Issue No. 11

Learning to Live Safely with COVID

“In the end, all pandemics burn out,” states a thoughtful article titled, “How the world learns to live with covid-19,” in the Oct. 16 issue of The Economist. “Eventually, sufficient numbers of people develop immunity so viruses can no longer find new hosts at the rate they need to sustain their growth. And yet only one human disease, smallpox, has ever been completely eradicated.”
 
What has happened to the others, such as influenza, cholera, or Hepatitis B? They “slowly became endemic, part of the landscape of disease around the world, checked but not eliminated by vaccines and medical treatments.” And “checked” may be too strong a word. Influenza killed 50,000 Americans in 2019; Hepatitis B killed 820,000 people worldwide that year.
 
That, inevitably, is the fate of COVID-19. Eradication is impossible. “Every country,” says The Economist, “will have to learn to live with the disease.” We would revise that to say that we have to learn to live safely with COVID. We will always have to take measures.
 
Also, endemicity, as it’s called, doesn’t happen overnight. “The world’s collective level of immunity to COVID is nowhere near that of other endemic respiratory diseases.” The Economist cites Ali Ellebedy, an immunologist at the Washington University School of Medicine in Missouri, who says that “it will take decades for humanity to reach a comparable level of immunity to covid.”
 
Even in a best-case scenario, older people and those with an array of co-morbidities – former Secretary of State Colin Powell, who had multiple myeloma and died Oct. 18 from COVID, fit both categories – will still be vulnerable, even if immunized, to contracting disease from others, even if also immunized.
 
The Economist’s conclusion: “The coming years, then, will be characterized by a slow process of cyclical decline that runs in tandem with a broadening and deepening of immunity to infection.”
 
Learning to live safely with COVID does not mean acquiescence. It means using technology to take continuous, effective actions – such as sanitizing indoor air – to guard against the spread not only of the SARS-CoV-2 virus but of other pathogens. And it means a recognition that the best we can hope for is that “slow process of cyclical decline.”
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Cyclical Decline Remains Elusive

Right now, however, cyclical decline is far from evident. COVID-19 cases have surged in rough cycles. In 2020, a summer surge began in the U.S. in early June and peaked in late July at a seven-day moving average of 67,000 daily cases. Infections bottomed in September at about 35,000 daily cases. The fall-winter surge began a month later, peaking at 260,000 cases in early January and falling to 15,000 in June 2021.
 
But this year’s summer surge was far worse last year’s, peaking at over 170,000 cases. Deborah Birx – the former White House coronavirus coordinator who is now chief medical and scientific advisor to ActivePure, a Dallas-based developer of technology that inactivates pathogens in the air and on surfaces – has noted that the U.S. is carrying many more cases into the winter than last year. On Sept. 30, 2020, the daily case count was 43,000; at the same date this year, it was 111,000.
 
A year ago, precisely no one was vaccinated. Today, 191 million Americans have received a full course of vaccines, or 57% of the total population; another 14 million have received a booster shot. Worldwide, 2.9 billion people are fully vaccinated or 40% of the population. But, when it comes to infections, the preventative power of vaccines has been counterbalanced by the Delta variant’s ability to spread at more than twice the rate of previous variants – and by its virulence in attacking people who are not vaccinated. Delta became the dominant strain in the U.S. in late June, and by the end of July, it accounted for 97% of U.S. COVID infections; today, 99.6%, according to the Centers for Disease Control and Prevention (CDC). The other counterbalancing factor is that the efficacy of vaccines wanes. A large study of patients in Veterans Administration hospitals, released this month, found that vaccine protection declined from 92% in March to 54% in August.
 
Caseload cycles appear to be geared to weather. In the summer, Americans, especially in the South, move indoors to escape the heat, and indoors is where the SARS-CoV-2 virus spreads most easily. In June and September, the months of low infection, temperatures are conducive to outdoor activity nearly everywhere in the United States, but as fall wears on, people in Northern states move indoors to escape the cold.

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Southern Decline in Disease Outpaces Northern Growth, But for How Long?

Overall in the U.S., we seem to be in a period when the decline in cases in Southern states is outpacing the rise in cases in Northern states. For example, in Louisiana, daily average cases fell from 5,800 in mid-August, to just 460 on Oct. 26. Missouri over the last two months has experienced a decline of two-thirds; Mississippi and Texas, four-fifths. In the North, meanwhile, surges are occurring in such states as Vermont, which set a record on Oct. 13, registering about half-again as cases than last January’s peak. Colorado cases on Oct. 20 were up 16% in two weeks; South Dakota, up 35%.

For the U.S. as a whole: The Department of Health and Human Services incidence map, which shows the case rate by county, is almost entirely red.

Still, infections have dropped by 23% in the past two weeks, and states where the surge in infections was especially disturbing in mid-September, like Ohio, Wisconsin and Indiana, have seen dramatic declines. In other states, such as Montana, sharp increases have leveled off.
 
One reason may be that the cold weather simply hasn’t arrived yet. As the website Yale Climate Connections on Oct. 18:
 
The first half of autumn 2021 came in as the warmest on record for a broad set of towns and cities spanning much of the northern tier of the United States. From Bismarck to Buffalo, millions of people have experienced a September and early October milder than any observed in almost 150 years of record keeping.
 
For example, Buffalo, Chicago, Duluth, Fargo, and many other cities broke records for average high temperatures during the period Sept. 1-Oct. 15.
 
Dr. Birx said on Oct. 18 in a webinar that included members of the Michigan Assisted Living Association (MALA) and public officials, “The current case load, even though decreasing, raises significant concern for the fall and winter 2021. Planning and preparing now is critical.”
 
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Cases vs. Hospitalizations vs. Deaths

As COVID-19 slowly transitions from pandemic to endemic, infections may remain high but severe cases that lead to hospitalization and death are expected to decline – mainly because of vaccinations and better treatments. During the peak of this year’s summer surge, there were two and a half times as many daily cases of COVID as during the peak of last year’s. But hospitalizations rose only by one-third and deaths by one-half.
 
More and more evidence points to the effectiveness of vaccines against death. A study published in the The Lancet earlier this year by three researchers – Aziz Sheikh, Chris Robertson, and Bob Taylor – examined records of 1.6 million adults in Scotland who underwent testing during the period when the Delta variant was prevalent in the community. It showed the beneficial effect of vaccines on hospitalization. Then on Oct. 20, in correspondence with the New England Journal of Medicine, the researchers reported a further analysis of the dataset – this time on deaths.
 
They found that, among persons aged 16 to 39, no deaths at all were reported among 13,000 people who were fully vaccinated with the Pfizer-BioNTech or AstraZeneca vaccines, compared with 17 deaths among the 35,000 who were unvaccinated. Among those aged 40 to 59, there was one death for every 145 unvaccinated subjects and one death for every 722 vaccinated subjects. For those 60 or older, effectiveness against death was 90% for Pfizer and 91% for AstraZeneca.
 
What we cannot expect from any vaccine is preventing vaccinated people from spreading disease to unvaccinated people – or even to immune-compromised vaccinated people. That is clearly happening with Delta, and it may be the main reason we are seeing so many infections – and such persistent mortality.

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Digression on Deaths

The subject of deaths is worth a digression on the true danger of COVID-19. The Economist has developed a model based on excess deaths (that is, the observed increased in mortality beyond what would normally be expected if the pandemic did not exist), which gives a more accurate picture of how many people COVID-19 is killing a day, worldwide.
 
Official figures understate deaths for several reasons, including the exclusion from the rolls of victims who did not test positive for the disease before dying, “which can be a substantial majority in places with little capacity for testing.” In addition, “the pandemic has made it harder for doctors to treat other conditions and discouraged people from going to hospital, which may have indirectly caused an increase in fatalities from diseases other than covid-19.”
 
While the official global death count on Oct. 18 was 6,600 daily deaths, The Economist’s analysts estimate that actual deaths were closer to 30,000, with a 95% confidence interval between 15,000 and 40,000. Excess deaths have fallen by more than half from the high of 70,000 in May.

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Unanswered Questions
 
Nearly two years after the initial COVID-19 outbreak, the FDA has given full approval to one vaccine (Pfizer-BioNTech) and emergency authorization to two others (Moderna and Johnson & Johnson). In addition, the FDA has approved Viklury, an intravenous anti-viral drug developed by Gilead for hospitalized adults and some children, and has given emergency authorization to several monoclonal antibody treatments for mild and moderate cases of the disease and, in one case (Regeneron) as a prophylactic for people who may have been exposed to COVID but haven’t contracted it yet.
 
On Oct. 1, Merck and Ridgeback announced that their investigational oral antiviral called Molnupiravir “reduced the risk of hospitalization or death by approximately 50%” compared to a placebo for patients with mild or moderate disease. And Pfizer and BioNTech have presented data to the FDA, which was released Oct. 22, showing that its vaccine was 90% effective in preventing symptomatic COVID-19 in children ages 5 to 11. A meeting of advisors to the FDA on whether to approve the vaccine for kids that young is scheduled for Oct. 26.
 
In short, enormous progress has been made in a short time, but there is still a great deal we don’t know about the disease in an epidemiological, or public health, sense. For example, how much does the waxing and waning of infections depend on seasonality and how much on the penetration of vaccines? How dangerous is spread from vaccinated to unvaccinated people? How important is masking and social distancing – in real, concrete terms?
 
Public health experts have not adequately answered practical questions, such as whether children in school should be masked all day or whether, even in a community without widespread disease, people should go to a concert hall where they are surrounded by 2,000 music lovers, some of whom are inevitably unvaccinated. What are the odds of becoming infected inside a restaurant as opposed to sitting outside? The question of who should get a booster shot is still murky, and a CDC panel only on Oct. 21 recommended that Americans can choose among the three vaccine offerings for their booster, no matter which company developed their first and second shots.

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The Japanese Mystery, or Is It?
 
Puzzles abound. An apparent one is that “Japan has become a stunning, and somewhat mysterious, coronavirus success story,” as Mari Yamaguchi of the Associated Press wrote on Oct. 17. Daily cases on Aug. 25 were 23,000; on Oct. 20, they were 434. Only 10 people died from COVID on Oct. 20 in Japan, a country with about 40% of the population of the United States, where, on that same date, 1,700 people died.

In Japan, “the bars are packed, the trains are crowded, and the mood is celebratory, despite a general bafflement over what, exactly, is behind the sharp drop,” wrote Yamaguchi. “Japan, unlike other places in Europe and Asia, has never had anything close to a lockdown, just a series of relatively toothless states of emergency.”

So what’s the answer? It appears to be an aggressive vaccination campaign that pushed rates from 15% in early July to 68% three months later. In other words, nearly half the Japanese population is living with the effects of fresh (that is, less than three months old) vaccine inside their bodies. In the U.S., by contrast, vaccinations peaked in mid-April at nearly 3 million doses per day and are now down to one-fourth that level. So, for vast numbers of Americans, vaccinations were administered six to ten months ago and effectiveness has waned.

Within a few months, Japan, too, may experience a waning, which is why this Reuters headline is poignant: “Japan's dip in COVID-19 cases baffles experts; winter 'nightmare' still a risk.”

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Some Certainties About COVID Spread Do Exist
 
There are things we do know about the virus for certain: that it is especially deadly for those who are old or have compromising conditions and that it spreads easiest indoors. As a result, ventilation plus technology that can continuously deactivate pathogens – not just filter them – is critical as a layered defense against the virus, especially in nursing homes and assisted-living facilities.
 
At the same Oct. 18 webinar at which Dr. Birx spoke, John LaRochelle, a veteran of the giant services firm Sodexo and now president of Lighthouse Environmental Infection Protection, discussed the challenges and opportunities of the pandemic for assisted-living facilities. He pointed out that “tragedy leads change” – in this case, a complete reassessment of the dangers of all kinds of infection in settings like nursing homes.
 
LaRochelle warned that there will be other pandemics as well as an increase in antibiotic-resistant bacteria and the spread of insect-to-human and animal-to-human diseases. Disinfection efforts, he said, often fail because treatments are difficult for humans to deploy. What is required is not merely ventilation but a layer of continuous, enhanced disinfection that is automatic – that doesn’t require daily or hourly human intervention. He cited ActivePure’s advanced photocatalysis technology, which is FDA-cleared and, he noted as an example, reduced Staphlococcus Epidermis Gram-positive bacteria by 99.9999% within 60 minutes after treatment.

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‘Who Wants to Go Back to a Building That Isn’t Healthy’
 
In an Atlantic article on Oct. 3, Joseph Allen, an associate professor at the T.H. Chan School of Public Health, reminded readers that, if they are in a typical office, home, or school, “about 3 percent of the air you breathed in recently came out of the lungs of the people in the room with you right now.” And that air can be contaminated with SARS-CoV-2, which spreads almost entirely indoors, or other pathogens.
 
“How many pathogens you take in,” Allen writes, “depends on one factor in particular: how much fresh air is coming into the building….. Before the coronavirus pandemic, the interior designers and HR professionals who decide how offices look paid little attention to ventilation. Allen’s point in the piece is that “the cool new [office] amenity won’t be a foosball table. It’ll be something we should have had all along—clean air.”
 
He concludes, “COVID-19 has prompted a universal awakening about the power of our buildings to make us sick or keep us well. At this point, really, who wants to go back to a building that isn’t healthy?”
 
That statement is certainly correct, and it reflects the comment of LaRochelle above about tragedy leading to change for the better. But ventilation is not the only way to provide safe air in offices or other interior spaces. In fact, because good ventilation requires very frequent exchanges of air, it can be a very expensive, energy-intensive way to sanitize the air and a way that harms the environment.
 
There’s another problem with ventilation. As Allen admits, “Bringing in more outdoor air should be good for cognition, but outdoor air is polluted with particles that hurt cognition.” His answer is filtration. “By capturing pollutants before people inside have to breathe them, buildings can give people the benefits of outdoor air without the downside.”
 
But filters are inefficient. They have to wait for pathogens to drift to them in order to capture them. Allen does not mention a much better technology: an advanced photocatalytic process that deactivate pathogens swiftly in interior air without creating ozone or volatile organic compounds.