COVID Pandemic: Medical Update
New variants of the coronavirus
February saw numerous reports about mutations and new variants of the pandemic coronavirus. A variant called B.1.1.7 was first identified in England (UK) last fall. B.1.1.7 spreads among people more easily (is more infectious) and may also cause serious illness more often. As of February 16, 2021, this variant has been identified in 42 states.
Another variant called B.1.351 was first identified in South Africa in January. This one has been identified in 10 states. It is also more infectious. Also, the AstraZeneca vaccine is less effective against B.1.351. Note, however, that even “less effective” vaccines still prevent serious illness in most people who are vaccinated.
A third variant called P.1 was first identified in January in Japan among travelers arriving there from Brazil. It has been found in two states. P.1 is also more infectious and current vaccines may be less effective against this one too.
These are troubling developments. The greatest concern is that a variant will appear that can readily infect and cause severe disease among people who have been vaccinated. Public health authorities around the world are on the lookout. Researchers are beginning to look for ways to modify or change vaccines to respond to new virus variants.
What is a mutation?
The coronavirus infects a cell by attaching to the cell surface and injecting its RNA genes into the cell. The virus uses pieces of protein that stick out from its surface to make the attachment. Those pieces of protein are called “spike proteins.”
All proteins are made of chains of molecules called amino acids. The genes direct the assembly of the chains of amino acids in a specific order based on the “genetic code.” The code is the order of four molecules (“bases”) that are linked together in a spiral (“helix”) that is the RNA that coronavirus genes are made of.
When viral RNA is being assembled during reproduction, an error may occur in the order of the bases that make the RNA chain. The more often the virus reproduces, the more errors occur. Those errors are called mutations, which means they are not the same as the original that was being copied during reproduction. Mutations seem to occur randomly on the RNA chains.
Mutations change the genetic code and can cause the wrong amino acid to be added to a protein chain that is being assembled. In most cases, those altered proteins don’t work at all, and the mutation is lethal. That one doesn’t infect new cells or reproduce. It is a dead end.
Occasionally, by chance, a mutation causes a change in the code that is not lethal. The protein still works, the mutated virus reproduces, and a new variant of the virus is loose in the population. It reproduces, spreads in the human population, and may even become the dominant variant in the pandemic.
OK. Back to the spike proteins. Mutations in the gene that codes for the spike proteins on the coronavirus can have serious effects on us, the human hosts of this virus. First, because the virus uses the spike proteins to infect cells, the new variant may be more (or less) infectious. It may also be more (or less) lethal to people who get infected. Second, the vaccines we are making stimulate the immune system to make antibodies to the spike protein. When a new variant of the virus has a different spike protein structure, the antibodies may be less effective in removing that virus. In that case, the vaccine is less effective (or possibly ineffective) and people are more susceptible to new infections with the variant coronavirus.
The AstraZeneca vaccine has not been approved for use in the U.S. yet, but it is being given to people in other countries. That vaccine was found to be effective against the B.1.1.7 variant, but was less effective against the B.1.351 variant.
South Africa, where B.1.351 is the most common variant in the population, has stopped using the AstraZeneca vaccine and redistributed its supply to other African countries.
The holiday surge in infections in the U.S. began in November and increased substantially into mid-January. That surge has peaked and is now declining rapidly back toward the high levels of infection seen last summer. With numbers of infections and hospitalizations trending down, some states are reopening indoor dining, bars, and sports events with reduced numbers of people indoors together. This is good for the economy in the short term but might not be so good for controlling the pandemic.
A new surge in infections may be coming. The Super Bowl may turn out to be a super-spreader event, because large numbers of people gathered indoors all over the U.S. to watch the game and celebrate together. We should expect to see Super Bowl related infections increasing by late- February.
In addition, the B.1.1.7 variant first identified in the UK is more infectious and is spreading rapidly in the U.S. now. With this variant, infections can double every 10 days. Predictions are that it will be the dominant variant of the virus here by mid-March and is likely to cause a substantial spike in U.S. infections. Tragically, this fast-spreading variant is appearing on the scene just as prevention measures are being relaxed. This is probably not the right time to participate in indoor activities with groups of strangers (if you have a choice!).
The U.S. Centers for Disease Control and Prevention (CDC) has recommended that people try to use more effective masks, similar to what health-care workers wear. This means tighter-fitting masks. It also means better materials that filter the inhaled air better.
You can make your mask fit tighter by tying a knot in each ear loop. This shortens the loops and pulls the mask tighter against the face, but tends to hurt the ears a bit.
Surgical masks filter air better than cloth masks and are widely available now. N-95 masks filter better than surgical masks, but may not be readily available. Another way to improve air filtering by your mask is to wear two masks at the same time. It’s not perfect, but it should work better than one.
All preventive measures should continue to be used. People who have been vaccinated can still get infected and spread the disease to others who have not been vaccinated. Everyone should continue to wear masks, avoid close contact with others, avoid spending time indoors with others, make sure occupied indoor spaces are well ventilated with fresh air, wash or sanitize hands frequently, etc. People exposed to infected people should still be quarantined. Infected people should continue to be isolated. Guards should continue to be tested frequently for coronavirus infection, screened for symptoms of disease upon reporting to work, and excluded from the facility if they test positive or show symptoms.
This month a study was reported on trials of four widely used anti-viral medicines to treat the pandemic coronavirus. There was no improvement in deaths among hospitalized patients with any of the medicines tried.
Two studies reported the effect of treatment with blood plasma from people who recovered from epidemic coronavirus infection. Plasma from recovered people has lots of antibodies to the virus and is called “high titer plasma.” One study showed that older people treated with plasma shortly after the onset of symptoms had milder illness than people who were not. Early treatment with high titer plasma seemed to work.
The other study, like others done before, showed no effect of plasma on outcomes for people who were already hospitalized with COVID-19 and pneumonia. Late treatment with high titer plasma did not work.
Debate about providing coronavirus vaccine to prisoners will continue as long as vaccine supply is not sufficient for all priority populations.
• Congregate Living: A few states have included prisons and jails with other congregate living human services institutions and group homes for the mentally ill, mentally and physically disabled, foster care, juvenile justice, alcohol and substance abuse, and homeless populations. These residential facilities are all higher risk for infection due to inability to stay safely apart and avoid indoor exposure to others. Prisons and jails are at higher risk for the same reasons and clearly belong in this priority category.
• People at risk for more severe infection due to age: Some states have begun to allow prisoners over 75 (or over 65) to receive the vaccine as people in the free world over 65 have been permitted to obtain the vaccine.
• People at risk for more severe infection due to chronic illness: Similarly, as free people under 65 with higher risk chronic illnesses have become eligible, so also have prisoners with similar conditions.
• Not until all free people have been vaccinated: Some politicians have asserted that incarcerated people should not be given vaccines until everyone else has been vaccinated. This is outrageous pandering to vengeful feelings of some people that prisoners should suffer in addition to being deprived of their freedom. This approach will assure that the pandemic is never controlled since it readily spreads into and back out of prisons.
The debate will end once sufficient supplies of vaccine become available and it is no longer necessary to prioritize who gets it. Emergency use authorization of the Johnson & Johnson vaccine is expected in late-February 2021. Substantially greater numbers of doses will then become available to priority populations.
Health Care in Prisons and Jails
The coronavirus pandemic has highlighted to the world the poor quality of health services in jails and prisons. The Lancet is the leading medical journal in the UK. A recent editorial discussed the widespread need for better health care for incarcerated people. The Lancet editorial board stated:
“Prison health systems remain a weak link in public health preparedness, racial and social justice, and human rights ... Humane and evidence-based prison health systems with community links will improve public health within and outside prison walls, both for COVID-19 and other health issues. Such an approach is key to the pursuit of a just and equitable society. As Nelson Mandela said, ‘A nation should not be judged by how it treats its highest citizens, but its lowest ones.’”
Michael Cohen was the medical director for the New York state juvenile justice system for 20 years and previously provided medical care for incarcerated adults at the New York City Rikers Island jail and at Greene CF in Coxsackie, New York. For 10 years, he participated in a support group for people with diabetes at Great Meadow CF in Comstock, New York. With the group, he co-authored the Prisoner Diabetes Handbook published by SouthernPoverty Law Center and distributed by Prison Legal News. Heal the sick. Raise the fallen. Free the prisoners.
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