Omicron, the required vaccination pass and the elections Omicron, the required vaccination pass and the elections

Will the pandemic and its latest avatar the omicron make the presidential election? It is certain that the hypothesis is not theoretical. The question is rather to know in what proportion. What has changed is the perception of the pandemic. Everything is linked, the French no longer buy "alternative" narratives, they know that it's a pandemic, that it has killed a lot of French people, that it's not over, that the exit will be by a long surveillance. Reality returns in this lull like a boomerang. They also understood very well that we need others, individually and as a nation. Personal protection (masks, but also all those used by medical personnel) must be produced and purchased before being used; isolation is very useful when you are positive but without assistance at the borders or inside it is a bad joke; drugs, vaccines, are goods that must be purchased mainly from abroad because our innovation-development couple has broken down. Finally, everyone knows deep down that we also need to shake ourselves up powerfully to face the challenges of the post-pandemic period; record absenteeism, whatever the cost, the medical consequences of the pandemic in families, are powerful factors of economic disorganization and cost. The State has borrowed massively, it must be repaid. These considerations are political and relate to the election and the economy.

EACH FRENCH FAMILY HAS A RELATIVE, A RELATIVE OR AN ACQUAINTANCE WHO HAS BEEN HOSPITALIZED OR HAS DIED FROM COVID-19

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At least 600,000 patients have been hospitalized for Covid 19 in France since the start of the pandemic. Officially, the number of Covid-19 deaths is 127,716 deaths, or 2 per thousand inhabitants. Each French person knows between 300 and 600 people and can even recognize 5000 faces, which is why most French people know a patient hospitalized for Covid-19. It is thus easy to understand that the ultra-minority deniers of the pandemic are howling in the desert. Most French people are tired of being taken for crap. Tired of being told that what they see is not true. Tired of individuals who are prominent in the media to make the audience come to tell the opposite of what we observed the day before or that we observe the next day. If a few people from the medical academic world have particularly abused these rhetorical devices, the palm undoubtedly goes to the specialists in the human sciences who have made the pandemic a very greasy dish that can be abused. But here they are, they don't know where their gallbladder is (thanks Claude Malhuret for the stylistic trait) but they have a definitive and certain opinion on hydroxychloroquine, remdesivir, the number of hospital beds in general, vaccines to messenger RNA, the transmission of a virus, masks and of course the philosophy of science etc, etc…

PANDEMIC MORTALITY IS UNDERESTIMATED IN OFFICIAL STATISTICS

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This is a major fact in some countries but there is also uncertainty and an underestimation in France (Figure N°1).

Figure N°1: A question whose answer has changed as the study of Covid-19 mortality has been based on evidence. Overall mortality is significantly underestimated worldwide.

On the one hand, data reporting is quite complex in France. Only hospital deaths are forwarded electronically. There are several difficulties with Covid-19 deaths at home, with assessments based on excess mortality. The latter turns out to underestimate Covid-19 mortality because of the drastic drop in mortality from other infectious diseases (Figure N°2).

Figure N°2: Drastic decrease in other infections during the pandemic. This is certain proof that the protective measures are very effective and could prevent deaths and hospitalizations outside of Covid-19 in the future. This evidence is to be meditated on to improve care. Vaccinating against the flu with an ineffective vaccine but not wearing a mask when treating is an aberration, Asians are surprised by our propensity for irresponsibility in this area of ​​public health. We will see if in the future coughing and spitting patients will wear a mask in closed places and in particular in the doctor's or nurse's waiting room.

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In short, there is still progress to be made in the real knowledge of mortality due to this pandemic and it is very likely today that this progress will lead to the discovery that we have involuntarily underestimated the deaths. This is also indicated by models such as the IHME (Figure 3).

Figure N°3: Cumulative Covid-19 deaths in France and their margin of error assessed in the IHME model.

COVID-19 IS AN EVOLVING PANDEMIC AND OUR IMMUNITY WALKS ON AT LEAST TWO LEGS: HUMORAL AND CELLULAR

It is important to take stock of what is happening on the pandemic front since the arrival of omicron. The question is whether the lower morbidity and mortality of omicron is due to characteristics of the virus or to the increase in vaccine immunity or to both. While the data from South Africa was very early and concerned a different population, the stability of the number of cases of patients on ventilators in the United Kingdom during the peak of omicron cases was a sure sign (Figure N°4) . Omicron leads to less Covid pneumonia, less respiratory distress and death. In passing, we note once again the mediocrity of the data communicated by the Ministry of Health in France. Without the severity criteria that are mechanical ventilation by respirator, multi-organ failure the prognostic meaning to be given to hospitalization is weak. And the sense of the number of non-hospitalized positive cases is even lower.

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Figure N°4: The omicron variant does not send patients to intensive care to be intubated and ventilated. The data from the United Kingdom is decisive.

Transmission and contamination are different from the disease with deep organ involvement

It is necessary to differentiate contaminations (measured by the number of positive cases), serious illnesses and deaths which are most often preceded by hospitalization (measured by hospital admissions and death certificates). Figure 5A shows the impact of SARS-CoV-2 variants on vaccine efficacy, separating reported efficacy in avoiding infection from reported efficacy in avoiding severe or symptomatic disease. It's simple, the variants gradually and partially escape surface immunosurveillance, mainly nasopharynx, but not the defense of deep tissues. This protection of vital organs by vaccine immunity remains, it is the lung whose Covid-19 pneumopathy leads to asphyxia and other organs which contribute to severe progressive forms. This is, let us remember, the initial purpose of vaccines. They were designed to protect against serious attacks. Figure 5B depicts the impact of the variants on two aspects of the immune response to the Spike protein: neutralizing antibodies (normalized to the expected peak response against the wild-type strain of SARS-CoV-2) and T cells. Projections are made for omicron based on the early evidence and analysis performed in this publication. While the percentage of antibodies effective against the virus decreases, ie the variants escape destruction by circulating antibodies, on the contrary the cellular immunity of the killer cells remains at a high level of protection. This is essential data in the analysis of morbidity and mortality. The two graphs aggregate data from several publications and vaccines/antibody tests to give a representative view of trends.

Figure N°5: the transmission without serious form is rather a reinforcement of the immunity of each one. This is what seems to happen with Omicron in immunized vaccinees. Among the unvaccinated, the decrease in mortality compared to Delta would be only 11%. It should therefore not be regretted that the vaccine is less effective against the transmission of Omicron infection and continue to encourage unvaccinated people who have not had Covid-19 to get vaccinated. It should be added that it is also possible to treat patients at risk with Paxlovid® or monoclaonal antibodies so as not to expose these people, especially if they are not vaccinated, to a risk of hospitalization.

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It is difficult today to know if the omicron variant is intrinsically less aggressive although more transmissible or if the accumulated immunity of the populations leads to a collapse of the serious forms, an expected event since this has been the objective of the vaccine from the start. . It's likely to be both. That is to say about 11 to 25% less morbidity and mortality compared to delta and an underestimated role of cellular vaccine immunity since the easiest assay is that of antibodies.

VACCINE CERTIFICATE REQUIRED: HALF THE WAY TO PREVENTION

"Die Intelligenz eines Individuums wird an der Menge an Unsicherheiten gemessen, die es aushalten kann."

Immanuel Kant

You have to be extremely presumptuous to claim to know what is going to happen. Some after having made a reputation for being wrong continue. It's a shame because medicine first uses caution and then because what you have to learn to control in a pandemic is uncertainty. We won't know that the pandemic is over until we see it. In this context, the vaccination pass is to be compared to the vaccination obligation.

The vaccination pass and transmission

The vaccination pass is an instrument of which everything and its opposite have been said. The Constitutional Council has just validated it.

The purpose of the vaccination pass is to avoid transmission by individuals who are carriers or likely to be carriers to individuals susceptible

Again in public health medicine nothing is black or white. Population medicine requires a solid understanding of numbers, arithmetic, percentages (the easiest data to manipulate since each % is a fraction), mathematical functions, statistics and probability. The vaccine does not 100% stop the contamination and the transmission that goes with it, but it significantly reduces it. The vaccinated are less contaminated, shorter positive and with lower viral loads. They protect themselves through vaccine immunity against serious forms and death. By reserving access to indoor activities without a mask for vaccinated people, transmission decreases, the risk of hospitalization collapses. Then we protect, by requiring the vaccination pass, the unvaccinated. With the health pass, they still had access to these places. They were the most likely to be contaminated and sick. In particular the non-vaccinated at risk who will thus go less to the hospital. Finally, the cured are taken into account since the number of vaccine injections is established at a full dose. Recall that those cured vaccinated with a full dose administered far enough away from the disease are the best protected people, the longest.

The behavioral consequence of the health pass is the reduction of vaccine hesitancy

This is typically an illustration of what a compromise choice can be: given the low risks of the vaccine, its benefits, my choice to go to closed places without a mask, I modify my initial choice and I make myself vaccinate. It is a consequence of the past. And this is what has been observed. This choice is much preferable to compulsory vaccination, which is favored by politicians and authoritarian regimes. It also illustrates how incentive policies balance risk taking and trust in our societies. And conversely, how authoritarian policies undermine this confidence. Finally, it avoids devoting the rare energy of police forces to time-consuming and inefficient control tasks. This is why it was clumsy to suggest, as the minister did, that the pass was a disguised vaccination obligation. It is a tool for reducing transmission, one of the consequences of which is to encourage people to get vaccinated. There are other negative externalities this time: the question of fraud and identity. For fraud it will decrease because, compared to the health pass, the only QR code is that of the vaccine. The question of identity is in theory very simple, but our phobia of transparent controls, while occult and permanent controls are in place in all our digital acts, means that there is no solution in France. So there will be identity cheats.

Knowing and reaching people at risk from 0 to 100 years old is the second half of prevention

Individuals at risk need a targeted device which has been lacking since the beginning. In April 2021 I had alerted on this issue. This second pillar is one of the blind spots of this pandemic: the most fragile. But first, it is worth returning to this concept. The complacent media with alternative and delusional narratives accredit the idea that it would have been enough to vaccinate "people at risk". It's a booby trap. Because the person at risk detector does not exist and there is a continuum of risk with many factors. Yes we have many factors of immune deficiency because we live a long time but also because we treat millions of people who have once fatal diseases that are now chronicized by treatments with a price to pay at the immune level. We also have "young people" weakened by obesity, a diet of >80% processed products, a sedentary lifestyle, etc. Some children are at risk of serious forms of Covid-19 or PIMS (around 364,000 according to HAS) . Finally, pregnant women are also people at risk because of their own risk factors and the immuno-tolerance associated with pregnancy. This point has been and still is greatly underestimated in public prevention actions. It is therefore totally illusory to advance such a theory which would consist in vaccinating only people at risk. This is just the umpteenth avatar of the antivax returned, those who “are not opposed to the vaccine but”… On the contrary, it is reasonable to get vaccinated if one has not been affected and is cured of the disease. And for those who have recovered from Covid-19, a full dose vaccine injection, remotely, is what protects the best and the longest. For children, vaccination must be offered on the basis of the child's own interests and in no way as a barrier. To do this, mobile public health teams are needed, the same ones that could have assisted in the isolation of positive people, the same ones that could have helped with the tests when it was difficult to find them or to do them for those isolated from the main healthcare system. But if the law created them, the government ignored it. We have no organized human means of projecting health policy towards those who cannot enter into prevention, whether it be isolation or vaccination and tomorrow outpatient treatment. In this regard, the fashionable phrase "move towards" is a bureaucratic slogan which is only an element of language.

INFECTION TREATMENTS

Antivirals and monoclonal antibodies are authorized in France.

Antivirals

Paxlovid® is available in outpatient medicine. Remdesivir (Véklury®) is available in France and has just been approved by the FDA for outpatient prescription.

Figure N°6: The efficacy of remdesivir has just been confirmed by a recent study which better targeted the patients likely to benefit from it.

Adoptive monoclonal antibody immunotherapy

Adoptive immunotherapy includes administration of monoclonal antibodies or adoptive transfer of lymphocyte-activated killer cells or cytotoxic T cells. According to the in vitro activity data available for the omicron variant, pharmaceutical specialties of monoclonal antibodies are authorized in France

The availability of all these treatments is a powerful means of reducing the serious forms of Covid-19. The combination of gradually improving vaccine immunity thanks to the booster and post-infectious immunity after recovery is extremely effective for the vast majority of us. Antivirals and monoclonal antibodies, if correctly prescribed, should prevent the non-immune from having a severe form either with omicron or with another variant.

WHAT IS THE VALUE OF THE SANITARY PASS IN REAL LIFE?

In this context, a note has been published on the website of the government's economic analysis council which is a study of the consequences of the health pass on the pandemic and the economy in France.

This study focuses primarily on the medical consequences of the pandemic (deaths and hospitalizations)

Is it a response to the CNIL which asked for “proof” from the government about the pass? An academic work aimed at laying the foundations for a protection strategy and a non-financial incentive tactic? To the credit of the authors, this study has the merit of existing. Proponents of science-driven public health policy are eagerly waiting for the numerous epidemiology and economics departments at state universities to embark on further assessments and submit them to a peer-reviewed journal. In the meantime, we can make a benchmark and note that this type of study is difficult, especially when they are not designed and started on a prospective basis. It is indeed a retrospective study based on observations and modelling. It is the bias of this type of study in all fields of epidemiology that it exposes itself to never being able to falsify the null hypothesis (it is the hypothesis that the health history has no effect on the two parameters studied, the medical consequences and the economic consequences). Then, the comparison with Germany and Italy raises an essential question, that of the confounding factors which could explain the differences observed without them having a causal link with the health history. To remove these uncertainties, we must wait for the result of the peer review process which analyzes the data studied and others as well as the model and its parameters. It is urgent to wait for this stage so that it is rather adventurous to make a study on which we can base ourselves (Figure N°7).

Figure 7: Daily deaths (top row) and hospital admissions (bottom row) per million (7-day moving average) in the actual deployment of the intervention (blue) and in the counterfactual scenario without intervention (red). In summary the blue line is the result observed with the pass and the red one that is modeled without the pass. The red shaded area is the 95% confidence interval. The daily death counterfactuals for France and Italy and the daily hospitalization counterfactuals for France are calculated using an age-stratified model. The other counterfactuals are not based on age-stratified models due to unavailable data. The black dotted vertical line is the date of the health pass announcement.

The vaccination pass is a crest line between the limited hospital resources and the counter-productive and impossible to apply vaccination obligation.

As has been well established in the literature, the issue of vaccination is intimately linked to the social contract. The unvaccinated do not represent a homogeneous target that would be accessible to a type of action. Many people who refuse to get vaccinated are simply afraid of vaccines. Authorities initially missed many opportunities to better explain how safe and important vaccines are. This does not diminish the irrefutable responsibility of those who lied, distorted information, scared people with documents like the film Hold-Up for example, and continue to instill doubt. In this case we can consider that it is the prodigious safety of messenger RNA vaccines which is one of the explanations for their activism. These vaccines are among the safest in the history of vaccinology and they exacerbate the attacks of those who feel that everything is slipping away from them. The authorities in France did not have a communication plan commensurate with the event and many professionals from the academic world cultivated the ambiguity without any expense.

We must continue to offer vaccination with communication tools that are a little more advanced and accurate than the leitmotif “all vaccinated, all protected”. We know that the agency that made it is at best very ill-informed. All vaccinated better protected, all vaccinated better immunized there is no shortage of real slogans that provide information as close as possible to scientific truth. It should be added that obliged or pissed off the French concerned who are not volunteers for the vaccine can react negatively. This is an additional difficulty that the country does not need. Then there are those who are not within the scope of the centralized, urban and well-organized healthcare system with a network of doctors and nurses. We cannot count on individual or associative initiatives for an issue of this size. And finally there are the militant, vociferous and violent antivax. Obligation deteriorates the social contract since it destroys freedom and responsibility. For example the necessary continuation of personal protections in a pandemic even if there is an effective vaccine. This obligation is out of reach for the police today in France. The vaccination pass is a transition towards the end of the epidemic. It could make it possible to conserve our resources (there are other complementary means such as personal protection, the TTIQ, medication, but it is one of them) and to maintain a social consensus, as shown by the opinion of the French.

The current context 10 weeks from the first round suggests a presidential election that would burst into the pandemic rather than the reverse. This can also be said of the showdown in Eastern Europe. There is no doubt that the current president is pulling the rug out of the pandemic as much as possible on other realities in order to trigger a blitzkrieg at his opportunity. It is not easy to unravel the threads of science tracking the virus on one side and national or international politics on the other. And we all know to be careful: when you mix science and politics you always get politics.