November 2021 - The Epidemiology Monitor

NIH’s Anthony Fauci Shares Candid Assessment On Where We Are In The Pandemic And Observations On The State Of US Society In two recent interviews in midNovember with Ted Koppel at ABC News and with Michael Barboro at the New York Times, the National Institute of Health’s Anthony Fauci shared his candid views about the pandemic and the public health role he has played as a frequent spokesperson in the media.

unvaccinated persons have left many Americans wondering how the pandemic will unfold from this point forward. Both Barbaro and Koppel asked questions about these topics.

Status of the Pandemic There are both positive and negative signs to use in interpreting the status of the pandemic, according to Fauci.

Among the positive features are the decline in cases in the latest surge, the

The recent decline in cases, the continuing circulation of misinformation about all aspects of COVID, the serious attacks and threats against public health officials, and the large number of remaining

-4On The Light Side -5COVID Monthly Recap Guest Columnist Katelyn Jetelina,

- Fauci con't on page 2

Interim Report From Corona Commission Identifies Several Shortcomings In Sweden’s Response To COVID-19 Did Sweden Underreact and Other Countries Overreact ?

Interest in the epidemiology of COVID19 in Sweden has been high since the onset of the pandemic because Sweden’s initial strategy in response to the pandemic was more low-key than that of many other Western countries, especially its neighboring Nordic countries.

Corona Commission, “Sweden chose a different path to many other countries, one based on a voluntary approach and personal responsibility rather than more intrusive measures. The majority of other countries, by contrast, made greater use of lockdowns or other intrusive regulatory interventions.”

As characterized by the Swedish November 2021

In This Issue

- Sweden cont'd on page 7 •

Volume Forty Two •

Number Eleven

-9Notes On People -11Near Term Epi Event Calendar -12Career & Event Marketplace

-Fauci cont'd from page 1 The Epidemiology Monitor ISSN (0744-0898) is published monthly

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vaccination program that has reached many people, the approval of vaccines for children, and the finding that booster doses of vaccine appear to be safe and effective in reversing waning immunity.

Among the concerning features of the current situation is the plateauing of cases at over 70,000 cases per day which can be seen as setting up the population to have a resurgence from an already high baseline.

Asked by the Times why the current baseline level of cases is even higher than it was over a year ago despite the existence of a large scale vaccination program, Fauci noted that the more transmissible Delta variant now exists, over 60 million persons remain unvaccinated, and waning of immunity against infection and hospitalization is occurring.

Booster Doses Predicted As Essential An important projection made by Fauci is that a booster dose may come to be seen not as an extra or bonus dose but as an essential part of the primary vaccine regimen when more facts are made available.

Other vaccines require multiple doses in the primary regimen. With additional success in vaccinating the unvaccinated and with boosting those who have had the initially recommended number of doses, then any future surges should differ from past increases in cases, according to Fauci.

Problem of the Unvaccinated

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Asked to comment by the Times on the problem caused by the large

remaining number of unvaccinated persons, Fauci pointed out that these vulnerable persons face a threat not only to themselves but they provide opportunity for the virus to circulate and create new problematic variants, and to cause breakthrough infections among those already vaccinated.

To increase vaccination levels, Fauci thinks that ideally these persons would get vaccinated on their own accord and that would be the preferable approach.

However, if that doesn’t work, then recognizing that individuals do not live in a vacuum but are part of a community, that we are in an emergency pandemic situation, and knowing that mandates work to get more people vaccinated, then we have to take unusual measures such as mandates. Said Fauci, “…unusual measures mean you have to sacrifice your own feeling that you have absolute control over what happens to you with what the good of society is. I think mandates fall under that category…I’m an idealist, but I’m also quite a realist. And that’s the reason I support mandates.”

Without Mandates If mandates don’t work because governors are opposed or the courts are not supportive, there are not many tools left for getting people vaccinated, according to Fauci. He added, “And that’s really very, very difficult and painful as a public health official to see that if we don’t do what is clearly and unambiguously the right thing to do-to use a tool that is highly effective to prevent the suffering and the death that goes on — then that would be very bad for us as a nation...”

- Fauci cont'd on page 3

-Fauci cont'd from page 2 We’ve lost over 750,000 Americans thus far. We have 46 million infections, likely more since many go undetected. And we know what we can do. I’ve been involved in public health for over 40 years, and there have been diseases that I’ve had to deal with in which you don’t have any intervention. That’s very frustrating because you say, if only I had an intervention, I could do something about this disease...

Now we have a historic pandemic, the likes of which we have not seen in over 100 years, and we have highly effective, safe tools to end it. It would be really, I think, a terrible tragedy if we let more Americans and more people throughout the world — because I believe that we need to pay attention to what goes on in the rest of the world — if we let more people die and more people get very, very ill by not using the tools that we are lucky enough to have.”

Asked to describe the scenario if mandates are not used, Fauci reminded listeners that ultimately all pandemics burn themselves out. He said, “At the end of the day…this is going to end one way or another. The preferable way, if you just think about it for a moment, is to do whatever we can to minimize the suffering and the death. And we have within our power to do it. If we don’t utilize it, then bad things are going to happen.”

Trust Asked about the lack of trust in public health officials and the threats and attacks they have been subjected to, Fauci used his own experiences to provide a perspective.

“Well, I think it’s a sad state of affairs, where you have public health officials

who are clearly doing things that have no other objective but to preserve and protect the health of the American public, who get attacked for that, whose lives get threatened, whose families get harassed. I mean, I’m experiencing it on steroids here for the last well over a year…

Where else and what other historical situation have you seen where a public health official, who is merely trying to get people vaccinated to mitigate against the outbreak by wearing a mask, by following very clear and standard public health measures, who continually gets his life threatened, gets his family harassed, his children harassed…

“...ultimately all pandemics burn themselves out."

I’m talking about me. So tell me what’s wrong with society when a public health official, who’s a civil servant and not a politician, gets that kind of threat. I think we have a real problem in society.”

Asked by the Times if he felt like he was less trusted now than when the pandemic began, Fauci replied his view depends on which population you are asking about. Persons who live by a lack of facts, conspiracy theories, and disinformation and misinformation, don’t trust him or those in the public health sector. On a more positive note, Fauci noted. “The people who look at this realistically and try to get correct information, I believe they do trust us very, very much.”

"I think we have a real problem in society.”

ABC Interview In the introduction to the ABC interview, the network said Fauci was fighting a war on two fronts, against the virus and against - Fauci cont'd on page 4

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-Fauci cont'd from page 3

“...the national response went awry early on when individual rights were presented as superceding society’s safety."

“...we cannot stop caring when we are experiencing 7075,000 cases and 1,000 deaths per day."

misinformation. When asked if the pandemic could have gone differently, if cases and deaths could have been avoided, Fauci said yes if the leadership had led differently. It denied what was happening and that is a real serious problem. He told Koppel that he believes the national response went awry early on when individual rights were presented as superceding society’s safety. In fact, the pandemic was much worse than what the administration was saying, according to Fauci.

Koppel noted that Fauci’s poll numbers have been dropping and wondered if Fauci is now only preaching to the choir. He told Koppel that if you just keep lying over and over again making preposterous accusations, then people will believe these lies. That’s the way it is, said Fauci and he can't change that aspect of our society, social media, and how it works.

Asked if the end of the pandemic will come as suggested by a Hopkins epidemiologist recently simply when

we stop caring. Fauci was quick to respond that we cannot stop caring when we are experiencing 70-75,000 cases and 1,000 deaths per day. He stated, it was unacceptable to live with this level of morbidity and mortality when you have a vaccine that is highly safe and effective.

Asked if having the right highly trusted person in full charge of the national pandemic response the next time would be the right solution, Fauci said yes maybe if the country recognized that a communal effort was needed. However, that is not where we are now. Instead there is widespread political divisiveness and this is the environment in which we have battled the virus. Regardless of what critics say about him by creating “crazy fabrications out of political motivations”, Fauci told Koppel he will continue to do the important work of his Institute until COVID is in the rear view mirror.

To listen to the interviews, visit https://nyti.ms/30DsjO7 https://bit.ly/3DpGpRi ■

On The Light Side Epidemiology and James Bond

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[Editor’s Note: Epidemiology is a serious business, by and large. As a result, we are always on the lookout for opportunities to introduce humor to brighten the lives of our readers. A recent headline caught our interest— “You only live once: Epidemiologists analyze health risks in all the James Bond films.” We found the tongue in cheek work published in the journal Travel Medicine and Infectious Disease. We can’t improve over the abstract. Here it is from authors in

the Netherlands and the United Kingdom.]

“Global travelers, whether tourists or secret agents, are exposed to a smörgåsbord of infectious agents. We hypothesized that agents pre-occupied with espionage and counterterrorism may, at their peril, fail to correctly prioritize travel medicine. To examine our hypothesis, we examined adherence - Light Side cont'd on page 8

COVID Monthly Recap By invited columnist Katelyn Jetelina, MPH PhD, aka, Your Local Epidemiologist In the first half of October, cases in the United States continued to decline nicely and Americans ultimately saw a 53% decrease in cases. We were well on our way to recovering from the Delta wave. Unfortunately, the United States plateaued around October 20.

Idling was not a good sign for a few reasons. First, we idled at a high transmission rate—73,000 cases per day. This case rate was higher than the peak of the first two waves (Wave 1 peak=32,000; Wave 2 peak=66,000).

This is not how we want to enter the winter season— when coronaviruses typically thrive.

Second, almost every country in Europe had exponential increases in cases. Europe has consistently acted as an early warning signal for the U.S., and at this point in the pandemic, they are far more vaccinated than the United States.

Notably, Germany has the highest case rate since the beginning of the pandemic.

Third, also looking to Europe, the case make-up was shifting. In Summer, the European wave was largely driven by younger populations (i.e. unvaccinated). By the end of October, the wave was driven by all ages equally. In Germany, for example, 1 out of 3 people over the age of 60 in ICU were vaccinated. This meant vaccines were waning and people needed to get boosters. In Germany, only 4% of the population was boosted.

Ultimately, the United States needed to heed this warning from European countries across the pond and prepare for Winter.

Vaccines Thankfully, October was a huge month for vaccine authorizations. After many advisory committee and agency meetings at CDC and FDA, several policies were finalized:

“Idling was not a good sign for a few reasons."

1. Vulnerable populations with the Moderna primary series were authorized to get a booster 6 months after the 2nd shot 2. Everyone with a primary J&J shot was authorized for a booster 2 months after 3. Mixing or matching vaccines was authorized. So, for example, J&J person could get a Pfizer booster, and, 4. 5-11 year olds were now eligible for a vaccine.

As expected, the FDA and CDC didn’t provide recommendations on how to effectively mix vaccines. This is because results from only one study were released at the time. From this landmark study, authors reported that mixing vaccines was safe with no severe events linked to the vaccines.

The authors also reported that some vaccine combinations were more robust than others. For example, those that received the J&J shot first and then got a Moderna booster had, by far, the most superior response with a 76.1 fold increase in neutralizing antibodies.

- COVID Monthly con't on page 6

"Ultimately, the United States needed to heed this warning from European countries..."

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-COVID Monthly cont'd from page 5 Pediatric Vaccines

“...7-8% of children will experience long COVID19.

"...we need to improve our breadth (getting unvaccinated vaccinated) and depth (boosters) of vaccinations..."

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At another meeting, regulatory agencies extended eligibility for the pediatric population. As ACIP pointed out, there have been more than 1.8 million infections among 5-11 year olds resulting in more than 8,500 hospitalizations. Interestingly, 1/3 of pediatric hospitalizations have been with children with no underlying medical conditions. And, in one year, 100 5-11 year olds succumbed to COVID19, which placed it as the 8th leading cause of death for children.

COVID19 infections kept close to 1.2 million children out of school and 7-8% of children will experience long COVID19. There are also population benefits to vaccinating, as mounting evidence shows that kids are incredibly effective transmitters of SARS-CoV-2.

Thankfully, this is now a vaccinepreventable disease for 5-11 year olds .

Barriers That is if we can convince parents of the need, safety, and effectiveness. The latest Kaiser Family Foundation poll reported that 1 in 3 parents will “wait and see” and 1 in 3 of parents will “definitely not” get the vaccine for their child. Top concerns include not enough known about the long-term effects and children might experience serious side effects. Importantly, access concerns were also voiced, with 25% of parents not being able to get the vaccine from a place they trust, concerns of having to pay out-of-pocket costs, and difficultly in traveling to a place to get their child vaccinated. By the end of October, 56% of Americans were fully vaccinated.

Boosters were ramping up in the U.S. with more than 18.6 million doses

administered. This equated to 9.7% of our vaccinated population (at the time, 60% of our population was eligible).

Those with a primary J&J vaccine seem to be opting for a Moderna (46%) booster followed by Pfizer (36%) and J&J (18%). Those with a primary mRNA series are largely sticking to their original vaccine sponsor for the booster.

Treatments In October, we also got our first antiviral treatment. Merck announced a new antiviral that can be used against COVID19: molnupiravir. When approved, high risk people would take four capsules twice a day for five days early in their infection. Antivirals are incredibly difficult to create because viruses can change fast (think flu), antivirals are very specific to a certain disease (we usually can’t use an HIV antiviral for COVID19), and/or the virus’s life cycle has limited targets for treatment.

Nonetheless, scientists figured it out for COVID19 and this pill series cuts the risk of hospitalization or death in half.

It’s certainly not as effective as vaccines, but we can use all the help we can get.

The FDA advisory committee has planned to vote on the approval at the end of November.

What to look for in November?

To avoid a winter wave, we need to improve our breadth (getting unvaccinated vaccinated) and depth (boosters) of vaccinations, we need to implement treatments, and remain vigilant. If we make it through the Winter months without a mutation, many epidemiologists, including myself, are hopeful for an endemic state - COVID Monthly con't on page 8

-Sweden cont'd from page 1 The question has always been did other countries overreact or did Sweden underreact. As phrased by the Commission, the question is “whether Sweden’s choice of path was reasonable, or whether it would have been better to introduce other types of measures to limit the spread of the virus.”

Unfortunately, the Commission has delayed answering that controversial question until its final report in February 2022. However, the Commission did conclude that Sweden’s handling of the pandemic has been marked by “slowness of response” and found that “the initial disease prevention and control measures were insufficient to stop or even substantially limit the spread of the virus in the country.”

But these conclusions should not be surprising since the rationale for the lower key response in Sweden was to have a more sustainable control strategy at the cost of allowing more people to get infected to begin with and thereby acquire a gradually increasing natural immunity. Whether it was reasonable to do that remains unanswered and the Commission will have to determine in retrospect if the tradeoffs involved were sound public health practice or not. The Commission will be making this determination in hindsight and not with all the uncertainty that surrounded the initial choice of strategy.

Anders Tegnell, Sweden’s chief epidemiologist who promoted the lower key strategy, is taking the longer view not focused only on the initial strategy and comparing Sweden to other European countries that are struggling now. He told the Financial

Times that “Now we're two years into this and Sweden doesn’t really stand out. We’re not the best but we’re definitely not the worst. That’s what I hear now: how much good did all these draconian [measures] do for anybody?”

The Financial Times reports that Tegnell is unapologetic for Sweden’s approaches.

Other conclusions reached by the Commission as of now are listed below.

These and all the conclusions are based on the work of thirty external researchers at various universities and institutions as well as several independent experts, many of whom provided background reports for the Commission.

“Now we're two years into this and Sweden doesn’t really stand out."

The most important conclusions to date are • Sweden’s pandemic preparedness was inadequate. This is similar to most other countries, according to the Commission.

• Existing communicable diseases legislation was and is inadequate to respond to a serious epidemic or pandemic outbreak. In commenting on this finding, the Commission added that “the Communicable Diseases Act has proved inadequate for handling a pandemic, as it is too focused on the individual. In a pandemic, the challenge is not just to look after individual citizens, but to protect an entire population.”

"We’re not the best but we’re definitely not the worst."

• Sweden’s system of communicable disease prevention and control was and is decentralized and fragmented in a way that makes it unclear who has overall responsibility when the country is hit by a serious infectious disease. The Commission called - Sweden con't on page 8

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-Sweden cont'd from page 7

"...there is a problematic lack of data..."

for strengthening and clarifying the positions of County Medical Officers and making other changes in how Sweden is organized for communicable disease prevention and control.

• The health care system has been able, at short notice, to adapt and to scale up care for people with COVID-19.

• In several areas there is a problematic lack of data, making it harder to monitor the pandemic while it is in progress and to satisfactorily evaluate its

management when it is over.

To access an English summary of the Corona Commission’s interim report, visit: https://bit.ly/3DtOPXT ■

-COVID Monthly cont'd from page 6 in Spring. An endemic state would mean we have an outbreak here and there (maybe at a nursing home or at a school), but there will not be high levels of transmission statewide.

Stay tuned.

■

On The Light Side, con't from page 4

"...a remarkably high mortality among Bond's sexual partners..."

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to international travel advice during the 86 international journeys that James Bond was observed to undertake in feature films spanning 1962–2021. Scrutinizing these missions involved ∼3113 min of evening hours per author that could easily have been spent on more pressing societal issues.

We uncovered above-average sexual activity, often without sufficient time for an exchange of sexual history, with a remarkably high mortality among Bond's sexual partners (27.1; 95% confidence interval 16.4–40.3).

Given how inopportune a bout of diarrhea would be in the midst of a world-saving action, it is striking that Bond is seen washing his hands on only two occasions, despite numerous exposures to foodborne pathogens.

We hypothesize that his foolhardy courage, sometimes purposefully eliciting life-threatening situations, might even be a consequence of Toxoplasmosis. Bond's approach to vector-borne diseases and neglected tropical diseases is erratic, sometimes

following travel advice to the letter, but more often dwelling on the side of complete ignorance. Given the limited time Bond receives to prepare for missions, we urgently ask his employer MI6 to take its responsibility seriously. We only live once.”

To read the entire paper, visit: https://bit.ly/3qLYLsd ■

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Notes on People Do you have news about yourself, a colleague, or a student?

Please help The Epidemiology Monitor keep the community informed by sending relevant news to us at this address for inclusion in our next issue. people@epimonitor.net

Died: Jennifer Kelsey, on October 13, 2021 at age 79 from complications following a stroke. Dr Kelsey was former head of the Division of Epidemiology at Stanford Medicine and earlier at Columbia. Before that she taught at Yale for more than a decade. According to the Stanford news release reporting her death, Dr Kelsey was known for her detailed methodology. Her research focused on the incidence and causes of musculoskeletal disorders. She was also known for her teaching skills as well as her love of golden retrievers.

Appointed: Bruce Dye, Department Chair for Community Dentistry and Population Health and the Delta Dental Endowed Chair of Early Childhood Caries Prevention at the University of Colorado School of Dental Medicine. Dr Dye comes to Colorado from the National Institute of Dental and Craniofacial Research. He is Scientific editor and Co Project Director of Oral Health in America, a soon to be released NIH report on Oral Health in America, the government’s first retrospective and comprehensive report on oral health in 20 years.

Honored: Salim Abdool Karim, with an honorary Doctor of Science degree from Rhodes University in South Africa. Dr Abdool Karim is widely recognized for his scientific and leadership contributions in AIDS and COVID-19. His primary academic appointments are as Director of the Center for AIDS Program of Research in South Africa (CAPRISA) and CAPRISA Professor for Global Health in the Department of Epidemiology at the Mailman School of Public Health at Columbia University. In remarks about his degree, Dr Abdool Karim said “…In the course of both the HIV and COVID-19 pandemics, I have personally witnessed the importance of staying true to science and evidence.”

Protest: by Cesar Victora refusing the Grand Cross of the National Order of Scientific Merit granted by the government of Brazilian president Jair Bolsonaro.

The award is one of the highest for scientists. According to Victora, Professor Emeritus at the Federal University of Pelotas and winner of the Doll prize in epidemiology in 2021, the government “not only ignores but actively boycotts the recommendations of epidemiology and collective health.” In a published letter Victora states “as a scientist and epidemiologist I have made public, through lectures and scientific articles, my complete opposition to the way the COVID-19 pandemic has been faced by this government.”

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Notes on People Do you have news about yourself, a colleague, or a student?

Please help The Epidemiology Monitor keep the community informed by sending relevant news to us at this address for inclusion in our next issue. people@epimonitor.net

Profiled: Vidya Maharaj, in Browngirl magazine as a research scientist and chef at Diya Miami restaurant. She told the magazine, “When we immigrated, my parents like most Indian parents, wanted me to be a doctor. I didn’t end up going to medical school, but got my degree in epidemiology and was interested in the lucrative business of pharmaceuticals.” When the opportunity arose she began cooking in her family's Indo-Caribbean restaurant and has since advanced her career both in pharmaceuticals and as an executive chef.

Died: Randall Todd, on October 7, 2021 from inoperable anaplastic astrocytoma.

He was Director, Division of Epidemiology and Public Health Preparedness for Washoe County Nevada for 14 years of his forty year career. He also had served as an adjunct faculty member teaching epidemiology at the University of Nevada Reno. His obituary notes his frequent struggle to provide good public health services in the face of political opposition. His family called him the “Dr Fauci” of Nevada.

Honored: Raman Gangakhedkar, with a 2021 Padma award in India. The Padma awards are one of the highest civilian honors of India given annually on the eve of Republic Day. The award for distinguished service seeks to recognize achievements in all fields of activities or disciplines where an element of public service is involved. Dr Gangakhedkar is a former scientist at the Indian Council of Medical Research. He is currently a member of the WHO expert group tasked with probing the origins of COVID-19.

Named: Paul Glasziou, as top researcher in epidemiology by the Australian’s 2021 Research Magazine. Dr Glaziou is a clinical epidemiologist and Bond University Director of the Institute for Evidence-Based Healthcare. The Australian's 2021 Research magazine names the top researcher and top research institution in each field of research, based on the number of citations for papers published in the top 20 journals in each field over the past five years. According to the magazine, Dr Galsziou’s research mainly focuses on what he calls “big neglected problems – like antibiotic resistance and antibiotic stewardship, non-drug therapies and overtreatment and overdiagnosis”. The causes of research wastage is another major field of study.

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8 Near Term Epidemiology Event Calendar Every December The Epidemiology Monitor dedicates that issue to a calendar of events for the upcoming year. However that often means we don't have full information for events later in the upcoming year. Thus an online copy exists on our website that is updated regularly.

To view the full year please go to: http://www.epimonitor.net/Events The events that we are aware of for the next two months follow below.

December 2021 December 8-10

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