The Things I Know About Covid-19

A bibliography in early October, 2021

And Another Thing is a sub-category of the Letters usually reserved for paid subscribers. I’m making this issue free for alla y’all.

Having been on the “Covid beat” in whatever unofficial capacity I can claim since the earliest whispers of the pandemic started in the waning days of 2019, I’ve spent a lot of time reading and learning from experts about Covid itself, about vaccines and virology, about public health and science communication, and about our communities of health. A lot of my information comes to me initially through my list of experts and professionals on twitter and through daily check-ins with Nature, The Lancet, Science-Based Medicine, JAMA, and digging down on press releases from the relevant pharmacology companies. It’s because of a year of tracking both publications and retractions that I know to take publications from the UK with an eye to potential retraction or debate, and to watch for the times when the CDC and FDA can’t agree, or when approvals in the US vary from those of other countries. I see when “my experts” disagree or take time to come to agreement on a question (like whether rapid testing is worthwhile, whether kids need priority vaccination, whether mandates make sense) and I actively follow those conversations as they evolve.

It’s time-consuming, usually a couple of hours a day at minimum, and it makes use of every information skill I’ve got. I generally don’t expect that everybody’s keeping up with the latest publications (and retractions) as much as I am, because it’s exhausting. I do it primarily because I know that there’s a not-small number of people who trust me to have relatively accurate and up-to-date information on what the heck is going on out there, and while I take that responsibility very seriously, it also strikes me as a symptom of a more complicated problem, which is that it’s hard for people to find a trusted source of good, accessible information and guidance. We’re all so freaking tired.

So anyway. What follows is a list of things I currently believe to be true about Covid-19, and some sources to back up why I believe those things.

Covid-19 is serious and has a higher IFR (infection to fatality ratio) than most strains of influenza.

Additionally, the death toll both from Covid itself and from the strain on healthcare systems (also known as “excess deaths”) is much higher than official estimates.

Vaccines are very effective, even against the Delta variant.

Getting vaccinated isn’t an impenetrable wall, but it means you’re much less likely to contract the illness in the first place (and if you haven’t gotten it, you can’t spread it). If you get a breakthrough infection, you’re infectious for fewer days than an unvaccinated person on average, and you’re much less likely to have complications up to and including death than an unvaccinated person.

  • Lederer, Katlyn, Kalpana Parvathaneni, Mark M. Painter, Emily Bettini, Divyansh Agarwal, Kendall A. Lundgreen, Madison Weirick, et al. “Germinal Center Responses to SARS-CoV-2 MRNA Vaccines in Healthy and Immunocompromised Individuals,” September 21, 2021. https://www.medrxiv.org/content/10.1101/2021.09.16.21263686v1.

  • Pilishvili, Tamara, Ryan Gierke, Katherine E. Fleming-Dutra, Jennifer L. Farrar, Nicholas M. Mohr, David A. Talan, Anusha Krishnadasan, et al. “Effectiveness of MRNA Covid-19 Vaccine among U.S. Health Care Personnel.” New England Journal of Medicine 0, no. 0 (September 22, 2021): null. https://doi.org/10.1056/NEJMoa2106599.

The following items in this group are pre-prints, which means they are not yet reviewed by other scientists in the field for accuracy or reliability. Because the science of Covid is moving extremely quickly (because pretty much all of our best minds are focused on some angle of the pandemic), pre-prints are a valuable source, but it’s important to follow up with information gathered from pre-prints to ensure the information wasn’t retracted after further consideration from the field. With that said:

  • Chia, Po Ying, Sean Wei Xiang Ong, Calvin J. Chiew, Li Wei Ang, Jean-Marc Chavatte, Tze-Minn Mak, Lin Cui, et al. “Virological and Serological Kinetics of SARS-CoV-2 Delta Variant Vaccine-Breakthrough Infections: A Multi-Center Cohort Study,” July 31, 2021. https://doi.org/10.1101/2021.07.28.21261295.

  • Ke, Ruian, Pamela P. Martinez, Rebecca L. Smith, Laura L. Gibson, Chad J. Achenbach, Sally McFall, Chao Qi, et al. “Longitudinal Analysis of SARS-CoV-2 Vaccine Breakthrough Infections Reveal Limited Infectious Virus Shedding and Restricted Tissue Distribution,” September 2, 2021. https://doi.org/10.1101/2021.08.30.21262701.

  • Kissler, Stephen M., Joseph R. Fauver, Christina Mack, Caroline G. Tai, Mallery I. Breban, Anne E. Watkins, Radhika M. Samant, et al. “Viral Dynamics of SARS-CoV-2 Variants in Vaccinated and Unvaccinated Individuals,” August 25, 2021. https://doi.org/10.1101/2021.02.16.21251535.

  • Shamier, Marc C., Alma Tostmann, Susanne Bogers, Janet de Wilde, Jeroen IJpelaar, Willemijn A. van der Kleij, Herbert de Jager, et al. “Virological Characteristics of SARS-CoV-2 Vaccine Breakthrough Infections in Health Care Workers,” August 21, 2021. https://doi.org/10.1101/2021.08.20.21262158.

Several of these pre-prints were covered in this piece:

Vaccines are safe for almost everyone, including kids and pregnant people.

We are still very dependent on keeping community spread down to reduce the frequency of exposures most people will encounter. Even vaccinated people are more likely to eventually be infected if they are exposed frequently in their daily lives. With that in mind:

Mitigation matters.

Because the first-round vaccination campaign hasn’t reached as many people as we’d like for a lot of reasons, many in countries with good vaccine access but lower-than-ideal vaccination rates are looking to third doses and boosters as one of these mitigation measures. For some people, a third dose is helpful, but for most of the population, the science says:

Boosters are sometimes, but not always, useful.

Now, one of the things that was very reassuring in the early days of the pandemic was that kids didn’t seem to be contracting the illness as often as adults, and that the younger you were, the less likely you were to have a serious case. This meant that even when schools were closed to all but remote learning, it was with the intention of protecting vulnerable adults, rather than out of fear for kids themselves. And while it’s still true to an extent that kids are lower risk than the elderly, we’re learning more all the time about the potential long-term effects of Covid, even when the initial infection was asymptomatic. And when it comes to the protection granted by age, things have changed dramatically with the Delta variant.

In the Delta era, kids get Covid at similar rates to other age cohorts. They are also experiencing adverse outcomes, including “long covid,” permanent disability, and death.

Further, because kids under 12 are the only cohort that remains entirely unvaccinated, they’re currently at the lead of several major regional case surges in the past six weeks, and the capacity of the healthcare system to handle both the Covid cases and all the other pediatric emergencies is under extreme strain. Spread among kids, and how to slow it while they wait for vaccines, is at the front of mind for most of my sources. But because Delta and the pediatric surges are relatively new (most case counts only started to climb in August), the majority of our knowledge is limited to case numbers and epidemiological projections.

Because of these statistics compared to the current relative safety data on vaccines, I believe kids of all ages should be vaccinated as soon as appropriate dosages are established and approved.

Mandates and “passporting” are legal in the US and Canada.

With legal challenges largely defeated, the tide of mandates and passporting seems to be growing across the US, UK, and Canada, and the good news is:

Mandates and passporting are working to improve vaccination rates and protect our communities.

All that said, concerted efforts have been and continue to be underway to undermine all this evidence, and we need to be on the alert for those who are willfully and deliberately misleading people in ways that are leading to thousands of deaths. If someone is telling you a mitigation strategy does more harm than good, they’re usually either lying or sharing something they believe, but that is untrue. Mitigation matters. Keep it up. Because:

Disinformation is causing harm.