And I’m back. When I signed off in early June, I had hoped it would be my last, but Covid has sprung up again. This one is a bit longer than usual, but there is a lot to cover. I chose to boot back up because I felt there were many questions out there that I could help answer. I am not writing because I think there is a considerable spike in danger to vaccinated people. Our vaccines are incredible, and I have not modified my behavior significantly due to the surge.

So let’s dig into the Delta variant. It is significantly more infectious but does not appear to be more fatal. A week ago, it was 85% of all cases in the US; it will be basically 100% of all cases moving forward.

The way we measure how infectious a virus is is R0, the basic reproduction number. This is the number of people every person who has the disease will go on to infect. The original strain of Covid is ~3, the Alpha variant we held off in the spring is 4-5, and Delta is 5-8. For comparison, measles is 12-18, mumps is 10-12, rubella is 6-7, and a bad flu is 1.5-2.  This puts Delta into a rare, extremely infectious category of pathogens.

The Delta variant appears to have two traits that cause it to be significantly more infectious: it has a shorter incubation time, and once you’re contagious, you shed significantly more virus.

The good news is that the current R in the United States is 1.4. Yes, we need to get that below 1, but it’s 1.4 instead of 5-8 that it would be, and that’s with the entire country being fully open. What’s more, there are 30 million people who have started their vaccine journey who are not yet fully immune.

If you are fully vaccinated, Delta does not have significant immune evasion for severe disease and death. If you’re partially vaccinated then, Delta is breaking through at a much higher rate than prior versions. Even those that are fully vaccinated are seeing breakthrough infections. Still, the vaccine is doing its job, and we see very low rates of hospitalizations and death.

I know that seeing breakthrough infections can be scary, but it’s not a shock. As Delta tears through the unvaccinated population breakthrough cases are the collateral damage. You can take solace in knowing that being vaccinated means the course of the disease will be much much easier.

When it comes to breakthrough infections, the analogy I like the most is the raincoat one. The vaccine is like a raincoat. In a bad enough storm, you’ll still get wet. It comes down to managing your overall exposure.

The UK seems to have peaked after a particularly brutal spike in infections. There are two critical takeaways from their surge. One is that they created the perfect storm for Delta spread. The Eurocup is a soccer tournament that took place from June 11th - July 11th, and England made it to the finals. I couldn’t create a better set of super spreader events if I tried. The entire country would cram into tiny little pubs and yell for two hours, and they did this every couple of days for a whole month!

However, what’s great is how few hospitalizations they have had. Most of the UK has the AZ vaccine, which is less effective than the mRNA ones, but even then, it shows just how incredible these vaccines are.

Just look at this chart that compares cases/deaths in the second vs third wave!

The bad news is that the US states that have rejected vaccination are seeing staggering rises in case counts and hospitalizations. In parts of the south, vaccination rates are 20-30% lower than the US average. At this point, it’s too late to try to rush in vaccines, as it takes six weeks for them to be effective. The other option would be to reinstate some sort of lockdown, but there’s no political will to do so.

The infection rate increase in Florida, Louisiana, Arkansas, Missouri, and Mississippi are nearly vertical. This is happening with significantly less testing than earlier in the pandemic.

I suspect they will all break new records for case rates in the coming weeks. Worse still, many of the least vaccinated states have begun to curtail their reporting of cases and hospitalizations, further clouding our view of the pandemic.

Nationwide over 80% of seniors are vaccinated, so we will see less death than we would have. Still, hospitalizations in all these states are also increasing quickly.

Lab studies suggest that the J&J vaccine is seeing a steeper drop-off in efficacy against Delta. However, those studies also suggest that there is still enough immunity to be effective. We don’t have much real-world data because most of the J&J use was in the US, and we aren’t far enough along in Delta to know.

A mix and match study, aka the Covid Arnold Palmer, done in Europe with one AZ shot [similar to J&J], and one Pfizer shot showed a better immune response than just two shots of mRNA.

If I had taken the J&J, I would go get an mRNA shot. If we later find out J&J needs the booster, you’ll likely have already gotten Covid. We have an abundance of vaccines in the US, so you’re not stealing anyone’s shot. I’ve heard rumors of people who got J&J just going to Walgreens and saying they haven’t been dosed yet to get their mRNA shot.

The FDA / CDC continue to drop the ball. Both Moderna and Pfizer have filed for a full license, and the government won’t even give a timeline for possible approval. It’s vital because some people are hesitant to take emergency authorized vaccines, but more importantly, it will help allow employers and the military to require it.

I’m probably preaching to the choir here but if you haven’t been vaccinated, go get your first shot today. Delta the most infectious, harmful virus you’ve ever seen in your lifetime. If you have any hesitation, please reach out to me, and I’ll talk you through it. There is a small collection of some of the vile humans to ever live that profit from the vaccine disinformation that accounts for nearly all of the false information. Unless you are back in lockdown, your choices are to get vaccinated or get covid.

So, where do we go from here?

I’m mostly sticking to outdoor bars and restaurants right now. I was about to rejoin a gym, but I’ve pushed that off. I’m still very comfortable at house parties with vaccinated people. My fully vaccinated office remains open with no restrictions. I have travel plans that I’m sticking with.

My gut says that we’ll see an uneven surge over the next few weeks, and in the areas with low vaccination rates, it’ll be bad. In those areas, hospitals will likely hit capacity, and we’ll see many breakthrough infections.

Then between acquired immunity and vaccinations, it’ll trail off. We’re not that far from herd immunity as it is. That said, the current models are widely divergent, no one really has a good idea of what the next few months look like.

I’m planning to write a few more posts in the coming weeks [still on Sundays]. One will be a rundown of everything we know about kids and covid. The other will be on the future of Covid as an endemic pathogen. If there are other topics you’re interested in, let me know.

I know it’s frustrating and can be scary to see the numbers rise again, but I’m really not freaking out over this. It’s a little worse than I thought it would be, but not unexpected. We created the best vaccines we’ve ever had, and they’re working; now it’s just the logistics of getting over this final hump.

As always, if you want to chat, please don’t hesitate to reach out.