Glossary

• Virus– a type of germ that consists solely of a bit of genetic material (DNA or RNA) wrapped in a protein coat.  The coat gets the genes into the target cell where the genes force the cell to make zillions of new viruses, and on it goes.
• Coronavirus– a species name of a number of different viruses.  Called corona because its protein coat is studded with spike shapes that form a crown, halo, or corona of spikes
• SARS-CoV-2– the specific name of the new coronavirus
• COVID-19-the name of the illness that the new coronavirus is causing
• Endemic– an illness always present in a region.  One could say strep throat is endemic in the US
• Epidemic– a sudden burst of an illness that comes and goes over a limited time
• Pandemic– an epidemic that bursts across the world not just one region
• Spreadability– how contagious is the disease, how many people will end up infected
• Symptoms- the experience of being ill, for example- fever, cough, headaches, loss of smell etc.
  • Asymptomatic– literally means “without symptoms”.  For COVID-19 it refers a person infected with the virus but has no and will have not symptoms
  • Presymptomatic– This is a person who was infected with SARS-CoV-2, and will feel sick, but hasn’t yet
• Severity– what harm does the disease cause, in terms of  how sick you get and how many it will kill
• Mask- a mask is a loose-fitting cloth or textile that covers the mouth and nose loosely.  A surgical mask is a mask used in surgery
• Respirator-  for the purposes of the COVID-19 pandemic and other respiratory illnesses, a respirator is a mask that fits very snugly or tightly to the user’s face.  An N95 mask is a respirator.
• Personal Protective Equipment (PPE)- PPE are any item that covers any part of the body with the design and intent of keeping viruses in the environment from infecting the wearer of the PPE. PPE’s include all masks (which includes respirators), face shields, eye shields, gloves, gowns.
• Ventilator- a ventilator is a machine that can force a person unable to breathe to inhale and exhale and control both effectively.  They are sometimes called respirators, but during this pandemic the word respirator is now reserved for reference to a tightly fit mask.
• Live Virus Swab– this is the swab which attempts to swipe live virus from one’s nose or throat to see if you are currently infected.
• Antibody Test- (aka serology test) this is the blood test which looks for antibody to the SARS-CoV-2 virus to see if you have been infected in the past.
• Vaccine Terms
  • Vaccine or Immunization– a dose of a substance that activates your immune system, as if you have the actual infection you are hoping to prevent, leaving you in fact protected from having that infection.
  • Efficacy– the percentage of people immunized with a particular vaccine who will not get infected if exposed to the target infection.  For example, a COVID-19 vaccine will be said to be 95% effective if 95% of people immunized with that particular COVID-19 vaccine will not get COVID-19 if exposed to COVID-19
  • mRNA– DNA works by dictating exactly which proteins your cell will make.  The message on how to construct each protein is delivered to the cell machinery that makes proteins by a piece of genetic material called messenger RNA, or mRNA
  • mRNA vaccine– an mRNA vaccine places a small bit of mRNA code that makes your cells make a protein that is the protein from a virus that alerts your immune system and activates it to make protections against you being infected
  • Viral vector vaccine– a viral vector vaccine takes a harmless virus that is known to infect people reliably and places that weakened virus in a person where that virus will in fact infect the person.  The virus is not only weakened, but also attached to a set of genes  that makes your cells make a protein that is the protein from a virus that alerts your immune system and activates it to make protections against you being infected.

At the End of 2020:
1/3 of a Million of Us Have Lost Our Lives

As this most tragic year of 2020 comes to a close, it is only right to pause.  In terms of total numbers of lives lost, 2020 is now the deadliest year in American history.

Plagues have been part of life since life began.  I recently learned that viruses that infect only bacteria, called bacteriophages, kill half of all bacteria on the planet- every 2 days!  The struggle of germ and life goes back billions of years and continues to this day. Human history has been profoundly impacted by the struggle of germs and humanity.

In some ways the course of many of our lives has been unusual for the respite we have all enjoyed from the horrors of mass infection and loss of life.  We have immunizations and antibiotics to thank for that respite.   Smallpox used to kill 30% of everyone infected, largely responsible for the loss of over 90% of Native lives in America, and now, solely because of immunizations, vanished completely from human lives.

So this year, 2020, will forever be the year that for almost every American, was the year germs reminded us of their brutal power, their ability to take away those we love.

In the past, the story of germs and humanity was mostly about the germ.  What it could do and what it did.   But starting with the introduction of immunizations somewhere around 400-800 years ago in China, humanity entered the story, and since then, the story of plagues has increasingly been about what humanity does, not just the germ.

And so we leave 2020 also forced to ask all of ourselves, what could we have done to end the year with fewer lives lost, fewer lives harmed?

The answer tragically is, quite a bit.

As readers of Real Answers over the course of 2020 well know, the impact of humanity’s response is clear for all to see when you take a look at various nations’ actual experience with this Pandemic.

Here is a site that gives everyone a chance to see just where every nation, and every state sits when it comes to the question- did we do a good job?  https://ig.ft.com/coronavirus-chart/?areas=usa&areas=gbr&areasRegional=usny&areasRegional=usnj&areasRegional=usia&areasRegional=usca&areasRegional=usnd&areasRegional=ussd&cumulative=0&logScale=1&per100K=1&startDate=2020-09-01&values=deaths

If you get a chance, take a look.  You can choose any nation or state to look at.  You can look at cases or deaths, by total numbers or per 100,000 people, and for any date range.  When one does look at the graphs, it is visually revealed that our nation, America, had some of the worst numbers in the world.  Not the very worst, but right up there.  I am not too interested in actually who loses this contest worst, only that a nation with the wealth, know-how, and resources to do a ton better, did not.

Keep in mind that with the H1N1 flu pandemic of 2009, the United States achieved a rate of loss of life 52 times lower than the world average.    And so a fundamental question we must ask ourselves as 2020 ends is how did a nation, our country, so able to manage deadly infections, fail so utterly to protect each other for this one?    The examples of Norway, Denmark, Taiwan, and South Korea- all democracies, and from 2 different continents and cultures- show that a nation acting wisely and with compassion, could keep its citizens safe during this Pandemic.   Taiwan is a nation of 24 million people, as 2020 comes to a close, they will mourn a total of 7 lives lost to COVID.  7.   Had we conducted ourselves as Taiwan did, with no forceful actions, only thoughtful actions, our number to mourn at the end of 2020 would have been about 100 dead, not 1/3 of a million!

It is urgent that we ask, what went wrong, because if we do not, if we do not change course, more lives will be lost for no good reason.

In looking back at 2020, the reasons we lost 1/3 of a million rather than 100 rest clearly on a small number of decisions:

1. The Federal government decided to take little action beyond vaccine development and some boosting of PPE and ventilator supply when sorely needed.   These were good steps, but as we all know, although vaccine development will save countless lives in 2021, it saved very, very few lives in 2020.
2. The United States failed to institute a process to identify the infected and isolate the infected.  The one strategy that every country that saved livesused successfully.
3. That failure to identify and isolate, or more simply, to stop the transmission of the virus over a whole year, can be traced to a completely absent national strategy of testing and tracing.  Even today, at the end of a year of Pandemic, Americans still struggle to find testing when needed.
4. Note should be made of the failure to develop any systems of isolation, places where people known to be infected, like myself a few weeks ago, could comfortably and safely go for 2 weeks, to ensure that we would not spread the virus to anyone else.
5. The fifth and final reality of America in 2020 was an overall national decision, by us, its people, to not really embrace the idea of taking some simple steps to save lives.  Somehow the urgency of getting together overwhelmed the urgency of life.   After every large national moment of gathering- Memorial Day, 4th of July, Thanksgiving, large rallies, large church gatherings, large weddings- COVID erupted.  We have proof.   And we fully anticipate that a final gift of this tragic year will be yet another deadly surge from the rather massive gathering that took place around Christmas.

And so we end 2020 with a tremendous sense of grief, and yes, outrage.  Grief at the 1/3 of a million lives now gone.  And outrage that we chose as a nation to let this be our experience with this Pandemic.

 At The Start of 2021: The Miracle of a Vaccine Gives Us Hope

One thing humanity, and America, got right in 2020 was the culmination of a 30 year triumph of creating a whole new sort of immunization technology.  This new technology gives us the ability, never held in our hands before, to dial up a new immunization for any virus that suddenly appears, in months!

Readers of Real Answers will recall that the BioNTech-Pfizer, Moderna, Oxford-AstraZeneca, and Johnson & Johnson COVID vaccines were not the result of some rapid fire sudden invention, but rather the fruit of 30 years of intensive, ongoing, very hard work.   These vaccines are not new in a very real sense, the technology they emerged from has been studied intensively for more than a generation of scientists.

To very briefly recap, all immunizations- even the COVID vaccines- work by presenting to our body the protein on a germ that the body naturally recognizes and makes antibody and other immune defenses to make us protected, immune, unable to get sickened by the germ.

All vaccines in use prior to 2020 had the germ make the protein.  That is easy to understand, after all the protein used in a vaccine is the protein on a germ that the body recognizes, so why not have the germ make the protein for us?   Turns out this works well, because large germ proteins are nearly impossible to conjure up in a lab, they are too complex, we simply can’t do that.  The problem is that if a new germ comes along, we have to find a way to grow massive vats of the new germ, purify the protein of interest.  That always takes years.

Now we have a new path, this is the path that took 30 years to develop.   In the new path, we no longer ask the germ to make the protein, instead we ask our own cells to make the protein.  To do this, we figured out the tiny signal of gene that will tell our cell which protein to make, and figured out how to deliver that tiny signal of gene to our cells.  That is what these COVID-19 vaccines do.

With this new path, any new virus can come along, all science has to do is figure out the protein on the virus that provokes immunity, determine the gene code that will tell our cell to make exactly that protein, and then the new vaccine is created.  That takes a few weeks now, for any new virus, anytime going forward.

So yes, the COVID vaccine was created in weeks, tested in months, and ready in record time, but only because of solid work spanning 30 years setting up shops to allow us to do this now for any new virus.

This achievement is a proud one, the work of scientists around the world, including American scientists, a great achievement for American science for 2020.  And, a true accomplishment of the US government to support rapid development of the COVID vaccine.  These are truly great moments in 2020!

Updates on the COVID Immunization Project in America

As everyone knows, two COVID vaccines are being given right now across the country- both deliver the tiny bit of viral gene signal via tiny droplets.  One is by BioNTech-Pfizer, and the other by Moderna.  Like testing, much was promised, but little delivered in 2020.  The good news is that over 13.5 million doses have shipped.  The bad news is that only 2 million have been actually given to real people.  No reason for why 11.4 million doses of COVID vaccine sit in freezers, when 11 million Americans could have been protected by now.  At current rates of actually giving this vaccine, it will take 10 years to reach the levels needed to stop the Pandemic.

But over 2 million doses have been given, and no serious side effects have been observed.

Again, when the public health system lets me know I can get my COVID vaccine, I will run to take my turn.  The data is overwhelming that this vaccine is safe, and that it will be effective.  If we have a tool to end the Pandemic, then the decision whether to accept an offered COVID vaccine now must include the harm done by choosing not to take the vaccine.  We know the virus can kill.  We know that it will spread rapidly enough that we cannot confidently stop the virus from killing more people until a great majority of us are immunized, Dr. Fauci says perhaps as many as 90% of us.  That means if one in 10 of us say no thanks, the door remains open for the Pandemic to continue.   

Therefore, the decision to refuse the COVID vaccine must justify being one of those who could total over 10% of America, and allowing this nightmare to continue.

The Oxford-AstraZenica vaccine

The trials of the Oxford-AstraZenica COVID vaccine have demonstrated the vaccine is very safe.  Some of the trials gave some participants higher doses than others and the lower doses seemed to work better.  At the lower dose the vaccine blocked all infections at a 90% level, and the higher dose at 62%.   This is the only COVID vaccine, so far to study rates of symptom free infection, and this vaccine dropped the chance of getting a symptom free infection by 60%.   Across all 24,000 in the study, none developed severe COVID.  So the ability of this vaccine to prevent serious disease is close to 100%.  Once approved, AstraZenica plans to make 2 billion doses and sell them at about $3 a dose.

This vaccine like BioNTech-Pfizer and Moderna, works via the gene mechanism already mentioned.  But as noted those two vaccines inject a tiny bit of viral RNA in a tiny droplet.  This vaccine places a gene code to make the same target protein, but it is a tiny bit of DNA, not RNA, and the DNA is tucked into a harmless common cold virus that only infects chimpanzees.  This chimp cold virus can deliver the bit of DNA to our cells, which then make the COVID protein that makes us immune.

The Johnson & Johnson vaccine

This vaccine is still being trialed, but those trials should be completed in the next few weeks.  Because the trials are ongoing, no one knows how well it works.

But we do know it works like the Oxford/AstraZenica vaccine, delivering the genetic instructions via a weak common cold virus that has not made people ill.

J&J has been building capacity to make billions of doses once approved, hopefully sometime in February.

Updates on When and If Vaccines will End the Pandemic

Why the COVID Vaccine could end the pandemic

Vaccines that have such high success rates have always ended transmission once enough people are immunized.  So IF the vaccines succeed in maintaining high efficacy levels AND enough people are immunized, the Pandemic will end.

Why the COVID Vaccine might not end the pandemic

There are a number of items to yet learn that will determine if and when this pandemic will end:

• We need to see the reported level of success in the trials appear in real life.  This is the least of my worries, trials of tens of thousands of people usually translate to the same levels of success in the big world.
• We will need to see if enough people get the vaccine.  Delivery and acceptance will define this concern, and it is a big one.
• The incoming Biden administration is gearing up to deliver 100 million shots given by April 30, which would be at most 50 million fully immunized.
• At 90% immuized, we need 295 million Americans already infected or immunized to stop the pandemic.  We estimate about 100 million have already been infected, and an unknown number yet to be infected by April 30. If we estimate about another 50 million, then that would be 150 infected and 50 million immunized by April 30, or about 200 million protected.  That could be enough to see cases and deaths really start to drop, but not cease.
• Only adults (and for Pfizer people 16 and older) are getting
• The question of what will happen in schools if all the adults present are immunized, but none of the children are, remains an open question.  Trials for children getting COVID vaccine have begun, but children getting immunized will likely not occur until later in 2021.One mutation, the one in South Africa has proven it increases the chances of infected young adults (20-39 year olds) of getting seriously ill, ending up in the ICU or worse.  Should changes in the virus make it more dangerous for children, such questions could be more urgent.
• The UK mutation clearly makes this virus more contagious.   That could increase the number of people infected every day by 70%, which could nearly double the number of cases.  It does not appear to make people any sicker, but even if there is no change, nearly doubling the number of cases will nearly double the number of hospitalizations and deaths, threatening to truly overwhelm our hospitals.   A more contagious virus needs a higher percentage of people immunized to stop it spreading, pushing our need of vaccine coverage closer to 90%.

Local Updates

The ICUs at UH are at 83% capacity, high but not fully occupied.  About 28% of adults with symptoms tested via UH are positive for COVID.  For kids with symptoms about 25% are positive, going up with age:  0-5 9.7%, 6-10 25%, 11-15 35.9% and 16-20 32.7%.  About 5% of kids with no symptoms have positive tests.  Positivity soared after Thanksgiving from 3% to 25%, confirming that holiday gathering was a great way to boost transmission of COVID-19, and that it played a certain role in the spike of deaths that followed.

Influenza Update

Data through Christmas nationally and on the Eve of the New Year locally show that the much anticipated winter influenza virus epidemic of 2020-21 still has not begun.  With each passing week it fails to appear, the possibility that we may avoid one remains, but still too early to know this good news will persist.

Bottom Lines

1. 2020 was a year of actual devastation for many nations, sadly including our own.  We end the year losing at least over 1/3 of a million lives to COVID, making 2020 the year more Americans died than any year on our nation’s history.  We mourn the loss of our family, of our friends.  This New Year’s grief is with us.
2. We could have done better.  The US has proven its ability to do better.  Other nations have done better in ways we could have as well.
3. 2021 offers the vista of the pandemic ending by vaccine.  That promise remains realistic, but several concerns raise worries about it lasting longer than hoped:  will the virus further mutate and find a way to not be blocked by our vaccines (no current mutations have achieved this)?  will the lack of immunizing children keep the virus spreading?
4. By the end of April or so, we may hit as many as 50 million Americans fully immunized, and another 150 million infected, enough to perhaps lift the burden of this tragedy, finally.  2021 may indeed be a Better Year.
5. As we struggle to end the nightmare we once again ask everyone to do these steps, they could help end it:
   • Wear a mask
   • Keep 6 feet apart
   • Do not travel
   • Do not gather
   • Get immunized for COVID

My Takeaway – In One Sentence:

Our hearts grieve, and as New Year’s approaches, we hope that 2021 will be better, here is to a Better New Year, and hopefully, a Healthy New Year.

To your health,
Dr. Arthur Lavin