Global Health Update

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Written by WorldClinic

October 6, 2022

Monkey Pox

Monkey Pox is not an issue that most people need to worry about. Looking purely at the incidence over time, this outbreak has followed a classic epidemic trajectory: It ramped from nothing to peak over 6 to 8 weeks, peaking around August 1st, and has been steadily decreasing since then. At peak, there were just shy of 450 cases/day reported in the US, and the current average is 68. Essentially all cases are restricted to the well-identified at-risk community or their very close household contacts and there have been single-digit numbers of deaths attributable to the complications of the disease in the US, with all of those for whom information has been reported associated with significant other disease processes. This is not a risk that organizations or most families need to spend time worrying about. For those in at-risk communities, the public health system generally does an effective outreach regarding important risk-reduction measures.

Flu

Moving to the flu, each week, we are expecting to see that the current unprecedented low levels of flu activity will end and we will start to see the typical early signs of flu season. That is not yet happening. Flu activity is at the lowest level measured in well over a year through the latest reported week, which is the week ending September 24th (the typical lag is about 2 weeks), with no state or region showing evidence of rates increasing. Looking at previous years, prior to COVID, it is roughly week 40 to 41 where the rate does start to pick up noticeably, and we are currently in week 40. If you have not gotten your shot yet, anytime from here on is reasonable. Remember that it does take 10-14 days for the vaccine to reach peak effectiveness, so don’t wait until flu levels have become high. Of note, currently, flu shot uptake is running at less than half of where it has been at this point last year and about 2/3rd of where it was the year before. This is very concerning given the potential for a bad flu season and a set-up for high transmission rates. Please get vaccinated and if you are in a leadership position, please educate people about the importance of flu vaccination and facilitate their ability to get vaccinated.

COVID

And this brings us back to COVID. Globally, rates continue to recede, and even Europe, which has seen about a 50% increase in cases since late August, is seeing at least a flattening of cases numbers over the last 2 weeks. All other regions of the world continue to see declines. The only countries with levels of concern are the countries of central Europe, the Baltics, Greece, Taiwan, and South Korea, although case numbers are finally coming down in South Korea and appear to be coming down in the Baltics.

In past weeks, we have emphasized the point that while we may have some moderate increases in cases over the fall and winter as people are driven indoors and closer together, we will likely continue to see long-term good trends unless there is a new variant. Well, over the past 2 to 3 weeks, we have seen the emergence of two new variants, BA 2.75.2 and BF7. The former has been tracked for some time and while 2.75.2 is showing growth, it is not significant at present and is not showing signs of breaking out. BF7, however, currently accounts for about 4% of cases, with a doubling time of about 2 weeks. Its highest rate is in the Northeast and Mid-Atlantic US as well as playing a major role in the low countries of Europe and the UK. Importantly, this is a subtype of the BA5 strain, more formally known as BA 5.2.1.7, and appears to be replacing the original BA5 without generating increases in total cases. While the replacement implies that BF7 is slightly more infectious, there is no evidence that it escapes the BA5 immunity from either past infection or the new bivalent vaccine. So, for now, at least, this is not a major concern as a true new major variant. Don’t let the new “BF” nomenclature confuse you – it’s just shorthand because scientists don’t want to say BA 5.2.1.7!

Vaccinations

Well, the truth is that few people are moving on to more vaccinations. As noted above, flu vaccine uptake is way down versus previous years, so the CDC has had to redirect much of its marketing budget from COVID to flu. This has meant that the word is not getting out about the new bivalent booster and that low single-digit percentages of those eligible for a bivalent COVID booster have actually gotten one. The most recent number is only 4.4% of eligible. This doesn’t mean that only that low number has omicron immunity because it does not account for all those who have had COVID over the summer and therefore likely have robust omicron immunity from a combination of prior vaccination and current immunity, but the number is low, nonetheless.

Our feeling on boosters has not changed. For us, it is not a slam dunk, as is having the basic vaccine, especially if you have had COVID, since the combination of initial vaccination plus having COVID gives excellent protection against serious disease or death, but it is also clear that if you are more than about 4 months out from either the primary vaccination or a booster, your chance of getting infected and at least mildly symptomatic is fairly high. People continue to express concern that we don’t have enough data yet to know whether the vaccines are safe in the long term, so many are choosing to forego vaccination and especially boosters. But people don’t consider that we know that infection can be associated with long COVID symptoms and potentially associated with neurologic or autoimmune sequelae, by no means in everyone or even most people, but a high enough small proportion to be important. Given the likelihood of getting symptomatic COVID if you are not current on vaccination, it seems to me that the unknown risk associated with the vaccine, which must be low, given the billions of doses administered without a large proportion of adverse events, compared against the relatively high number of reports of long-COVID or other sequelae, we would rather take our chances with the vaccine. This is especially true when you consider that not only does current vaccination reduce your chance of getting COVID in the first place, but a study from the UK last month demonstrated a 41% decrease in the risk of reported long-COVID symptoms in those vaccinated, but who get COVID anyway.

Currently, in the US, primary vaccine uptake is just over two-thirds of the eligible population, but only half of those have gotten a booster. This compares to over 80% in most of the economically developed world, with booster rates at well over half.

Speaking of Long-COVID, that is a hot topic in the news, with some outlets reporting up to a third of all people who have had COVID reporting symptoms consistent with Long-COVID, with some outlets even saying that some of the economic downturns is due to loss of workforce productivity due to Long-COVID. We think that’s a bit of a stretch. The same UK study noted previously that, in the UK at least, with a more stringent definition of Long-COVID, only about 2% of Brits report symptoms consistent with long covid despite estimates that at least 80% of people in England have had COVID at least once. Remember that there is always a survey bias in health disease surveys as it is almost always true that the people conducting surveys have an interest in finding more cases so as to generate funding for their research and treatment programs, and this includes the CDC. This does not at all mean that long COVID does not exist, only that the real incidence is probably much lower than you hear about in the media and likely well below the level required to impact economic productivity to a significant extent.

 

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