada, Northern Ireland, Israel, Germany, and now the United States.
B117 has been identified in in the United States in California, Colorado, and Florida. There are likely many others, but the United States is doing very little genomic testing to identify the variant compared to other countries. In other words, I believe this variant is likely widespread in the US, but we don’t have verification of this yet.

None of these patients had travelled, nor had known contact with international travellers, indicating this variant is out in the general population, called “Community Spread”.

This variant Covid-19 virus appears to spread about twice as fast as the usual virus, although no more deadly. However, in the short run, faster spread is much worse than being more deadly, as many, many more people will be infected, resulting in many more deaths than a deadlier virus.

This all the more reason to wear your mask, wash or sanitize your hands frequently, socially distanc, and, most importantly, avoid poorly ventilated interior spaces, especially bars, inside restaurants, churches, gyms, etc., and including your home if you have visitors

Covid-19

What’s going on in the World:

World: 81,126,416 cases worldwide since the start of the epidemic, with 1,771,407 deaths. It is likely we will, despite starting vaccinations, see another increase after Christmas get-togethers, and likely a spike after New Years as well.

US: 19,126,416 cases. 341,138 deaths.

The Variant Covid-19. Initially identified in England, and now called the 2020 Kent variant. Now detected in Canada, Belgium, Netherlands, South Africa, Sweden, Germany, Lebanon, Australia, and Singapore. The United States is not doing sufficient genomic testing to determine whether it is here or not; I suspect it already is.

This variant of the virus is believed to be 53% more infective than the prior virus mutations.

There are 23 mRNA sequence mutations compared to the original Wuhan version. The mutations allow for substitution of an an amino acid on the spike protein, replacing a tyrosine with an arginine. Why this causes it to be more contagious isn’t completely clear at this point.

Genomic sequencing has now identified other mutations that have been clinically significant. The 2020 Lombardy variant allowed approximately 10X as much spike protein on the cell surface compared to the original Wuhan variant; this probably accounts for the more rapid spread in both Italy and New York in the spring. California was primarily infected with the original Wuhan virus, which is probably one of the reasons California fared better in the spring.
The 2020 Kent variant doesn’t make patients sicker, but it is approximately 54% more infective. We don’t know whether this will affect the effectiveness of the vaccine, but computer modeling of the protein suggests it probably will not.

What the increased infectiveness DOES affect is the number of people that need to be vaccinated to reach herd immunity.

Herd immunity is the percent of the population that needs to be immune to stop viral spread. Herd immunity is highly dependent on both viral and host factors. A more contagious virus results in a higher Rt at the same level of human behavior.

We’ve all heard that the population immunity needs to be at approximately 60 - 70% to reach herd immunity; with the higher Rt, that number may well be over 80%.

A simplified calculation of the number needed to reach herd immunity is 1-1/R0 (R0 is the reproductive number calculated at the beginning of a pandemic). Estimates for Wuhan R0 are around 3. (1-1/3 = 67% of the population immune in order to reach herd immunity). If the variant R0 is increased to 4.59 (53% more infective), the number to reach herd immunity is much higher. (1/1 – 1/4.59 = 78% of the population immune in order to reach herd immunity).
Herd immunity is the sum of acquired immunity (infected) and vaccinated immunity. As about 12% of the US population is estimated to have been infected with Covid-19 by CDC modeling (studies indicate about one in 8 cases of Covid-19 have been identified)., we have a 12 % natural immunity., and therefore will need around 70% uptake of the vaccine to reach herd immunity. That may be a difficult goal to attain.

About 0.1% of the population, one in 1000, have died from Covid in 2020, and that number is likely to be close to 2 in 1000 (0.2%) by March of this year, so attaining herd immunity is really critically important to minimize more suffering and death.