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Saturday, April 3, 2021

The first time I encountered the phrase “impending doom,” it appeared in the section on acute hemolytic transfusion reactions in my medical technology manual. It read like this: “Ominously, the patient may report a feeling of ‘impending doom.’ ” Such an emotional-sounding phrase seems out of place alongside physical symptoms like chills, fever, back pain, and a burning sensation at the transfusion site. But “impending doom” is a medical description of the internal dread that a person can feel when facing a heart attack, anaphylaxis, or stroke.

The hydra’s name is Covid.
“Jason and the Argonauts,” trailer, 1963

Remember the hydra in Greek mythology? The monster that had nine heads and every time you cut one off two grew in its place? Its new name is Covid.

Fortunately I never had to deal with an acute hemolytic transfusion reaction during my career as a medical technologist. Or a hydra, for that matter. But the phrase stayed with me. It expresses that sinking feeling you have when everything is about to go wrong. So when CDC Director Rochelle Walensky used it this week I took notice.

Her actual words were:  “I’m going to lose the script and I’m going to reflect on the recurring feeling I have of impending doom.”

I was not so much surprised by her use of the phrase as I was by Dr. Fauci’s defense of it, when he failed to point out that this is a medical term which might come easily to a medical professional especially when going off script. He himself has been known to worry in public about the many faces of Covid. Epidemiologist Michael Osterholm called it “a category 5 hurricane on a global basis.” ICU physician Michael Warner, in the midst of Toronto’s third wave, said, ““Every single one of my patients has [a] variant. This is a different pandemic with the variant”. German Chancellor Angela Merkel announced recently, “We are now basically in a new pandemic. The British mutation has become dominant.”

Korber, et. al. Cell 182, Aug. 20, 2020

Why this level of concern when everything here is going so well? The problem is the increase in variants. We are used to discussing Covid-19 as if it were a single entity, when it is actually a many-headed hydra. The virus version we talk about in everyday conversation is itself a variant of the “original” virus.  The mutation that changed the spike’s protein’s 614th amino acid from D to G back in 2021 may have helped the virus spread faster. This G614 strain is now predominant worldwide.

But it has been changing ever since. Changes in Covid’s genetic code are ongoing. Research on the virus’ genome has been accelerating in the effort to determine which mutations matter to us. The CDC and the WHO recently constructed a hierarchy ranking the variants that have changes in genetic markers that can affect transmission, disease severity, efficacy of treatments, or resistance to immune response (i.e. antibodies from exposure to vaccine or previous infections). These are the weapons the virus develops. These are the genetic changes that matter.

Viruses with those types of changes are ranked on three levels:

  1. Variant of Interest: These variants have changes in the markers for the characteristics described above. They are being tracked and studied.
  2. Variant of Concern: These are the variants in the news. We have evidence that they are more transmissible or cause more severe disease or resist treatment or can overcome the immune protection expected from vaccines or prior infection. They are being closely monitored so we can adapt treatments and vaccines when necessary.
  3. Variant of High Consequence: Significant reduction in vaccine efficacy, significant resistance to treatments, and more severe disease. Currently no variants have been assigned to this category. This degree of variant would be reported to the WHO and the CDC to coordinate emergency measures.

See the chart below for a ranking of currently know variants in mid-March.

From WebMD, March 18, 2021. See link below.

Basically, the variants found today are ranked relative to the variant(s) we have been getting used to throughout most of 2020. They range from about the same, worse, or much worse. All over the world the virus is spreading and replicating and changing its genome. Any variant that gets through our defenses spreads more. For example, two variants, the B.1.1.7 (UK) and the P1 (Brazil) are now the dominant strains in British Columbia, with a surge of the P1 variant now identified in the ski resort of Whistler Blackcomb.

CDC: Variant Proportions in the U. S.

A variant has a set of mutations, not just one. But one mutation that has recently attracted attention is the E484K mutation. An article in the BMJ (see below) recently called this an escape mutation, “because it helps the virus slip past the body’s defenses.” Defenses like vaccination or previous infection. The E484K mutation has been found in the South African (B.1.351) and the Brazilian (B1.1.28) variants and some of the UK (B1.1.7) samples. They are less susceptible to our current vaccines.

So why all the gloom and doom when we are so happy about opening up?

  1. We are aiming at a moving target. Hot spots throughout the U.S. and throughout the world are the incubators where new variants test their wings. The strong ones find new locations fast.
  2. The rollout of vaccines makes us feel good. And it should. But it is uneven in the U.S. and throughout the world. Any unprotected area can become a hot spot. Hot spots are areas of rapid spread. Areas of rapid spread produce variants. Variants are a threat to all of us. Even if we are vaccinated. Even if we have already had it.

We can fight this hydra. But not by underestimating it.

Today’s Notable Headlines

“CDC Director Rochelle Walensky warns of “impending doom” amid COVID-19 spikes.”, CBS News, March 30, 2021. https://www.cbsnews.com/news/rochelle-walensky-cdc-chief-covid-concern/

“Coronavirus pandemic: How experts say Canada can escape the third wave,” KCTV5, April 2, 2021. https://www.kctv5.com/coronavirus-pandemic-how-experts-say-canada-can-escape-the-third-wave/article_a58464db-f1c1-5514-919c-dd9e3a731fec.html

“’Basically In A New Pandemic,’ Says Merkel, As Germany Extends Lockdown,” NPR, March 23, 2021. https://www.npr.org/sections/coronavirus-live-updates/2021/03/23/980272577/basically-in-a-new-pandemic-says-merkel-as-germany-extends-lockdown

SARS-CoV-2 Variant Classifications and Definitions, CDC, updated March 24, 2021. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/variant-surveillance/variant-info.html

“Researchers believe coronavirus variants are now dominant in B.C., official figures outdated,” CTV News, April 2, 2021. https://bc.ctvnews.ca/researchers-believe-coronavirus-variants-are-now-dominant-in-b-c-official-figures-outdated-1.5373168

“Outbreak Of Brazilian P.1 Coronavirus Variant Closes Iconic Whistler Ski Resort,” Forbes, March 29, 2021. https://www.forbes.com/sites/victoriaforster/2021/03/29/outbreak-of-brazilian-p1-coronavirus-variant-closes-iconic-whistler-ski-resort/?sh=70a2727c3839

Additional Sources

Blood Groups and Red Cell Antigens, National Center for Biotechnology Information, https://www.ncbi.nlm.nih.gov/books/NBK2265/#:~:text=Acute%20hemolytic%20transfusion%20reactions%20occur,in%20the%20back%20and%20flanks.

“Tracking Changes in SARS-CoV-2 Spike: Evidence that D614G Increases Infectivity of the COVID19 Virus,” Cell, Korber, et. al. https://www.cell.com/cell/pdf/S0092-8674(20)30820-5.pdf

“CDC, WHO Create Threat Levels for COVID Variants,” March 18, 2021, WebMD. https://www.webmd.com/lung/news/20210318/cdc-who-create-threat-levels-for-covid-variants

“Variant Proportions in the U.S.,” CDC, updated March 31, 2021. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/variant-proportions.html

“Covid-19: The E484K mutation and the risks it poses,” BMJ, Feb. 25, 2021. https://www.bmj.com/content/372/bmj.n359

Why am I doing this?

The coronavirus pandemic will be indelibly written on our memories just as the Great Depression or the Battle of Britain left their mark on past generations. I intend to journal the pandemic experience from three perspectives: as a retired medical technologist, as a historian (Ph.D., 2014), and an ordinary person living through an extraordinary world crisis.

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