New Year, New Strains, and the Race Against Time
Dear All,
Happy New Year and hope 2021 is off a to a good start. While we all wished we’d wake up on New Years Day and COVID-19 would be gone, it is not only still present in our lives but evolving, or more medically-speaking, mutating as we enter the new year.
Specifically, there has been much reporting about a ‘new strain’ of the virus that started in the U.K. and is now known to be present in the U.S. as well as a strain initially found in South Africa that has scientists concerned. Getting several questions about the new strains and vaccine rollout that I thought I’d address:
What is the deal with these new strains?
First, some quick biology: Viruses care about one thing and that’s reproducing or replicating as much as possible. In the case of COVID-19, the virus enters the host (ie – us humans) and utilizes our cellular machinery to make as many copies of itself as possible. Inevitably in the replication process, an error occurs where the new virus strain has a mutation as compared to its parent virus. Most of these mutations are due to random chance and many are inferior to the original strain in terms of their ability to replicate. However, some of these mutations end up being more efficient and effective at replicating, and therefore, spread faster than the original, less efficient strains. These newer, more effective strains, ultimately become the dominant strain of the virus due to the same Darwin ‘survival of the fittest’ laws that govern all organisms.
And so, it’s not terribly surprising that the COVID-19 virus has mutated, and that strains that are more efficient and effective at replicating are becoming more prevalent in the population. There are 2 strains that are getting the most attention:
The U.K. Strain / B.1.1.7
The specific mutation from the U.K., which is being referred to as the B.1.1.7, is more easily transmitted from person to person, or put another way, is more contagious than the initial strain of COVID-19. Current evidence does not suggest it causes more severe disease, but rather, it is more easily passed from person to person. U.K. officials did come out Friday and suggest that the new strain might be more deadly but they acknowledge it’s too early to tell. I would argue that there are other confounders in the U.K. that could explain a recent uptick in death rates such as understaffed, overwhelmed hospitals as opposed to the strain, but it is too early to identify any underlying cause for their increased death rate with confidence.
The bottom line is this strain is definitely more contagious and might cause higher rates of death but that is still under investigation.
Per the CDC, the strain has been detected in 12 U.S. states thus far and accounts for a small fraction of current infections. However, CDC modeling suggests that it could become the dominant strain in the U.S. by March.
What can we expect if this strain becomes the dominant strain?
More people will be infected, thus leading to more hospitalizations, and death. We can look to other countries where this variant has spread more widely to get a sense of what to expect. See chart below from Eric Topol on rates in the U.K., Ireland, and Israel where the B.1.1.7 strain is prevalent
The good news is that recent reports on studies done by Pfizer and BioNTech are showing that the current vaccine protects against the B.1.1.7 strain. The timeliness of vaccine rollout will be critical as we discuss below.
While we’re fortunate that this B.1.1.7 strain probably does not cause more severe disease and is not vaccine-resistant, the fact that it spreads more rapidly is very concerning for the health system. As the rate of new infections goes up, so will the rate of hospitalizations which is problematic given that many of our hospitals are already stretched thin. We can look to the U.K. to see what type of effect the B.1.1.7 strain is having on its hospital system as a warning. In the U.K., many hospitals are on the brink with current occupancy rates 50-70% higher than their initial surge last April. Portugal is now experiencing a similar surge from this new strain. The concern in the U.S. is that many parts of the country are already seeing very high rates of infection/hospitalizations before the new strain has embedded itself.
The South African / 501Y.V2 Strain
The other mutant strain getting attention is one that is most prevalent in South Africa referred to as the 501Y.V2 strain. The most concerning element with this strain is that it is thought to be more resistant to the vaccine. It’s important to note that information like this is evolving almost daily and subject to change, but based on recent information I’ve reviewed from respected publications like Nature as well respected virologists like Trevor Bedford, it does appear the vaccine will have reduced neutralizing capacity, or less efficacy, against this strain.
How much less effective? This will likely be individualized and depend on your immune system and its response to the vaccine. When they looked at samples of vaccinated blood against this strain, the results ranged from near total protection against the strain to a 64-fold reduction in protection and everything in between.
Bottom line – It’s still too early to make declarative statements on the exact level of immunity or lack thereof to this strain, except to say it is showing some degree of vaccine escape. When Nature articles such as the one I linked above are saying “What this week’s results mean for battling the pandemic are not yet clear,” it means that nobody fully understands the implications of these new strains, so take all the news you’ll consume about the new strains with several grains of salt recognizing this is a rapidly evolving situation. Focus on what you can control which are your own actions such as the precautions you can take from becoming infected and getting vaccinated when the opportunity presents itself.
Some good news is that neither of these strains appear to be widespread in the US yet and we can always update a vaccine in the future if a mutant variant does prove to be vaccine-resistant.
Speaking of the vaccine….
What’s going on with the vaccine rollout?
It could be characterized as anything from difficult to a disaster depending on your initial expectations. Whereas one would have hoped the bottleneck or constraint would always be manufacturing, it seems that distribution is the current bottleneck. Doses are sitting on shelves and the vaccine rates have not hit initial projected targets of where we all hoped we’d be by this point.
I would say we’re in a horse race pitting vaccine distribution vs the likely spread of the new B.1.1.7. and other strains. Sure, masks and physical distancing are going to help mitigate the spread of these new strains, but I worry that the continued pleas for masks and avoiding gatherings is a tired message that is falling on deaf ears due to COVID fatigue. The real solution is mass vaccination ASAP.
The other concern is that the more people who become infected, the more times the virus replicates, and therefore, the more chances for additional new mutant strains to develop.
Hence, the horse race noted above. The faster we can get folks vaccinated, the less potential these new strains have of overwhelming our communities and health systems.
From a macro perspective, we’ve gone from a science problem of not having a vaccine to a supply chain problem where we’re not very good at manufacturing/distributing the vaccine at scale, and in the coming months will likely have a sociology problem in helping convince the vaccine skeptics to go get the shot. While I keep hearing a lot of chatter on vaccine hesitancy, that is not our immediate problem yet. It very well could be at some point and preparing for that eventual challenge is reasonable, but almost all efforts need to be focused on breaking the constraints around manufacturing and distribution. Once we get to a point where we have so many doses on the shelf because there’s no demand left from folks who want the vaccine, then we can turn our full attention to addressing the sociology problem. Until then, focus on breaking the constraint at hand. Whether we or the virus win the horse race may depend on it.
I am back in the hospital in New York the next few weekends and will report out on my next blog what I’m seeing now as compared to how things looked back in the Spring in the next post.
Be well and stay safe,
Harry
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