We Need to Talk about Kraken (XBB.1.5)

I watched this livestream tonight:  an interview and Q&A with Dr. Eric Feigl-Ding (EFD), an U.S. epidemiologist who broke the news that the CDC knew XBB.1.5. was a variant of concern but didn't tell us and Dr. David Berger (DB), an emergency physician in Australia. Here are the main points as I heard them, a bit summarized to take out repetitive bits, and somewhere between quoted and loosely paraphrased. I bolded the bits I liked. Dr. Berger gives particularly good soundbites. You can watch the whole thing here. 

EFD: XBB is from Singapore, but XBB.1.5 is lightyears apart. It started in October in New England, Connecticut, New Jersey, Massachusetts, and New York. They are the same areas hit at the very beginning. This is a U.S. variant, from the northeast part of the U.S. I wasn't the first to track it, but posted and disclosed the unreported memo from the CDC. They are supposed to report if a new variant reaches over 1%. This blew up in October with BQ not being reported fast enough. XBB.1.5 was unreported until it hit 40%, so the CDC knew for weeks prior. This is unprecedented except for the original Omicron. There are lots of variants out there, but this one is highly immune evasive and and highly invasive in human cells. 

DB: XBB.1.5 has a high affinity for (likes to stick to) ACE2 receptors found on cells throughout the body. It's used to get into the cell, so it's easy to transmit it, and it may cause greater severity through dramatic growth in the cells. There could be very significant breakthroughs. Most important is that if we weren't discussing this one, we'd be discussing another in a few months the same way. We've encouraged unrestrained replication of this virus in a partially immune population - the ideal way to create mutants that will escape immunity, and here we are.  

It's so important to consider everything that's happening: The tactics - things we do in the local short term to mitigate effects, and the strategy for the overarching planet. Vaccines are always running to catch up with the illness. There was great hope that mRNA would be able to move quickly and keep up, but it may not be possible with enough speed scientifically or politically. Vaccinations are like a jet fighter pilot ejection seat -- it may save your life, but you may well still get damaged. The biggest message is that vaccination is extremely important, but #1 is suppressing transmission. Masks, filtration, and clean air - none care which variant it is. The only strategy with any chance of success is to suppress the virus. Living with it is nonsense. We're not in the middle of the pandemic. We're not even at the end of the beginning of the pandemic. We're setting ourselves up for longterm problems. 

Before the pandemic, there was increasing awareness of the role of viruses in longterm illness. As a doctor in emerg, I can't remember the last time I saw a woman die of cervical cancer. We have a vaccination against the HPV virus that causes cervical cancer. We know the virus causes that. We know there can be extreme longterm effects of viruses in the body. It wasn't until the 1950s that we knew shingles were from chicken pox in the body after 30, 40 years. Last year, we found that multiple sclerosis required a prior infection with the Epstein Barr virus to occur. We know viruses are important in cancer, neuro, all kinds of longterm illnesses. We know Covid is a longform virus. It has untold effects throughout the body. Studies published found it in gastric tissue - just one of many organs. [An autopsy study found Covid all over the body.]

Three years ago, I would think this insane. We're providing an environment for an already dangerous virus with unknown but significant longterm effects, to evolve to be increasingly immune evasive causing a reduction in cardiac function in children after asymptomatic or mild covid. We know it causes myocardial fibrosis, which is a poor indicator for the future. We don't know kids will have heart failure, but the could. Potential high consequences + low probability = high risk. 

Our governments are sticking their heads in the sand: "It's an existential threat; it's too complicated. Most seem to get better." But we need a twenty-year perspective on this. That's how long we know these viruses have an effect. It's not a surprise. Donald Rumsfeld, back in Gulf War 1, said, "There are known unknowns and unknown unknowns." XBB.1.5 is a known unknown. We didn't know when it would happen, but we knew something like it would come along. 

Q: Why aren't we using a new letter of the Greek alphabet?

EFD: The difference between the original Omicron and this XBB.1.5 is like the difference between humans and elephants. 

DB: The naming of it is a a way to guide management. In late November 2021, they said Omicron is mild. It was seized on by government, and they fund the WHO. With more Greek letters, they think there's more room to evolve. The real battle is not against he virus. This is an information civil war the human race is fighting among itself. The classification system is highly charged politically. 

EFD: By calling it Omicron, it's disingenuous. It's really far from the original Omicron; it's a clear indicator of the leapfrog effect. Using a new Greek letter would wake up people: just because they were previously infected doesn't mean they're protected. It's a whole new strain. Delta has way less of a difference. 

Q: Do RATs still work?

EFD: They work, but with much lower sensitivity. A 5% sensitivity drop would be huge. We'll miss more cases. It's a worrisome problem. We need multilayers: test, mask, ventilate filtration, use a HEPA or CR box. Do all these things. Open windows. It's critical. 

DB: We need a multi-layer strategy. RATs just aren't reliable enough. We can't make actionable decisions if everyone tests negative with CO2 at 2,000. We also need HEPA, etc. Tests are just one part of a larger strategy. It's a screening tests like a mammogram or pap smear. To take action based just on them is too much for anyone. 

EFD: Even if we assume 98% accuracy, but in a room of 2,000 people (like the White House Correspondents' Dinner, where there was an outbreak), and everyone tested negative, the chance that someone has it is still 95-99% positive! With 1,000s of people, it basically guarantees we'll miss a case. If ventilation is poor, you'll have an outbreak. They debated having UV, but didn't want people to look blue, but the lights were blue anyway!

Q: What should we expect with respect to severity of sickness and hospitalizations?

EFD: [General gist because things got complicated]: We can't isolate it enough to determine if severity is worse. But based on ACE2 fusionicity - the stickiness that makes it get into cells easier - the chance of it invading and replicating is high. It won't be milder, but it's hard to say how severe it could be. 

DB: Will it cause more severity is the wrong question. It's too late. The point about viral spread is that it's an exponential phenomenon. It looks like it has potential to be severe, but we don't want to find out. We want to stamp it out, but the problem is we just sit and wait and see. Don't wait to see -- Suppress it!! 

EFD: Don't F around and find out! 

DB: It's going to cause another wave. 

EFD: Compare two viruses: if one is more severe, but less contagious, and the other is less severe but more contagious, you might think you want the less severe one, but that more contagious one will sicken more people with long covid and send more to the hospital. 

Q: What about immune response? 

 

DB: If the virus enters cells that turn over more slowly, it can hang around longer. We're seeing persistence in all sorts of tissues. We're playing a game of roulette, and we have no idea what the odds are. It's just dumb. 

EFD: XBB.1.5. is the only variant with R above 1 right now. The rest are trending down because XBB.1.5 is forcing extinction of the rest. It's like Facebook vs Myspace and Friendster. It's the new Tiktok. It's definitely bad. The question is how high will it be until it burns out. The government is doing nothing to mitigate the spread. They're using a burn out approach: wait until everything in the forest is burnt. It's a huge pool of people. There will be increased tropism -- scientific code that it will be more severe. 

DB: XBB.1.5 has an increased affinity for certain tissues. The virus enters tissues through ACE2 receptors, and will enter more if there are more ACE2 receptors. 

EFD: There are ACE2 in so many organs. It's one of the most common receptors. Previously we needed  a lot of virus to interact with ACE2; it's like a poor key that you need to jiggle the lock. A perfectly cut key turns effortlessly. XBB.1.5 is like a perfect key: even with less virus, it can get in and replicate en masse. Even cells with fewer ACE2 receptors, it's a better lock and key fit, and we need fewer to have a big effect. 

Q: What about outside? Do we need to be more careful now?

DB: Be careful if outside in a crowded street. Eat on a terrace of a well-spaced cafe. But outside in a packed football game, you'll need protection, or standing in a crowded line. You have to use your sense. It's transmissible outside. Improved ventilation, even if it's fantastic, you can still get covid if you're sitting next to someone. It's a question of common sense. 

EFD: Avoid mosh pits outdoors. Outdoor terrace under a tent is better than indoors. If indoors, have people open windows. The solution for pollution is dilution: you have to dilute the virus. For those who say God gave us an immune system, millions have died of this infectious disease. [I'd add, God also gave us people able to make vaccines and masks and CR boxes!]

We can't rely on Paxlovid. We need HEPA, CR box investments if you have to work indoors. Please have a HEPA right next to you. There's optimally what you should do and then there's the reality of where people work, many without masks. If you're surrounded by people smoking, you have to take precautions against second hand smokers. Even if you think you're healthy, you have to protect relatives, family and neighbours. 

DB: The 'you do you' idea is nihilistic and depressing. We're all part of networks and need to look out for each other. Even if you' think you'll be fine, someone downstream from you could have a bad time with it. 

ETA: This bit of satire from the POV of the virus: