I hope everyone had an enjoyable 4th of July holiday. As we read last time, this COVID pandemic has no plans to take a vacation and continues to strengthen its grip on the nation. As predicted by its very rapid rise in South Africa and Europe, the Omicron BA.5 variant has become the dominant strain in the US in just 5 weeks.
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See its trajectory in France as an example. |
“R0” is how contagious a virus it is - it’s the average number of people who will be infected by one person with that virus.
- The original COVID strain had a R0 of 3.3.
- Delta had a R0 of 5.1
- The first Omicron had a R0 of 9.5.
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The current variant has a R0 of 18.6, on par with measles in contagiousness.
"The omicron subvariant BA.5 is the worst version of the virus that we've seen," Eric Topol, MD, founder and director of the Scripps Research Translational Institute. “BA.5 is a different beast, with a new superpower: enough alteration in the spike protein that immunity from either prior vax or prior Omicron infection (including recent infection) doesn't offer much protection."
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Bob Wachter, UCSF Chairman of Medicine writes,
- The asymptomatic test + rate, has been 5-6% for a couple months. If 1 in 16 people who feel fine actually has Covid, spend enough time maskless indoors & it’s near-certain that you’ll get it. (If 6.5% of an asymptomatic population has Covid, in a crowd of 50 people, there’s a 96% probability that someone there is positive)
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This is particularly true since vaccination (even w/ 2 boosters) and/or prior infection now offers relatively little protection against infection, although they still remain enormously protective against severe infection & death.
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In fact, this is one of the biggest implications of BA.5: a prior infection – including an Omicron infection as recent as last month – no longer provides robust protection from reinfection. That old notion about hybrid immunity (vax plus infection) providing “immunity superpower” (& thus no need to be careful) is no longer true – we’re seeing such folks get reinfected within 1-2 months.
As reviewed last time, it is becoming more evident that each repeat infection, even if minimally symptomatic, increases one’s risk of long-term damage and Long-Covid complications in the brain and nervous system, lungs, heart, and other organ systems.
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Health care workers can reduce this risk by ensuring your vaccine and booster status is upto date. I would recommend all of you, particularly those with risk factors for serious outcomes, receive a 2nd booster dose.
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- Bob Wachter writes, many ask: “Shouldn’t I wait on boost #2 until fall, when a new bivalent vaccine (combo of original & Omicron-specific boost) is available? For those over 50, I’d say no – there's too much Covid around and evidence of benefit from boost #2 is persuasive.
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- Pfizer/Moderna are now developing a booster targeting BA.4/5 (the one they’ve built vs the original Omicron will have limited utility against BA.5). If the new booster is highly effective (not guaranteed), I doubt that getting a 2nd boost now will block you from getting bivalent boost in fall.
- Inevitably, a fall booster will be needed, but every instance of vaccine or natural immunity raises one’s level of neutralizing antibodies to combat future infection and minimize severity.
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In this longitudinal observational study conducted among health care workers with SARS-CoV-2 infections not requiring hospitalization, 2 or 3 doses of vaccine, compared with no vaccination, were associated with lower long COVID prevalence.
- Azzolini E, Levi R, Sarti R, et al. Association Between BNT162b2 Vaccination and Long COVID After Infections Not Requiring Hospitalization in Health Care Workers. JAMA. Published online July 01, 2022. doi:10.1001/jama.2022.11691
BA.5 is particularly good at evading immunity from vaccination and prior infection. Researchers from Beth Israel Deaconess Medical Center in Boston recently found neutralizing antibody responses against BA.5 were twentyfold lower than against the original omicron strain. Such findings help explain why it spreads faster than other omicron relatives and indicate the potential for reinfections to become more common. The variant's dominance also comes as more Americans have dropped public health measures, such as masking, and as many people experience a natural waning of vaccine protection, both of which may contribute to the subvariant's rapid spread.
SO what can you do to avoid this highly contagious variant?
The following thread presents a very simple, logical and scientifically-sound perspective on how to avoid becoming infected. It is worth reading!
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Because #COVIDisAirborne, two rules formed the backbone of my protection:
(1) Wear a well-fit N95.
(2) Don't not wear a well-fit N95.
#1 is relatively easy. #2 can be hard, and my guess is this is where most people catch COVID, whether in day-to-day life or traveling.
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Rule #1: Wear a well-fit N95. |
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A high-quality mask is your best defense against not just COVID, but also other airborne infections. Finding an N95 that is comfortable and fits your face shape well is critical. For me, Honeywell's H910 fits great + are cheap.
Every time I put it on, I spend a minute bending the nose piece to make sure it doesn't leave any gaps around my nose/eyes. I shave my face daily to ensure it gets a good seal. And, I run my fingers around the edge of the mask to make sure it's pulled snug to my face.
Then, the easiest thing for me to do is think of COVID like cigarette smoke. I ask myself, "if someone was smoking/had smoked here, might I smell it?" If the answer is yes, I put on my mask.
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Alone outside? Probably wouldn't smell a cigarette. But, a crowded patio? Absolutely.
Hopping on public transit? Mask on. Arriving at the conference venue? Mask on. Showing up to a crowded outdoor social? Mask on. Walking into the hotel? Mask on. Getting a cab? Mask on.
That's rule #1: Wear a well-fit N95. Rule #2 is harder.
Rule #2: "Don't not wear a well-fit N95." It's really tempting to break this rule, and that's when the virus strikes.
For ex, conferences often have coffee/snacks/wine receptions. Unfortunately, an N95 in your hands is like a bike helmet on the handlebars... it's useless.
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Rule #2 is hard because it's SO EASY to make excuse after excuse to take off the mask ("well, they have pretzels on the plane," "well, this room is crowded but the wine is free," "well, it's my turn to present")... and then wonder how COVID snuck through.
Ultimately, you need to make the call about what risks you want to take. For me, it was worth unmasking for patio dinners with people I care about... when we could find very well-ventilated patios! Your threshold might be different, and that's okay.
But, at the very least, it's 100% possible to avoid getting COVID doing things that AREN'T worth it (e.g., standing in a jet bridge, riding an Uber, or listening to a lecture) and save up those risks for when it is (e.g., spending an unmasked weekend with someone you love).
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Regarding our QualDerm safety protocols, a recent JAAD study of 1,118 asymptomatic dermatologic surgery patients involving skin cancers on the head/neck showed almost 2% tested positive for COVID-19 three days prior to surgery, most of whom were asymptomatic. It illustrates how important it remains to stay vigilant to protect yourself and other vulnerable patients.
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Vaccinations and boosters
I continue to recommend boosters for all our QualDerm teammates due to their protective effects. By priming the immune system to produce higher levels of neutralizing antibodies COVID-19 infection severity is reduced, even when not a perfect match for the specific variant.
- The FDA has instructed vaccine makers to retool COVID-19 shots to target BA.4 and BA.5. Vaccine makers are working to finalize and manufacture the shots in time for a fall booster campaign but there remains debate over this strategy. Many experts would prefer a second ‘Operation Warp Speed’ with government investment in pan-coronavirus options, especially since new variants outpace efforts to manufacture targeted vaccines.
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Testing
Rapid antigen tests remain cheap, widely available, and very effective at source control. Use them whenever you are considering a higher risk setting to ensure you and others are safe and unlikely to be highly contagious. These Rapid Tests remain very effective even with Omicron variants and the following figure helps explain how and why.
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Good news
While cases are surging worldwide, there is not much evidence BA.5 causes more severe disease. BA.5 and BA.4 fueled a surge in cases and hospitalizations in South Africa this spring, despite 90 percent of the population having some immunity against the virus. However, the country did not see a sharp rise in deaths accompanying this surge, and the wave was not as high as previous COVID-19 waves. The same trend is occurring in the United States. Hospitalizations are rising, but still remain low relative to the initial Omicron surge this winter, and deaths remain fairly stable. The greatest risk still involves people with medical problems like obesity, heart or lung problems, diabetes, immunosuppression and the elderly who develop more severe disease and more complications as well as the risk to everyone of Long COVID from repeat infections.
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MonkeyPox
As Dermatologists trained in skin related infectious diseases, it remains critical that we understand the new monkeypox outbreak so that we can identify and treat the growing number of these patients, particularly in our more urban practice sites. The American Academy of Dermatology has prepared resources to assist in evidence-based high-quality care.
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Please continue taking care of yourselves, your teammates and your patients and send any questions or suggestions to health@qualderm.com.
Sincerely,
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