Since the beginning of the COVID-19 pandemic, the incidence of spontaneous carotid artery dissection has increased in young patients, despite the lack of risk factors…The mechanisms of vascular damage and endothelial dysfunction may include the direct invasion of endothelial cells by SARS-CoV-2 or the cytokine storm resulting from systemic inflammation.
This week will be a little bit different. This is an open letter to hospital and clinic administrators, as well as any healthcare organization. Feel free to share widely, particularly to any administrators you may know.
Executive Summary
The US is starting the next pandemic wave. Most of the population has not received boosters in the past four months and are not taking mitigation measures. Data from other countries suggests that this will be a challenging wave, particularly as school starts which is a known source of community spread.
Globally, these new variants have led to the cancellation of elective surgeries due to the infected patient volumes as well as ER diversions and patients held in the ER for days with no beds available on nursing units.
Wastewater COVID concentrations in the US are at the highest they have been during this time of year since the start of the pandemic. Both COVID ED and outpatient visits are climbing across the US.
Most of the population thinks of COVID as a respiratory disease, when in fact it is a vascular disease with an acute respiratory phase, but that has chronic sequelae in almost every organ system and repeat infections significantly increase the risk of chronic disease. It is driving increases in infectious disease due to immune system dysregulation. This can be seen in increase rates of pertussis, RSV, tuberculosis, and even is thought to be a contributing factor to the rise in dengue, among other diseases.
There are secondary impacts as well, such as increased MVAs, major increases in long-term disability, major increases in sickness among HCWs, and the failure of businesses.
The threat of a H5N1 pandemic continues to climb and could become far worse than what was seen with COVID.
Administrators should take measures to reduce infections among employees, visitors, and the community and serve as leadership examples to other health providers and organizations across their communities.
I recommend several strategies to reduce sickness and decrease costs.
Stockpile N95s.
Purchase more PAPRs.
Review and monitor supply shortages.
Mandate respiratory protection during pandemics and the normal cold/flu season.
Test all patients on admission for COVID, and H5N1 if it begins to rapidly spread.
Situation
The KP.2 and KP.3 variants, collectively known as the FLiRT variants, have become dominant in the US, representing about 50% of samples.
“Patients at the Hospital de Sant Boi (Barcelona) have reported waiting up to three days before being hospitalized on the ward, remaining during that time on stretchers in the emergency corridors of the center, Efe has confirmed. This center covers about 172,000 residents.
Sources from the Hospital de Sant Boi have confirmed that, since last week and coinciding with the increase in respiratory infections (especially covid), there has been “a greater influx of patients in the emergency room, much higher than expected and compared to what there was in previous weeks”.
In fact, they point out that the figures are “very similar to those in the winter months”, so, in the face of this unusual scenario, “more hospital admissions have had to be made than expected, with many patients having to be admitted in isolation, limiting the beds available for hospitalization.”
Hawaii has been the canary in the coal mine for the US, due to the high levels of travel from SE Asia and Oceana where the FLiRT variants have become more established. Their hospitalizations show what is to come for much of the US.
Wastewater data shows this increase is happening throughout the US. In addition, note that these concentrations are at the highest for this time of year since the start of the pandemic.
This wastewater data suggests that there are somewhere between 600,000 – 800,000 cases/day in the US. That translates into a little over 1:100 people being actively infected. Michigan is at the very beginning of this rise based on wastewater samples.
This trend is also clear when looking at other data for the entire US, including positivity and the percentage of ED visits that are confirmed COVID.
All of this is happening in the context of a public that has not had any type of booster recently and very few taking any personal mitigation measures using various non-pharmaceutical interventions. Part of the reason that we have had reduced COVID in 2024 is that we have to this point been dealing primarily with the same variant since last fall, which has given some herd immunity, but that only lasts for a few months. That will change with the new variants. (Note that the FLiRT variants are not separated out in this plot and are part of the light blue area.)
Background
The severity of COVID has been grossly underrepresented by the media. The public thinks that it is a respiratory disease, when in fact it is a vascular disease with acute respiratory symptoms. The affinity of the virus to bind to ACE-2 receptors leads to damage throughout the body and across organ systems, which is clearly illustrated in a mouse model comparing H5N1 influenza to COVID.
Rong et al. used transparent mice to image the affinity of SARS-CoV-2 spike protein, and two control proteins (the WT spike protein which doesn’t have an affinity for ACE-2 receptors, and influenza virus hemagglutinin [HA]) to ACE-2 receptors using fluorescently labels. The results paint a clear picture of how the SARS-CoV-2 spike protein affects most of the organs in this model.
Dr. Danielle Beckman is a leading neuroscientist studying the impact of COVID on the brain and has produced some stunning images, such as this one.
All of this endothelial damage and resulting microthrombi cause focal tissue necrosis and scarring. While young, healthy tissue can currently offset the deficit, as that tissue ages, it won’t have that capacity. In my professional opinion, we will be facing severe pandemics of diabetes, heart failure, pulmonary fibrosis, and many other chronic conditions, as well as infectious diseases due to the immune system dysregulation by the virus.
A study by Bowe et al. showing the cumulative risk and burden of sequelae in people with one, two and three or more SARS-CoV-2 infections compared to noninfected controls. As a society, we are expediting those chronic disease pandemics because of a lack of mitigations.
Even someone without any medical training can easily see the damage to the coronary vasculature.
The epidemiology of infectious diseases is drastically changing due to COVID as well. Unfortunately, data from the CDC is often 2-3 years old in these areas, so UK data provided the most current data for these increasing rates. This visualization of pertussis (whooping cough) rates was quite clever if you are a Star Wars fan.
These are Legionnaire’s disease cases. I added approximated trend lines for both pre pandemic and since the start of the pandemic.
Tuberculosis is a concern as well. The blue line is the number of new cases per 100,000 population. Overall, it has been decreasing over time, except in the red period. The yellow line is the percentage change from the prior year and the dotted yellow line is the five-year average of that percentage change, which helps smooth out the random variation from year to year. In the 1980s, the percentage change increased for the first time since the 1960s. TB was a marker for AIDS, which takes about 10-15 years to develop after untreated exposure to HIV. It’s concerning that we are approaching what could be another positive period in that trend, possibly due to the immune damage from COVID.
This is simply not sustainable. This is evident by the number of sick calls by HCWs in the UK since the start of the pandemic, which has increased by about 30%.
It’s not just sickness that will be drawing down the healthcare workforce. In this survey from 2023, nearly half of unionized healthcare workers are indicating that they might retire or quit. The main points of this survey are quite alarming.
Half of healthcare workers say they are likely to leave the healthcare profession in the next few years.
Nearly 80% of healthcare workers report feeling burned out by their jobs.
Short-staffing and workplace safety are among the top reasons healthcare workers are considering leaving the healthcare profession.
Nearly half of healthcare workers report feeling unsafe at their jobs.
Healthcare workers overwhelmingly support safe staffing standards.
Nearly half of healthcare workers report patient harm at their hospitals that they believe was due to short staffing.
A study prior to the pandemic predicted quite a significant shortfall in the nursing workforce by 2030. “There will be a shortage of 154,018 RNs by 2020 and 510,394 RNs by 2030.” Both sickness and burnout will make this situation much worse. We have a clear warning in data again from the UK.
These problems are creating issue for all industries. This data on the economic impacts of unmitigated spread from Australia paint this picture clearly and are another warning of the financial, social, and economic headwinds that we are facing as a society.
These problems also increase substance abuse rates climb when unemployment or loss of loved ones from COVID itself or the sequelae from the disease increase mental health strain.
COVID also impairs spatial awareness, which could be part of the reason for the increase in MVAs in the US, which also would impact patient volume and drive burnout among HCWs. This is data from the National Safety Council showing this increase since the start of the pandemic, further increasing demand on the healthcare system, particularly in ER and trauma care.
It’s only a matter of time until we see increases in air travel incidents that cause injury and death as well as “brain fog” and other cognitive impairment influences decision making, whether it is during aircraft maintenance or in real time with pilots and air traffic controllers. As an example, “Military Pilots Reported 1,700% More Medical Incidents During the Pandemic. The Pentagon Says They Just Had COVID.” These problems are being seen in commercial aviation as well. “Pilots who had been infected with COVID-19 had a 1.8 times higher risk of SCD compared to those who had not been infected (RR: 1.8, 95% CI: 1.3-2.5).”
The cognitive impact from COVID becomes especially apparent when looking at younger populations. This also increases the risk of medical errors and thus hospital liability.
It’s clear that the supply side of healthcare is going to be heavily impacted. Some data from Spain also gives a clear warning about the demand side. Compare the percentage of the population with chronic illnesses before the pandemic and currently. It’s alarming thinking about what is coming, given how most of the chronic conditions caused by COVID are likely 5-10 years off.
Even more concerning, the rates of hospitalization in Spain since the start of the pandemic are about 9 standard deviations from the prior mean.
These are just some of the reasons I expect healthcare to collapse globally. Healthcare organizations owe both their staff and the population they serve to protect the health of both and to provide to the needs of the area for as long as possible.
Given how surgery is the financial lifeblood of hospitals, it is an important strategic move to reduce the spread of the pandemic among staff and as a result, in the community as much as possible. As such, I recommend returning to mask mandates immediately and preparing for what is to come. I suspect that just as Standard Precautions evolved in response to HIV/AIDS in the 80s, we will see respiratory protection become a part of Standard Precautions because of COVID. It would be best to start normalizing that immediately.
In a study from Australia published this week, McAndrew et al. found “Compared to no admission screening testing and staff surgical masks, all scenarios were cost saving with health gains. Staff N95s + RAT admission screening of patients was the cheapest, saving A$78.4M [95%UI 44.4M-135.3M] and preventing 1,543 [1,070-2,146] deaths state-wide per annum. Both interventions were individually beneficial: staff N95s in isolation saved A$54.7M and 854 deaths state-wide per annum, while RAT admission screening of patients in isolation saved A$57.6M and 1,176 deaths state-wide per annum.” A graphic portrayal of the financial costs by implementing these preventive strategies is very eye opening.
The H5N1 Threat
Everything to this point has been strictly related to COVID. However, we are hanging on the precipice of a H5N1 pandemic. Even if it were somewhat mild, the volumes of affected people would be overwhelming. On Wednesday, 71 poultry workers who were responsible to cull infected chickens were suspected to have H5N1. Five have now been confirmed. As this moves into more and more mammal populations, and especially among humans, the risks of the virus mutating into something that has efficient human-to-human spread and high morbidity and mortality climb.
At the worst outcome end of the spectrum, the calculations are horrifying.
Global Population: 8.1 billion
Attack rate of the Spanish Flu in 1918: 30%
Mortality rate of H5N1 to date: 50%
This means that if H5N1 gains the ease of transmission between humans as we saw with Spanish Flu and maintains its mortality rate in humans, the number of deaths we can expect (assuming we can give everyone full medical care and not counting secondary deaths from failing infrastructure), the calculation is 8,100,000,000 x 0.30 x 0.50 = 1.215 billion deaths globally. COVID gave us our warning shot and we have failed miserably. The CDC should have been at forefront in prevention but has been poor in communicating risk.
Recommendations
Healthcare organizations should immediately implement a number of strategies that are both ethical to help prevent disease spread among staff, patients, and the community and are fiscally advisable to reduce hospital costs in the long run.
Stockpile N95s.
Purchase more PAPRs.
Review shortages during prior surges with pharmacy and materials management and increase stock appropriately. There is currently a shortage of BD BACTEC Blood Culture Systems. Most generic medications used in the US begin as APIs in China, are shipped to India for manufacturing and packaging, and then travel to the US in the cargo holds of passenger flights. There are many points of failure along these supply chains, including government decisions NOT to export to protect their own populations.
Mandate respiratory protection during pandemics and the normal cold/flu season. This is where I expect to see Standard Precautions going in the future.
There really are just two choices. Implement measures to protect staff, patients, and the public and perhaps delay the most severe impacts on healthcare organizations or continue as we are acting as if everything is normal and expedite their failure. Temporal discounting is our Achille’s heel.
The last few weeks have been insanely busy, culminating with my move yesterday to my home for the next two months. I haven’t been able to keep on top of emerging stories as a result.
The lack of data has been bad enough to contend with due to reduced CDC reporting. Now, they no longer report PCR positivity by state, but by region. I hope this changes, but I have my doubts.
I messaged the person who has been my source for variant data for visualizations. She indicated that she too has been phenomenally busy but will be updating, which is good news since I pull her data which I can use directly instead of from GISAID, which would be a lot more work given that I don’t have the IT kind of background to extract from what they use as a format.
Regardless, when it is available, I’ll start incorporating the variant data again. It’s a bit laborious since it requires setting up an entirely new template again and changing a number of variables to create it for each country or state. That will take most of a weekend.
I’ll cover H5N1 next week.
COVID
Spain – h/t @SamuelHurtadoBE, Head of Macroeconomic Modelling at Banco de España
“New data from the official Spanish health survey. The share of the population that has a chronic illness now stands 9.8 standard deviations above its prepandemic average. Hospitalizations, 5.9 standard deviations above its average. All age groups doing badly.” Full thread here.
Tuberculosis
This might be one of the more alarming data sets I’ve visualized since the start of the pandemic. The blue line represents new cases of TB per 100,000 population in the US. As you can see, it’s been trending down for many decades, except in the red area along that line. I will return to that.
The solid yellow line is the percentage change of new TB cases year over year. The dotted orange line represents the 5-year running average. We want these to stay below the black dotted line at zero, indicating few new cases.
Back to the red part of the line, as well as the area of the orange dotted line. Look at the dates that this happened. It was around the time that we recognized AIDS, which was a result of the immune system damage caused by HIV. One thing that is important to remember is that untreated HIV takes about 10-15 years to develop into AIDS. TB was considered a marker for AIDS at the time.
Now take a look at the orange dotted line in 2022. It looks like it will be crossing to a positive value for a second time since the 1960s. That strikes me as a very bad omen about the immune damage that is being driven by COVID.
Systemic, Not Respiratory
I still get surprised by how many people think that COVID is a respiratory disease. It’s not. It has acute respiratory symptoms but is a vascular disease. As such, it affects every organ system within the body. This is an excellent illustration comparing H1N1 influenza to COVID in rats.
Economic Impacts
At the very beginning of the pandemic, I remember all of the whining from people about the economic impact of what really were pretty half-hearted “lockdowns.” I tried to warn people that this was temporal discounting because the impacts of not having mitigations in place would be far more devastating. Some data out of Australia supports my case.
The Olympics
Do I really have to say it’s a global superspreader event? I fixed the logo today.
We found evidence of persistent T cell activation in a variety of tissues. In some individuals, this activity may persist for years after initial COVID-19 onset and be associated with systemic changes in immune activation as well as the presence of LC symptoms. Last, we found evidence of SARS-CoV-2persistence in gut tissue including potential ongoing viral transcriptional activity. Together, these observations suggest that even clinically mild SARS-CoV-2 infection could have long-term consequences for tissue-based immune homeostasis and potentially result in an active viral reservoir in deeper tissues.
We found evidence of SARS-CoV-2 persistence in gut tissue including potential ongoing viral transcriptional activity.” [676 days after infection there was evidence of the virus still replicating.]
LC is increasingly framed as having potential neurological underpinnings, it is possible that [our work suggests] T cell trafficking to CNS tissues with residual viral components.
We evaluated the results in a transversal (18–24 months) and longitudinal (6–12 months vs 18–24 months) manner and found a persistent functional impairment with demonstrated restrictive pattern, as well as progressing CT abnormalities pointing to evolving fibrotic-like lesions and small airways involvement 18–24 months after hospital discharge…in our study, 20 (8%) of 237 patients with chest CT abnormalities in the 6-12-month follow-up, progressed to fibrotic lesions 18–24 months after hospital discharge.
This cohort study revealed that post-COVID-19 patients presenting persistent pulmonary involvement in previous follow-ups can evolve to late fibrosis-like lesions 18–24 months after hospital discharge.
The pooled analysis found no significant increase in the risk of myocarditis among vaccinated pilots compared to unvaccinated pilots (RR: 1.2, 95% CI: 0.8-1.8) (1). This suggests insufficient evidence to draw conclusions about the association between COVID-19 vaccination and the risk of myocarditis in pilots. (Figure 3).
The data suggest that:
The pooled analysis found no significant increase in the risk of myocarditis, a condition linked to SCD, among vaccinated pilots compared to unvaccinated pilots (RR: 1.2, 95% CI: 0.8-1.8) (1). This suggests that there is insufficient evidence to draw conclusions about the association between COVID-19 vaccination and the risk of myocarditis in pilots.
Pilots who had been infected with COVID-19 had a 1.8 times higher risk of SCD compared to those who had not been infected (RR: 1.8, 95% CI: 1.3-2.5)
This will be short again because of the amount of time needed still early this past week to finish creating all of the US state graphs. Next weeks should be back to normal. The only thing that might change that is if the variant data I use is broken down further, which requires an overhaul once again.
Hawaii is a good indicator of what is coming. They are affected much earlier than the rest of the US with the FLiRT variants because of vacation travel from Oceania and SE Asia. Wastewater readings (brown line) are quite high.
The TLDR: It’s back. You really should be wearing a respirator indoors. Sadly, there won’t be vaccine in time for these variants and much of the population hasn’t been boosted this year.
H5N1
This is a graph of wastewater readings for H5N1 in California. The burnt umber squares are detections of H5N1. I’m mostly concerned about it in Palo Alto and San Francisco. I truly hope this is a signal from cattle or wild bird runoff. Cattle seems unlikely though because of the locations.
Wild birds are a possibility, but do they really excrete enough to create a sufficient signal in wastewater (except Canadian geese, they have super-pooper superpowers).
I really hope this isn’t evidence of movement of H5N1 into a human population in a high-density area. That could easily spell the start of a major global disaster.
SCOTUS
The Supreme Court struck down the Chevron deference. In essence, it has been the administrative practice of allowing regulatory agencies with expertise to take the lead in policy. Now, any of those decisions are up for litigation.
This matters because without the Chevron deference in practice, dangerous drugs and medical products could enter the marketplace more easily (FDA), companies could pollute the environment and provide products that cause harm (asbestos is a good example), workers will have less protection (OSHA), food could become more dangerous (FDA and USDA), public health measures could be limited (CDC), and healthcare could become more dangerous (CMS). That’s all just the tip of the iceberg.
An article in JAMA warned of the implications in March, stating it “threatens to roll back the very regulations that have advanced medicine and public health through medical product regulation, reduced disparities in health care access and coverage, and allowed for deliberate and informed responses to public health crises. The analogous disempowerment of agencies tasked with safeguarding the environment, housing, civil rights, and workers’ rights will similarly threaten regulations directly implicating social determinants of health.”
The entire country is going backwards in time, and not in a good way.
Since a new variant wave is starting to hit the US, I spent a lot of time trying to find data that could help paint a larger picture of what is happening in a particular state given that much of the CDC data has gone extinct. I’ve stayed off social media to get this done. It was far more work than expected. In the past, it was possible to download 3-4 national data sets and then pull from them locally. Now, the way the data is configured online, I have to download individual data sets for each state each week. It’s frustrating.
Here’s a breakdown of the visualizations on the US page. Given the changes in data for many of these metrics, the most important thing is to look at the change over the last couple of months as opposed to comparing one particular point to one a few years prior. This example is California.
Early Indicators Tab
The background is the percentage of each variant colored using the same color scheme as can be found on covariants.org.
The black line is the PCR positivity rate which is on the right axis.
The brown line is wastewater and is really more of a relative scale, especially how the baseline that the CDC uses isn’t constant.
The hollow black line is COVID emergency department visits.
Google Searches – This is the newest set of data I’ve added to the site. It’s been available for a long time, but given that there was plenty of hospitalization data until recently, it seemed a bit superfluous. The search terms are listed in parentheses. This data comes from the Delphi Group at Carnegie Mellon University.
Control (type 2 diabetes, urinary tract infection, hair loss, candidiasis, and weight gain) – These are medical search terms that have nothing to do with COVID, although one could argue that searches for diabetes will be increasing over time as a result of COVID infections.
Nasal (nasal congestion, postnasal drip, rhinorrhea, sinusitis, rhinitis, and common cold)
Oral (cough, phlegm, sputum, and upper respiratory tract infection)
Fever (fever, hyperthermia, chills, shivering, and low grade fever)
Throat (laryngitis, sore throat, and throat irritation)
Lung (shortness of breath, wheeze, croup, pneumonia, asthma, crackles, acute bronchitis, and bronchitis)
Senses (anosmia, dysgeusia, and ageusia – these are the proper terms for the loss of smell, foul taste, and loss of taste, respectively). The Delphi Group made a particular point that “The symptoms in this set showed positive correlation with cases, especially after Omicron was declared a variant of concern by the WHO.”
Medical Care – these are the percentages of diagnosed COVID patients in each of these settings.
Outpatient
Emergency Department
Hospital admissions – this is a particularly lagging indicator because it is coming from claims data.
The most common cause of GAS is Streptococcus pyogenes. They look like clusters of grapes, here seen being attacked by a neutrophil, an immune system cell.
Viral infections of the upper respiratory tract (including Influenza, RSV, and COVID-19) are associated with increased susceptibility to invasive diseases caused by Streptococcus pyogenes (group A streptococcus), including pneumonia, necrotizing fasciitis, toxic shock syndrome, and bacteremia.
There has been a sharp rise in non-invasive GAS in children in the last couple of years, such as this study involving pediatric clinics in France.
Of course, none of this really should be surprising when we know that COVID causes immune system damage. In addition, the virus likes to hang out in places like the tonsils.
This is a brief account of necrotizing fasciitis in a 55-yo male who had a mastectomy for breast cancer (yes, men do get breast cancer) as a means to provide just how damaging this can be. It can be much worse than this.
Three months after his mastectomy, “the patient revisited, presenting symptoms of swelling of the entire left arm which started from the axilla 2 weeks ago, high-grade fever for 5 days, severe pain, multiple wounds on the lateral aspect of his elbow with bloody discharge.”
He had to undergo surgical debridement of the wounds on his elbow. That’s a procedure to cut away dead, diseased, or infected tissue to give healthy tissue a chance to recover. This is how is elbow looked a two weeks (a) and six weeks (b) after surgery.
After cleaning out the wounds, it was apparent that the bacteria had eaten completely though his scalp leaving the skull exposed.
Here you can see the extent of damage to his face and scalp ad the debride the tissue in the affected area, including enucleating (removing) the left eye.
He will carry the scars of this for the rest of his life. (A, B) are images at six months after surgery, (C, D) are images at one year after surgery.
Fortunately, GAS is relatively rare. What doesn’t make sense is increasing the risk of it and other diseases by getting infected with COVID.
Just a picture from my trip almost exactly 5 years ago so people who didn’t want to see those in the GAS section have a buffer.
“Strikingly, sC5b9 levels [a biomarker for microthrombi] were abnormal even in children with minimal disease or an incidental finding of SARS-CoV-2 infection, suggesting that any exposure to SARS-CoV-2 may be sufficient to induce elevations in this biomarker. In addition, schistocytes were prevalent in blood smears of patients with minimal COVID-19, severe COVID-19, and MIS-C. IL-8, a marker of endothelial damage, was also significantly higher in patients with MIS-C and severe COVID-19 compared with the minimal COVID-19 group [ie, even in mild infections, COVID causes blood clots and vessel damage].
The presence of elevated sC5b9 even in children with minimal symptoms of COVID-19 disease is particularly striking. This finding implies that SARS-CoV-2 clinical syndromes are associated with robust complement activation, even when symptoms are minimal.”
“In the main and replication cohorts, individuals with SARS-CoV-2 infection had a higher adjusted hazard ratio (HR) for post-acute respiratory sequelae compared to the general population (main: HR, 1.68 [95% confidence interval (CI), 1.62–1.75]; replication: HR, 3.32 [95% CI, 3.27–3.37]) in Table 2. Furthermore, patients with SARS-CoV-2 infection had an increased risk for acute respiratory complication compared to non-infected controls (main: HR, 8.06 [95% CI, 6.92–9.38]; replication: HR, 4.17 [95% CI, 3.90–4.45]). When directly comparing the risk for acute respiratory complication between SARS-CoV-2 and influenza infections, SARS-CoV-2 infection was significantly associated with an increased risk (main: HR, 4.32 [95% CI, 2.73–6.83]; replication: HR, 6.51 [95% CI, 5.38–7.87])”
H5N1
The current situation in the US can be captured in two screen grabs. The higher these number go, the greater the chance of a nightmare beyond most people’s comprehension.
Well, I wrote a book about the psychological underpinnings explaining how it’s possible that one could work in the area of health promotion & disease prevention, yet discount an ongoing pandemic for an omnipresent…
No big updates this week because I took a much needed weekend away. However, I will point out that two of the FLiRT variants are both at about 25% each of samples in the US.
With other variants, hospitalizations increase when we are around the 50% mark. I would estimate that would be sometime around the end of July.
The biggest news this week was of a third farm worker with H5N1. The most concerning part is that “The patient reported upper respiratory tract symptoms, including cough without fever, and eye discomfort with watery discharge.” The question then becomes one of if the virus has adapted more to the human respiratory tract. That poses obvious challenges, particularly around gaining easier respiratory spread, thus leading to higher chances of mutations that make spread easier or make the virus more damaging. It seems like we have crossed a threshold though and the only thing ahead is for this to get worse, especially in a culture of pushback against any mitigation efforts. The costs and suffering will be far worse the less that is done. It will be particularly interesting to see how COVID-damaged immune systems respond. I think we are heading into a very bleak period.
I will be using SARS-CoV-2 and COVID interchangeably, but SARS-CoV-2 is the virus that causes COVID, which is the disease.
An interesting study came to my attention this week that has me thinking much more about the dynamics of the interaction between influenza A virus (IAV) and the SARS-CoV-2 virus in a way that hadn’t occurred to me before.
The investigators infected a cell culture with IAV and then used spike protein from SARS-CoV-2 attached to a marker to study uptake of the spike protein. They found that “cells became highly sensitive (up to 10,000-fold) to the pseudo-SARS-CoV-2 virus after infection with IAV at different doses.”
They proceeded to repeat the experiment, but instead using live SARS-CoV-2 virus and then measured some of the genetic sequences that were produced as a metric for viral replication. They found that “cells that are inherently susceptible to SARS-CoV-2, IAV preinfection further increased SARS-CoV-2 infectivity by > 5-fold.” This suggests the production of far more of the COVID virus if they are already infected with influenza A, meaning that they will be much sicker but also much more likely to spread COVID because of the higher viral load.
They continued their study in mice. “A significant increase in SARS-CoV-2 viral load was observed in lung homogenates from coinfected mice compared to homogenates from SARS-CoV-2 single-infected mice…The lung histological data further illustrate that IAV and SARS-CoV-2 coinfection induced more severe lung pathologic changes, with massive cell infiltration and obvious alveolar necrosis, compared to SARS-CoV-2 single infection or mock infection.”
They went on to test a few other respiratory viruses to see if the same COVID virus amplification would occur, and it didn’t. This suggests that there is something unique about IAV that enhances COVID infection. In addition, they studied ACE-2 receptor (the binding site for COVID) expression and found that cell cultures infected with IAV expressed THREE TIMES as many ACE-2 receptors. In coinfection of the two viruses, ACE-2 expression increased 5-28x based on the cell culture line used.
My interpretation of the increased ACE-2 expression is that it suggests that someone who is coinfected with both IAV and COVID is MORE susceptible to infections that use the ACE-2 receptor to infect cells.
At this point, you might be wondering why this grabbed my attention since it seems obvious that getting infected with two different viruses simultaneously is bad for someone.
H5N1 is a type of an influenza A virus.
If a H5N1 pandemic starts with rapid human to human transmission, we can expect a massive surge in COVID cases as well based on this evidence. The big problem is that hospitals wouldn’t be able to handle that increased demand. Early in the COVID pandemic, we saw the need for the use of BiPAP and CPAP machines in some areas to help reduce ventilator demand, which I had alluded to in an interview in 2006 (no paywall here). If we have a concurrent H5N1 and COVID pandemic, I don’t think we will be able to stumble through the demand anywhere as easily, and those who were on the front lines at the start of COVID would tell you it wasn’t easy at all.
Caregivers for Future Chronic Disease Pandemics Due to COVID
A really good review of the literature on respiratory protection was just published, prompting me to update two pages on this site. You can read about it and two other review articles in the first link. The second link addresses some of the misinformation about respiratory protection, particularly calling out the Brownstone Institute as well as the Cochrane Review that is often mischaracterized.
There is enough to cover with two topics this week. There wasn’t much new on H5N1 other than it is showing up in more places and continued resistance by big agriculture to allow public health to conduct surveillance monitoring. That seems to be an analogy to the “Goodbye Data” section related to COVID this week.
Worse, the CDC had pulled the plug on mandatory reporting of COVID data by hospitals on May 1st. I simply had thought that the consequences of this would be having a smaller sample size from which to draw inferences. I had been using two large data tables as important sources for the visualizations on this site.
Last June, the CDC had dropped the reporting requirements for suspected cases. I had developed a methodology to still visualize data adjusted for these changes and had thought that I could use the same approach for when some hospitals stopped reporting. The data from the CDC lags the reporting dates by two weeks, so this current weekend was when I expected to see just how that was starting to impact data. May 1st was on a Wed, so there would have been full reporting for the first half of the week and then voluntary for the last.
Unfortunately, that’s not how things played out. Instead, CDC just stopped updating the data tables altogether. This was unnecessary because many sites continued to report. I still continued to report daily for my hospital, even on weekends and did so this morning (Saturday). I can see what hospitals are reporting in my region of the state I’m currently in and saw that hospitals that represent 84% of beds in the region are still reporting. This makes me think that the CDC is still getting a lot of data but is not making it available under political pressure. Sometimes I honestly wonder if this site put enough pressure on the CDC or embarrassed them enough to drive the change. I know that many had tweeted out some of my tweets using it to @cdcdirector and @cdcgov.
I have been doing MORE to make this data readily understandable by the public which is part of the reason I created this site since nobody had been doing so. I hoped that a university might do something as well, but it didn’t happen. Early on we knew the need for data for making public health decisions.
In the article, they state “Persons can use information about the current level of COVID-19 impact on their community to decide which prevention behaviors to use and when (at all times or at specific times), based on their own risk for severe illness and that of members of their household, their risk tolerance, and setting-specific factors.”
Unfortunately, this is pretty much impossible to do now. In May 2022, the CDC dropped their “Community Levels” tool, which really had been efficient at minimizing COVID compared to their prior tool, but at least it was something. Even so, this data lagged quite a bit because of the 7-10 days it takes to develop symptoms after an infection. Forbes stated it nicely. “Relying on hospitalizations and deaths to determine what to do can be sort of like saying that you are going to wait until you’re fired or the company is bankrupt before determining whether you need to improve your job performance. Or waiting until the divorce papers arrived before saying, ‘Hmm, maybe I should start doing the dishes and not do all that that cheating stuff?’ Hospitalizations tend to occur about one to two weeks after people have gotten infected.”
True, things would have been far worse under a Republican administration, and there are many studies supporting this, leaving us three bad options for president. One who minimized the pandemic from the beginning setting the stage to make it political, one who is a science denying quack infested by a brain worm, and the current one who is following the minimizing lead of the prior in the support of politics. From a public health standpoint, we are screwed.
This is incredibly bad timing with the emergence of the FLiRT strains, not that any time is good IN THE MIDDLE OF A PANDEMIC.
SHAME ON YOU CDC
Antibiotic Resistance and COVID
A massive (n=892,312) global study and metanalysis of 173 studies on antibiotic resistance was published this week. What was particularly alarming is the high prevalence of resistant organisms among COVID patients.
Part of my role in healthcare is related to antibiotic stewardship and ensuring that patients with any of these above categories of resistant organisms are properly isolated to prevent spread. It makes me wonder if we should be asking patients on admission if they have a COVID history. If they do, I wonder if we should be doing surveillance cultures given these high rates to ensure that they are placed in contact precautions.
Antibiotics are useful when indicated. Unfortunately, many of the antivax/ivermectin grifters include antibiotics in their protocols. Antibiotics do as much for viruses as hydroxychloroquine and ivermectin – absolutely nothing. They are beneficial if there is a secondary bacterial infection, but widespread use of them pushes us closer to the post-antibiotic era.
One of the organizations pushing these protocols is the Front Line COVID-19 Critical Care Alliance (FLCCC). Their protocol BEGINS with ivermectin and hydroxychloroquine. Both have been shown to be useless for COVID, but they are making a lot of money of people by selling this stuff. I’ve previously written a rebuttal to one of the websites that is often used to push ivermectin. What is written in this screenshot is simply unsubstantiated garbage used for grifting patients.
DON’T DO THIS:
If patients don’t improve within three days, then they suggest adding antibiotics.
Imagine living in a world where tending to your rose bushes causes a small scratch to your skin or a small scrape to a knuckle like I had yesterday could become fatal if an infection invades.
The last time I spoke on antibiotic resistance was about 10 years ago. I’m going to provide a few slides from that presentation many of which contain references if interested. I would also recommend the book reviewed here if this topic interests you.
