IM Doc pt 26
Dec. 11th, 2021 05:16 pm![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
temporaryrealityEric Topol Discusses Covid Vaccines Not Meeting Expectations, Breakthrough Cases Sicker
It looks as if conventional wisdom on the Covid vaccines has run head first into some ugly realities. Eric Topol, formerly a “Get vaccinated, problem solved” cheerleader, grapples out loud with troubling data about Covid deaths and breakthrough cases with a serious journalist, David Wallace-Wells of New York Magazine. The short version is that both measures are much worse than expected and the trajectory bodes ill.
We’ll go through many of the bad trends Topol and Wallace-Wells identify, including one we hadn’t wanted to believe when IM Doc started telling us of it privately via e-mail weeks ago, and presented in comments yesterday: that his breakthrough cases have been typically sicker than those among the unvaccinated. Topol is seeing the same thing and his population isn’t from IM Doc’s part of the world.
Topol may have fallen for orthodox thinking, but sits on the Scripps Research board as the founder of the Scripps Research Translational Institute , he has tremendous clout and can’t be dismissed, both by virtue of his reputation and because the data he and Wallace-Wells discuss speaks for itself. But the officialdom has bet so heavily on magical vaccines being the solution for Covid that the denialism is likely to remain strong and get even uglier.
As we say often here, it would be better if we were wrong, but it appears we haven’t been. And I don’t like sounding triumhpalist; I felt nauseous during September 2008 when just about everything we said about the credit, mortgage and derivative markets in 2007 and 2008 was proven correct, and then some.
However, Topol and Wallace-Wells substantiate what we and our experts, IM Doc, GM, KLG and Iganacio have been saying from early on: the vaccines were overhyped. For starters, there was no basis for believing a vaccine for a coronavirus would produce immunity that lasted more than months to at most a year. While the vaccines were under development, data from Imperial College indicated that the rate of decline in neutralizing antibodies from contracting Covid provided immunity on the order of six to eight months. A vaccine might produce more durable immunity, but not vastly so. Plus no expert expected a vaccine for a respiratory virus to confer sterilizing immunity.
Yet not only did our putative leaders tell outrageous howlers, with both the CDC’s Rochelle Walensky and Biden repeatedly and falsely stating that if you got vaccinated, you would not get Covid (“If you’re vaccinated, you’re protected”), they also committed the cardinal sin of betting on their own PR. They treated vaccines as the one-stop answer to the Covid problem.
And not only did they actively discourage the use of non-pharmaceutical interventions like masking and social distancing (can’t harsh the mellow of convention sponsors and holiday makers) but they also crippled an already slipshod Covid data gathering system by telling public health officials not to collect data on breakthrough cases among the vaccinated. So now we have to rely on figures from less incompetent countries like Israel, and Topol is forced to make back-of-the-envelope computations.
Some of the grim news from Too Many People Are Dying Right Now:
Lower reduction in mortality than expected. Wallace-Wells starts with the expected Covid vaccine death reduction of 90% or at least, per another expert, 75%. That means Covid fatalities should be 25% or lower relative to last year…which is not where we are. Instead, from Wallace-Wells:
But at the national level, at least for the moment, the reduction of mortality risk seems to be considerably smaller. In the worst of the winter surge, the country was registering 250,000 new cases per day; at its peak, that surge was killing roughly 3,000 Americans each day (often a bit above, but with a few dips below). Today, we have a bit more than 100,000 new cases each day, though the numbers are still rising as part of the Delta wave. If we had reduced mortality risk by 75 percent, that would mean about 300 daily deaths. If we had reduced it by 90 percent, it would mean 120. Instead, in our seven-day average, we just passed 500.
Things may be even worse than that, though. In general, epidemiologists expect a lag of a week or two, perhaps more, between case peaks and death peaks… comparing case data from even one week ago with today’s death data reveals an even grimmer picture: about 75,000 cases per day then yielding the current average of 500 deaths, suggesting the mortality rate had fallen by less than half since winter. If you work from two-week-old data, it suggests that the mortality rate had hardly fallen at all. Applying the winter ratio to the case load from July 24 would predict an average of 600 daily deaths. On Friday, there were 763.
And Topol:
Just looking at the U.K. and Israel, which had been our guideposts, I thought we would keep the hospitalizations pretty darn low — maybe a fourth of where we’d been in prior waves. And deaths 10 percent of prior waves. But we’re not doing that at all. If you look at the log charts of the U.S. and the U.K, you’re starting to see some real separation for death. It’s certainly going in the wrong direction, and it had been tracking incredibly closely, until recently.
Weaker effectiveness of vaccines. The bold is Wallace-Wells, per the original, and Topol, in regular type, in response:
What I just can’t understand is why all three things are all moving up together so rapidly. Given everything we’ve seen in other countries and everything we think we know about the vaccines, even if cases rose dramatically, we’d expect much lower rates of hospitalization and death. But we’re not.
It’s like we didn’t have vaccines. Or worse. I was just putting this talk together and I made the same observation. I’m looking at the four waves, and, as you know, in the monster wave, we got to 250,000 cases per day. And at that time we had 120,000 plus hospitalizations [per day]. About half. What’s amazing is, we’re at about 120,000 cases now, and we’re over 60,000 hospitalizations.
It’s the same ratio.
Yeah. So when I look at that, I say, what happened to the vaccines?
Topol also pointed out these results were all that much attributable to low vaccination rates in certain states. Florida, for instance, is the standout mortality state yet is has an average, not low, vaccination rate. Los Angeles County, an early and continuing high infection/death area, has a higher vaccination rate than the US overall. He returns to that issue later:
I mean, one of the worst signals that I’ve seen is San Francisco. San Francisco is like Vermont, they’re even a little higher than Vermont for fully vaccinated — it’s 70 percent of the population of San Francisco county and it’s going through a very substantial hospitalization spike, unlike Vermont.
We flagged this indicator of apparent limited vaccine impact last month (hat tip GM). Admittedly only one week of data, but it showed infection rates were proportional to vaccination rates, implying that the vaccinations weren’t reducing the case count.
Data from Israel pic.twitter.com/Qmu4ZDtN7a
— Irene Tosetti (@itosettiMD_MBA) July 10, 2021
Severity of breakthrough cases From Topol:
What I’m hearing — and I’ve been helping with a bunch of patients — is that people who are breaking through are getting very sick. They’re getting Regeneron antibodies.
There may be something to this waning immunity story. It’s fuzzy, but the people who are getting hit are more apt to be people who were vaccinated very early. I had a patient in recent days, who’s in her 70s. She got vaccinated in January. And, I mean, she almost died. I mean, it’s just terrible. I think — I hope — the monoclonals are going to save her life. But she was a healthy 70-year-old lady, and just following her case was illuminating — she thought she was protected, but she also wore masks everywhere. She was on guard and still got infected and desperately ill.
It is crazy-making to see Topol act as if he hadn’t considered that the vaccine-induced immunity might wear off in six months or so, particularly when much worse that expected immunity data coming out of Israel (which got pretty much everyone jabbed who was going to be jabbed in Jan-Feb), with efficacy down to 64% in June and 39% in August and Delta being markedly different than wild-type Covid.
And that’s before you get to an elephant in the room that oddly no one appears to have mentioned: immune responses in the elderly are weaker. That is why the good old fashioned flu vaccine has a more potent (and more expensive) version for those over 65. But these vaccines had very thin representation in their clinical trials of the over 65, and effectively none for over 80. So it isn’t hard to think that the vaccine-conferred immunity would be weaker and/or shorter lived in the elderly.
Other researchers were already sounding the alarm:
That is plainly wrong – people die on re infection with variants different to the original infecting virus. Immunity from natural infection decays within 6 months and often earlier
— Gupta Lab, Cambridge (@GuptaR_lab) July 11, 2021
The boosters might not work. OMG, Topol dares to say it!
This booster thing is yet another issue, because we don’t even know if they’re going to protect against a Delta. I mean, everybody’s assuming it, but there’s no data. You know, there’s some neutralizing antibodies from the Pfizer report in 23 people and there’s an Israeli pre-print, it says there’s waning immunity without any neutralizing antibodies. So we’ll see. But these are just classic spike-protein boosters. There’s nothing special about them to handle Delta. So I don’t know. I mean, I suspect they’re going to provide some protection, but I’m not sure I’m so confident it’s going to be great.
Oddly, Topol appears to have missed the Moderna data, which as GM had pointed out to us, showed that a third booster shot generated only 40% the level of neutralizing antibodies of the first vaccinations. Again, that translates into some combination of less robust immune responses and shorter immunity.1
The credibility of the public health establishment and the establishment generally is on track to take a big hit. We’ve published this observation from GM before, and we believe it bears repeating:
That part about the patients taking it out on their doctors will sadly become an even more common occurrence. In retrospect that was predictable, but you can’t really blame the patients — the medical establishment has been telling them lies for many months, and they see the doctors in front of them as part of one monolithic such entity. In reality it is no such thing — there are the honest doctors directly taking care of patients and then there is the corrupt lying actual high-level establishment, but that is not how the regular people perceive it.
The part about the willing self-deception of the elites is also very important. I too have come to the conclusion that either there is some absurdly nefarious grand conspiracy behind this (not really likely) or it is just stupidity and shortsightedness all around. COVID has shown, again and again and again, that you can ignore it for some time, but eventually you will pay for it. Wuhan CCP officials, Trump, the Tanzanian president, and many others learned that lesson the hard way. And it’s been 18 months of that. And it’s not like it was not known there is antigenic drift with these viruses, or that they have all sorts of tricks up their sleeve yet to be played, or that the vaccine was not going to last (was talked about from the start), or that we were never going to vaccinate enough people to reach herd immunity, etc.. So why would you possibly spend half a year blatantly lying when it was crystal clear from the start that it will backfire eventually? Unless you are indeed that deluded and unable to think rationally about the long term…
Unfortunately, this is rule by MBA, or pathological big organizational behavior, writ large. Too many bosses want to hear only good news from subordinates, which means they engage in cover ups or delays, hoping things will either blow over or they can find someone else to scapegoat. And now we run our country based on short-term careerist calculations.
While we can hope for well deserved days of reckoning to come eventually, too many people will suffer in the meantime due to their negligence and cowardice.
I am looking forward to is the well-deserved pillorying of Rochelle Walensky. We called her as likely to perform poorly as the newly-elevated head of the CDC, but our assessment turns out to have been far too generous. The CDC is a above all a data shop. Topol laments in passing about our inability to do rapid Covid testing, as if this is just some sort of regrettable outcome. It’s not. It’s Walensky’s fault. Getting testing right, and pushing Biden to use the Defense Procurement Act to requisition materials if they were in short supply, should have been a top priority in her first two weeks. Instead it doesn’t even appear to be on her list.
And how about getting more accurate and timely reports out of the various states? Has Walensky gone out into the field to meet a single official to offer CDC help and quietly threaten public embarrassment if they didn’t shape up? I could go on, but she seems to have the same conception of her job as Marcie Frost at CalPERS: being a pretty face for the organization, making PR her priority, and leaving the dirty work to minions.
____
.1 From GM via e-mail in July:
When Moderna put out their preprint on the B.1.351 booster (now obsolete with the rise of B.1.617.2):
https://www.medrxiv.org/content/10.1101/2021.05.05.21256716v1
There were two concerning observations there:
1. No neutralization activity left against P.1 and B.1.351 after 6-8 months
2. The booster worked, but only increased the neutralizing titers to ~40% of what they were originally against the Wuhan variant and what they are against it when boosted.Based on the fact that the booster “worked”, OAS was dismissed by most, but this would in fact consistent with an “original antigenic sin” effect — nAbs only got boosted to less than half of the previous level.
But then the AZ booster preprint came out:
https://www.biorxiv.org/content/10.1101/2021.06.08.447308v1
They saw the same <50% boosting against B.1.351, and they also analyzed neutralization against B.1.617.2 and saw that it was even worse against it (B.1.617.2 is antigenically more different from B.1.351 than it is from the wild type).
But they also did several more important experiments:
1. They immunized naive mice with a WT and with a B.1.351 vaccine, single dose
2. They immunized naive mice with a mixture of the twoAnd the neutralization against B.1.351 was still half of what it is against the WT
So one has to conclude that it is the virus itself that is the difference, not an OAS effect.
Hopefully we get such analyses for B.1.617.2 soon, as B.1.351 is probably not going to be relevant moving forward.
GM also noted that the Pfizer vaccine has been functionally equivalent to Moderna and in an e-mail last week, that Moderna’s latest investor update essentially repeats earlier date, with nothing new on Delta
The following comment was the one that started my endeavor to copy IM Doc's posts here, so it's a repeat. Still worth rereading, though:
IM Doc vis e-mail:
In August and September of last year – Texas Florida and the rest of the south were getting killed – and then it kind of let up by October.
And just like last year – the action moved to the Northern Tier – Montana, Idaho, Wyoming, Dakotas, and Nebraska and the surge started right around Labor Day – and crescendoed through NOV and DEC – just like it is right now. In OCT and NOV last year – it began the surge into the upper Midwest and New England – and the West Coast – and then eventually into the South again –
We are starting just like we did last year –
And Texas and Florida are slowly receding just like last year.
And we are on a definite upswing here – almost literally the same week it started last year.
It is so far exactly like last year as far as the timing and geography. Thankfully – the case numbers and deaths are not as high so far.
Not really here because of the IM Doc comment, but he liked the previous poster's charts, so I thought I'd include the thread:
Good Morning.
I have endeavored to share all I could about what is going on on the ground in my world. I have had a very emotional past 10 days – and sometimes on the ground reporting as a physician is going to have to include very emotional things. This current situation has really taken a turn for the worse. The patients who are getting to the stage of critically ill are very very ill indeed. It seems they are not responding to things that were useful in previous waves. I am not sure what that means at this point. And although, we have not seen any kids here that are critically ill, I know this is happening to some degree across the USA. Furthermore, I have now seen with my own eyes cases of other viruses that should be confined to winter now making people very sick right now. I fear that our COVID friend may be learning some new tricks.
We now have multiple doctors and nurses on quarantine because although fully vaccinated they too have fallen ill, just as I did a few weeks ago. So I am going to be very busy and this will be the last report for a long while.
I have two brand new students with me starting this past Monday. As I always do, I start their rotation off with a very simple statement – THIS IS STILL A NOBLE PROFESSION. I endeavor always to make sure they know that through their entire time with me.
I have a lot in common with them as they enter their careers in this COVIDtide. When I was 25 and a brand new doctor, AIDS was raging. Death and dying hung in the air. But what kept me grounded back then was the other aspect of being an intern in that era – taking care of the WWII generation as they hit their 70s and 80s. As I always tell my students, go through your life learning more from your patients than they ever learned from you – and those WWII folks could not have been a better font for a young man.
One of the mystical things about being a PCP is the opening up that happens much of the time right as people know they are about to leave this realm. It happens all the time. I was 24 back then. I do not need to watch Saving Private Ryan to know what life was like for a 24 year old on D Day. I saw it repeatedly in haunted eyes and words as these men were dying generations later. I did not need to watch Judgement at Nuremberg to know what it was like to see the Nazis being executed one by one – I lived it out through memories of a 24 year old who was there – spilling his soul years later to his 24 year old doctor as he lay dying. I could go on and on with kamikazes, Iwo Jima, the USS Missouri, and Pearl Harbor.
I have also realized that patients will tell me in all kinds of ways that they are ready to go. And I best not stand in the way. And the thing that has become so important to me – this process can be just as mystical as watching a baby being born.
And as I have learned so many times in the past, life lessons are often given to me as their physician as they are dying – it is one of the greatest gifts of my life.
This happened this past weekend. A very elderly woman, fully vaccinated, told me in her own way that she was ready to go. This has been a very difficult struggle for her, but she took it with all the grace and dignity that I know she has. Her family has been here in this area for generations and she is as tough as nails. She gave it everything she had. But it was her time to go.
That morning, when I walked in the room, she looked up at me – “Doctor, there are angels in this very room – Do you see them? – They are all around me. They are getting ready to take me home. I am not afraid. They are standing right behind you and have their hands on your shoulders. Take their strength. They are trying to lift you up. Let them.”
One lesson I have learned is to not get in the way. When people are talking like that, they are indeed ready to go home.
And I walked out of her room, and promptly fell to the floor and I started weeping like a baby. I am no longer 24, and this gets harder and harder every year. I also think there is just an overall exhaustion at play. This whole thing is really taking its toll on all of us in the hospitals. There is also some PTSD at play with me personally. Abandoning people to face this moment alone was common in the AIDS era. It was horrible then. I thought I would never see it again – but it is happening all over again now. People dying all alone.
But her family and her church family were just not going to let that happen. A few minutes later, as I was doing her note, a chorus started to ring out from the windows in the room – an old American hymn – There were about 50 people outside her room letting her know they were right there.
O COME ANGEL BAND
COME AND AROUND ME STAND
BEAR ME AWAY ON YOUR SNOW WHITE WINGS
TO MY IMMORTAL HOME
And they kept right on going with another African American hymn —
MOSES LED GOD’S CHILDREN, 40 YEARS HE LED THEM
THROUGH THE COLD AND THROUGH THE NIGHT
THOUGH THEY SAID LET’S TURN BACK
MOSES SAID KEEP GOING
CANAANLAND IS JUST IN SIGHT
THOUGH WE WALK THROUGH VALLEYS, THOUGH WE CLIMB HIGH MOUNTAINS
WE MUST NOT GIVE UP THE FIGHT
WE MUST BE LIKE MOSES, WE’VE GOT TO KEEP ON TRYING
CANAANLAND IS JUST IN SIGHT
THERE WILL BE NO SORROW
THERE IN THAT TOMORROW
WE WILL ALL BE THERE BYE AND BYE
MILK AND HONEY FLOWING – THAT IS WHERE I’M GOING
CANAANLAND IS JUST IN SIGHT.
It was a joyous occasion. And as has always been the case – I learned many many lessons.
But the reason I bring this story up – I think we can all learn lessons.
That last song is from an ancient story sacred to Jews, Christians and Muslims. It has a message that should be visible to even agnostics and atheists.
I will sum it up for you like this –
Americans – time is running out. We need to begin to realize we are all on the same team here. If we fail to do so, it will likely lead to 40 more years in the wilderness. If we find it in ourselves to start working together, the milk and honey will be flowing. We are going to do this together or not at all.
If you are high risk, get vaccinated NOW. All of us should be eating well, exercising, out in the sun, losing weight and getting the stress off. We should all be looking for moments in our lives that are transcendent like I described above. It is very important for all of us to know that there is a higher purpose and we must get there together.
Live not by Lies
Live not in fear.
*******
The Great Russian Flu of the 1890s almost assuredly was a coronavirus and is the most applicable historical model to what we face now.
It came in 5-7 waves over 12-15 years.
What is happening right now is Wave #2 of this one.
“Are vaccines becoming less effective at preventing Covid infection?”
Forgive me if I take a small victory lap on behalf of our Covid brain trust and Lambert for yet again delivering on the NC aspiration of being early and accurate. The headline above is from a Financial Times story, based on a spate of recent research showing waning efficacy of the Covid 19 vaccines, particularly Pfizer, from a variety of sources: data from Israel, which injected most of its population early, in January and February, with the Pfizer vaccine; a Mayo study, which showed falling efficacy for all vaccines, particularly Pfizer, which it found at 42% (Moderna holds by contrast at 76% over the same time period), a new Oxford report, and a study from Qatar.
The MSM finally starting to acknowledge that the vaccines are not all that they were cracked up to be came about largely due to foreign sources (doing a better job of tracking Covid cases than the US, a very low bar to beat) and one large US institution beyond reproach posting what has largely been missing from the CDC: actual pretty to very reliable findings. The fault isn’t simply that of the fragmented US public health care system. The CDC has not gone on the road to try to help/prod state public health officials. It hasn’t staffed up to fix VAERS. And the CDC has gone to some lengths to corrupt fact-gathering, most notably by saying it would not track breakthrough cases among the vaccinated as part of its May “Mission accomplished” chest thumping. And the CDC has engaged in dishonest PR by telling Americans that the vaccines would prevent Covid infection.
Mind you, in polarized, attention-deficit-disorder afflicted America, not being all in with vaccine cheerleading is a dangerous editorial position. Merely pointing out that the vaccines were overhyped was seen as being against them. So we’ve had to be more careful than we’d like in providing what we thought were early and important indicators that things were not well in vaccine-land. One was the number of breakthrough cases that IM Doc and his MD professional network (large by virtue of their participation in regular Grand Rounds and other sessions) when conventional wisdom was that that was impossible. And as time went on, IM Doc was seeing the breakthrough cases presenting as sicker and was also seeing and getting reports of breakthrough cases winding up in the hospital. From a mid-July e-mail:
The next day, in a different hospital, when confronted with showing confirmed Covid cases in the area running nearly 57% vaccinated, one doctor went into meltdown, saying something pretty close to:
Within a month, he and 6 family members, all fully vaccinated, came down with Covid.
Along with IM Doc’s on the ground sightings, GM was relentlessly watching data. He had predicted in April, which was confirmed by Moderna data in May, “So basically protection against those two variants {P.1 and B.1.351] is gone after 6-8 months if you have been vaccinated against the original strain.”. And they have proven to be more vaccine-tractable than Delta.
Recall that GM was also alarmed at the rapid rise in cases in the Seychelles, which opened up after it hit a 63% vaccination level and immediately saw a spike in cases. GM also caught this snippet in early July:
The latest Israel reports show vaccine efficacy against severe Covid for the >65 year olds vaccinated first to be down to 54%:
The Financial Times article also discusses another topic we’ve dared to broach: that the vaccines have not proven to be terribly effective in preventing the spread of the highly contagious Delta. Ys the officialdom is doubling down on at best marginally effective vaccinations rather than promoting cheap tests and quarantines.
For convenience, we’ll repeat an extract from Charles Ferguson’s newsletter that we showcased in Links yesterday:
The Financial Times article is very much worth reading in full.1 Key sections:
Interestingly, the Financial Times acted as if a third shot might not be the way to go since UK health officials are still weighing the issue:
Perhaps they’ve looked at Moderna data on a third shot, which GM reviewed months ago. His bottom like (supported by earlier tech-speak): “The booster only upped the neutralization activity against the variant to half of what the levels were against the original strain.” And again, these were against easier-to-thwart variants that Delta.3
For the bioscience-literate among you, Igancio added:
As you can imagine, no such research effort will occur in the US. If we are very very lucky, the UK might take a stab and we will piggy back on it.
So the US gearing up for a third shot of the current mRNA vaccines against Delta looks an awful lot like “If the only tool you have is a hammer, every problem looks like a nail.” And the really sorry part is our health establishment has other tools that for the most part, they are refusing to use.
___
1 It appears to have a misconstruction, which is not the reporter’s fault. A source claimed that the Moderna vaccine had “three times the mRNA” as Pfizer. That sounded simplistic enough to be wrong. From GM:
And Ignacio:
2 From later in the article:
3 It’s weird to see the campaign of silence against J&J in the US. As GM pointed out: