I wanted to write one more update to give a final overview of where we are and the future.

Welcome to our new normal. Covid has become an endemic disease that will be here for the foreseeable future. Obviously, we all wished we had been able to crush this and never look back. Still, the contagiousness of Delta is too high to expect it to go away.

I know it seems scary, but the reality is that we have dealt with endemic diseases our whole life. Colds and flu kill tens of thousands every year. We have to deal with disease concerns like an exotic disease when traveling, STDs, or situational ones like Lyme disease and tetanus. We’ve long ago learned how to understand and mitigate possible infections and still live our lives. Covid is now part of the pantheon of diseases we have to think about.

Delta continues to dominate. I know that people are always worried about new variants, but it appears that Delta will be the only one here for a while. It’s important to remember that we first saw Delta in the fall of 2020 and immediately saw that it was significantly more contagious. It took nine months to become dominant in the US. Currently, I am not tracking any other more fit variants [combination of immune evasion and contagiousness].

Over the last few months, the most significant development has been discovering waning immunity in all the vaccines we have. Just this week, the FDA authorized boosters for all adults. I highly recommend you get a booster immediately. I was looking at the data this morning, and it’s deeply compelling. After your booster shot, you are *more* protected than after your second shot.

The open question is, “Is this the last booster we’ll need?” The short answer is we just don’t know. If I’ve learned anything writing about Covid for 18 months, it’s that the immune system is complicated and hard to predict.

For childhood vaccines, many are 3+ shot series given over several years to provide immunity. The spacing is a vital part of training the immune system to recognize the pathogen best.  So a third shot of a Covid vaccine six months in isn’t a huge shock. Some immunologists had previously worried that the original two shots were closer than they should have been, but we were running on a compressed schedule.

Even then, some of them wane. The most notable example is that you need to get a tetanus booster once a decade if you are going to be in a position of being exposed. Obviously, we also have an annual flu shot, though that is due to the speed at which the flu mutates. The reality is that we’ve designed a system that will continue to monitor case counts and immunity. If protection starts to drop off, I expect that we will have plenty of warning as we did this time.

The holidays are coming up, and there will likely be case count jumps nationwide. We’ve usually tracked about 3-4 weeks after Europe, and they are starting to see some concerning spikes. They have, however, been slower with boosters, and some of the vaccines popular there aren’t as effective. Nonetheless, I expect case counts to jump in many parts of the country due to the combination of the winter driving us indoors, the holidays, and waning immunity [combined with a low uptick of boosters].

A significant change this winter is the widespread availability of treatments. Last fall, we were just rolling out the monoclonal antibodies, and they are now widely available. A friend had a breakthrough infection last week and got treated the next day. The downside is that it’s an IV drug and needs to be administered by a nurse, not something that’s particularly scalable. In a surge, it would likely be limited to only those at high risk.

In the last few weeks, two huge new breakthroughs were announced in new treatments. Both Merck and Pfizer announced oral antivirals that are shockingly effective. Both are so powerful they stopped the studies early because the data was so compelling.

Merck’s drug is called Molnupiravir [after Thor’s hammer] and lives up to the name. The pill can be started up to three days *after* symptoms are detected. The study was done on unvaccinated patients with at least one significant risk factor, and results showed a 50% reduction in hospitalization and no deaths! It’s one of the most incredible antivirals ever studied.

Hot on the heels of that announcement, Pfizer reported on its oral antiviral drug, Paxlovid, and the results are even better! The drug is 89% effective at preventing hospitalization and death in high-risk patients if given within three days of symptom onset and still 85% effective if given up to 5 days of symptom onset. Like the Merck trial, this was with high-risk unvaccinated patients.

Prior estimates I looked at expected Covid to kill about twice as many people as typically die in a flu season this year. With these drugs, we’re looking at taking it to a fraction of a typical flu season. Most importantly, they can be dispensed from pharmacies, like any other pill you take. It’ll take a little bit to get the supply chain up and running, but these are both game-changers for the Covid. Also, it’s likely they will work on all variants equally, blunting fears of a new variant due to how they work.

Recent reports this week suggested that vaccines for 6-month-olds - 5-year-olds will be out in the spring, possibly earlier. The data overwhelming shows that children in that age group tolerate Covid extremely well with few side effects. The 5-year-old to 11-year-old rollout has gone well and with minimal side effects.

I’ve spent the last six weeks in New York. I got my booster right before I left, and I’ve been out and about with no restrictions. NY requires proof of vaccination for indoors, and with that, I’ve been to bars, clubs, and comedy shows. I understand that I can still contract Covid, but given the state of the vaccines and treatments, I don’t take any more precautions than I do with the flu.

For the holidays, I will keep a set of rapid tests handy, and if I feel off, I’ll take the test. It’s critical to test as soon as you have symptoms to give these drugs the best chance of working. It would be reasonable to have people test if there will be a large group from disparate areas. However, honestly, if everyone is vaccinated, I think it’s still pretty low risk.

We made it. You have survived the worst global pandemic in a 100 years. Go get your booster and have a great holiday. I’ll see you out there.