Nick Kadysh: COVID-19 case counts don't matter anymore

For the vast majority of vaccinated people, COVID is a flu. We should be tracking hospital and death counts, not case counts

Growing up, I was told that math was important. My biological father was a PhD mathematician. His mother, his father, his step-father, all PhD mathematicians. My namesake and great-grandfather, Nikolai Efimov, was a downright famous mathematician. You can imagine the shame in discovering that young Nicholas had not only no real talent for math, but no real interest in it either.

But math is important. Numbers can help us make sense of our world — you just have to catch them when they start to change on you.

From the U.K., to Alberta, COVID-19 case counts are once again beginning to rise as restrictions are eased. This is, understandably, prompting concerns from the usual quarters, those people who would like to see us all in some kind of lockdown society until the risk of the disease passes permanently — a prospect that will never come.

Ignore them.

Case counts no longer matter, because the math has changed. The metrics we should be watching now are hospitalizations, ICU admissions, and deaths — all of which have remained reassuringly low in highly vaccinated populations like ours, even with the Delta variant.

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How has the math changed? Let’s start at the beginning, with 1/10. 

1/10 (or 10 per cent) is an important number. That’s the upper end of the case fatality rate for COVID-19, in particularly hard-hit countries. Mexico. Peru. For every 10 cases of COVID in those countries we could expect one death. Canada fared better in this regard, landing at 1.8 per cent; nearly 1/50 according to research published by Johns Hopkins. Chalk this up to better health care, better citizen response, a bigger country, or just blind, dumb luck — reasonable people can disagree, and do.

But one thing that is true in every single country is us. We were all a completely naïve population for COVID-19. It’s a novel virus: none of us had been sick with it before late 2019, none of us had an immune response ready to roll at the first sign of infection. And so the case mortality rate had been relatively steady. Mortality might be 10 per cent of patients at the top end, and 1 per cent on the bottom end, but generally fell in that range.

All that changed six months ago when we rolled out mass vaccination. Even those of us who have never had COVID are no longer naïve hosts for the virus, and that changes the math. Here in Canada, PHAC has estimated that the case mortality rate for COVID-19 in patients with one vaccine dose is 0.0027 per cent and for those with two doses as 0.0018 per cent — and for those following along with the math, that’s 1/375 and 9/5000, respectively. But that data is still relatively old; herd immunity being what it is, as Canada raced towards full vaccination of more than 50 per cent and single-dose vaccination of over 80 per cent, that number is going to fall. And it’ll keep falling. In the U.S., the CDC reported in May that for 101 million people fully vaccinated, they recorded 10,262 SARS-CoV-2 vaccine breakthrough infections.

2,725 (27%) vaccine breakthrough infections were asymptomatic, 995 (10%) patients were known to be hospitalized, and 160 (2%) patients died. Among the 995 hospitalized patients, 289 (29%) were asymptomatic or hospitalized for a reason unrelated to COVID-19. The median age of patients who died was 82 years (interquartile range = 71–89 years); 28 (18%) decedents were asymptomatic or died from a cause unrelated to COVID-19.

At this point you’re probably wondering why the nice man keeps talking about math, and possibly when he will stop. But math is important. Because for the past year, we have been trained to follow daily case counts the way gambling addicts follow horse racing times, and those numbers no longer matter much.

In a post-vaccine world, daily case counts are no longer a great predictor of outcomes. Death rates, hospitalizations, breakthrough illnesses, mutation of COVID into new variants — these are all important data points. But the daily case counts which we pay so much attention to will cease to hold the same importance and meaning.

This is important because COVID-19 case counts will go back up. In Canada, where respiratory illnesses are highly seasonal, they will almost certainly go back up in the fall, just as they did last year. The virus will continue to prey on those who can’t, or won’t, get vaccinated. And of that cohort, those most vulnerable, the unvaccinated elderly and those with co-morbidities like obesity. Like the flu, this disease will hospitalize people, crowd ICUs, and even kill a few unlucky individuals. But by the fall, we will no longer be the same naïve population we were last year.

There is another element to consider here: not biology but sociology. There will certainly still be many loud voices calling for restrictions, lockdowns and other deeply painful measures to “stop the spread” — and perhaps even get to “#CovidZero” — and they will almost certainly be using rising case counts to do it. The example of The Netherlands may be telling — a few weeks ago, as cases began proliferating there, a number of people in Canada began pointing to the small European country as a case study in why further societal restrictions are necessary. 

But the wave in the Netherlands seems to have crested about 10 days ago, around July 18th — and more importantly, while there were approximately 10,000 cases per day recorded at the height of this wave, there were almost no deaths. Fewer than 500 people hospitalized, where two months ago it was almost 2,000. There have been 64 deaths in the last month, while in January the Netherlands was recording an average of 100 deaths per day. As with other places, those getting seriously ill are almost exclusively the unvaccinated; the Netherlands have only vaccinated about 50% of their population vaccinated — less than Canada.

At the beginning of this pandemic, we accepted extreme measures like lockdowns as an unfortunate necessity to prevent our fragile health-care systems from being overwhelmed. In a post-vaccination scenario, that no longer seems reasonable. Too many of us are now vaccinated, and the math — the number of us who can become seriously ill by COVID-19 — simply doesn’t add up.

There are also those who remain fearful of COVID-19’s impact on children, or about long COVID-19. Fortunately, the math is already in on the former demographic; this illness is, thankfully, no more a threat to most children than the common flu (potentially less), and their exposure to it will decline as the virus ceases to spread in the population at large. Meanwhile, long COVID-19 is still a speculative illness, and it appears to be rare. If vaccination can radically reduce the most serious adverse outcomes — death and hospitalization — there is no reason to think it will not make a similar dent in other rare reactions to serious illness as well.

We must steel ourselves against the temptations of panic now, before the fall, and before people trained to panic at the sight of rising case counts begin to panic once more. The message should be clear: The vaccines work. They’re highly effective. COVID isn’t going to disappear, but if you’re fully vaccinated, you don’t have to worry much. Case counts don’t matter if nobody is dying. '

And to my friends in the press: ignore the urge to amplify the rare breakthrough cases. Treat rumours of vaccinated people falling ill with the appropriate amount of skepticism; they’ve been proven wrong in the case of the Alpha, Beta, Gamma and Delta variants. And for god’s sake, look at the math — even if, like me, you’re not particularly interested in or good at it.

Nick is the founder and CEO of PharmAla Biotech, a Toronto-based psychedelics research company.

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