Friday Night Update From the ER in Arlington, VA: “I am in favor of kids going back to school…Masks should be worn by everyone >2 years old regardless of vaccination status”

Thanks as always to Dr. Mike Silverman (Chair, Department of Emergency medicine at Virginia Hospital Center) for his latest “Friday Night Update from the ER in Arlington, VA”; these are very helpful!

Friday Night Update from the ER in Arlington, VA

For the most part, I’ve been on a working staycation, so I’ve had some time to research and write. This might be a good opportunity to grab your favorite vacation cocktail before you read for a bit.

Cases continue to increase around the area. The week ending July 7th, we actually had 0 newly diagnosed COVID patients among our ER population for the entire week. Since then, we’ve seen a steady increase in the number of cases going from a handful a week to 20+ a week. At our highest peak over the past 18 months, we were 80-100 a week. The number of patients who arrive and require “covid isolation” has increased 50% compared to a few weeks ago. While we are not as overwhelmed with COVID as we have been previously, we’ve seen a full return of ER volume, including traumas, sepsis patients, heart attacks, etc…ER’s around the area are very crowded. The hospital is also quite full of our normal mix of patients. Our percent positive rate continues to increase and our COVID inpatient census has also grown over the last 6 weeks and has more than doubled since last Friday. (keep in mind that we have patients from Arlington County but also the entire surrounding DC metro area). In the comments I’ve put a link to the Virginia Department of Health website that allows you to see the 7-day averages of breakthrough cases and hospitalizations for vax vs unvax. You can also sort by region.

Nationally, the seven-day average of new cases is up over 26% from last week. Average daily deaths are up 18% since last week. We are all hopeful that the death rate will be lower with our current surge because of the large number of people who have been vaccinated. In mid-July during the recent surge in the UK, the 7-day average was about 47,000 new cases/day but only 80 deaths per day. Pre-vaccine, with other surges, the UK would have seen 1000 deaths a day with those kind of new case numbers. Decreased hospitalizations and deaths potentially make this surge different from previous surges in areas with high vaccination rates. There are two schools of thought on what will happen with the Delta variant. The first is that it will rapidly go through the US and burn itself out in the near future. We saw awful disease and spread in the UK and India with Delta and then it quickly disappeared. The other school of thought is that we will have continued spread through the fall with start of school and people spending more time inside. I suspect that as a country we’ll see numbers increase into the fall. We’re so much bigger than the UK and India, the US won’t burnout as quickly. I am hopeful that hospitals being overwhelmed in the South will improve over the next few weeks as the virus “burns out” and as masking usage and vaccination rates improve.

We finally have some data on the effectiveness of the J&J vaccine against the Delta variant. It’s interesting because a couple of weeks ago, a hospital in San Francisco started offering mRNA boosters to anyone who previously received the J&J vaccine. They were criticized as some scientists felt a booster should have been part of a study. With that said, there was no data so I understand the logic of wanting to make sure people were adequately protected. But now we have data based on a study of 480,000 healthcare workers in South Africa. The researchers are reporting that the one-shot J&J vaccine was 71% effective against hospitalization and up to 96% effective in preventing death from the virus. In fact, they’re saying the vaccine appears more effective against Delta than earlier strains and has good durability, lasting 8 months. These findings have led the scientists to conclude that no booster is needed at this time.

We also have another study looking at the efficacy of both Pfizer and Moderna. This study, conducted through Mayo, in pre-print form and not yet peer reviewed, highlighted a drop in efficacy of the Pfizer vaccine in July when the Delta variant predominated, much more so than Moderna dropped. With that said, both were very effective against hospitalization and death. The recent vaccine efficacy studies have had mixed results and I’m not sure we have a clear efficacy answer except to say that efficacy decreases over time and the vaccine is most likely not as effective at preventing COVID against Delta than the original virus. With that said, the vaccines remain very effective in reducing hospitalizations and deaths. We are, however, not as bullet proof as we were a few months ago and I think masks will be important this fall as we await info on boosters.

You’re probably not surprised to hear that there are doctor social media groups where we discuss cases and issues and ask for help. Over the last few weeks, it’s become common place for ER docs to go online and ask for help from tertiary care hospitals who can take their critically ill COVID patients, either because the local hospital(s) are out of ICU beds or because the patient needs potentially life-saving treatment like ECMO. As of this morning, the Dallas-Fort Worth area is out of pediatric beds. I even saw an ER doc having trouble transferring a patient with appendicitis, which is about as routine as it gets for the OR and post-operative care. Doctors are routinely asking for help from hospitals hundreds of miles away and even across multiple state lines. The DMV is not yet experiencing these types of surges that are taking place in other areas of the country, but it doesn’t mean it can’t happen. As a clinician, it’s incredibly sad to see docs begging for specialty care for their patients.

I’ve intentionally held off on writing about the start of school year since the dynamics around COVID can change so quickly. A few months ago, we weren’t so worried, and life was getting back to normal. And then the Delta variant arrived. With cases mounting, it’s clear we need to approach the school year differently than we anticipated in May. Here’s what we know: there are 50 million children <12 years old who are not yet able to get vaccinated. There’s about 25 million 12-17 year olds, yet only about 1/3 of the 12-15 years old’s have received one shot; that number increases to 45% when looking at 16-17 year old’s. Vaccination rates among teachers are good, estimated to be at least 80-90%, but most school systems aren’t mandating vaccine. The American Academy of Pediatrics has advocated for the return of students to in person learning. It’s better for learning and better for the mental health of our students. Other benefits of opening schools include social and emotional health, nutrition and safety, and opportunities for physical activities. They’re recommending a layered approach of mitigation strategies. First off, we protect our kids by being vaccinated. Get vaccinated! Also, if you’re a teacher or work in the school system or >12 years old, you should be vaccinated. The more people that are vaccinated, the safer everyone is. Masks should be worn by everyone >2 years old regardless of vaccination status. Schools must also look at testing, quarantining, ventilation, and cleaning and disinfecting. School districts should be in coordination with public health agencies for contact tracing.

Last summer, we were talking about at home testing. Cheap saliva tests were in development but I haven’t seen them really materialize like we expected. There are other at home kits that can give you a relatively timely answer. In a recent review I read, none of them were perfect but for $25, it may be worth having a few at home just in case. Ultimately, if your child (or you) are sick with fever, cough, malaise etc…they should stay home and get tested. The goal is really to keep students and staff as safe as possible. Inevitably, there will be positive cases, exposures, and the risks of spreading disease despite using all available mitigation strategies. Returning kids to school is not a risk-free situation and needs to be balanced with the risk to an individual against the benefit of the many. The Delta variant is infecting more kids but it’s unknown if Delta is causing more severe disease. Fortunately, most kids still have mild illness. However, children with underlying medical conditions including obesity, diabetes, lung disease, and seizures are still at higher risk and I have no doubt many parents are struggling with the decision to return their kids for in-person learning. Additionally, studies suggest that 10-13% of kids have one lingering symptom five weeks after diagnosis. In a recent study out of the Lancet Child and Adolescent Health, it seems like about 5% of kids have symptoms longer than 8 weeks. Long COVID is now defined as 12+ weeks of symptoms. I am in favor of kids going back to school. My son is vaccinated, and he’ll wear a mask though he doesn’t want to. He learns better in school and needs to be with him friends. I also heard enough horror studies from teacher friends this summer, some of which are not even appropriate for repeating here. It will not be easy, and I hope that PTA’s work with their schools to consider things like outdoor lunch space to reduce risk of spread when kids would otherwise be packed inside without masks. Like I started this discussion, COVID can change quickly so we will all have to flexible and adapt to the local situation.

There was a recent MMWR publication looking at Kentucky residents who had COVID in 2020 and then had it a second time in 2021. The researchers looked at the likelihood of getting it a second time comparing vaccinated to unvaccinated people and found that you had 2.34 times the odds of being reinfected if unvaccinated compared to fully vaccinated people. This study reinforces the CDC recommendation that all eligible people be offered the vaccine, even if you’ve had COVID previously.
Booster shots are coming. For starters, it appears it will be the 3% of the population who are immunocompromised either by underlying disease or because of medications they take (transplant and cancer patients). This subgroup of the population has been shown to not produce a good immune response to the first two doses of the vaccine and make up a large proportion of the breakthrough cases that result in hospitalization. This move is clearly the first step for booster shots and I suspect there will be more. We’re waiting to hear about boosters for waning efficacy over time that enhances the durability/duration of the vaccine. As healthcare workers are now 8 months out from our series of shots, I hope this will be addressed soon.

I wrote recently about the OBGYN specialty societies who strongly endorses the safety and importance of pregnant women receiving the COVID vaccine. Complications from COVID can be worse in pregnant women, though many vaccine hesitant people are concerned about the risk of miscarriage or harm to the baby being induced by the vaccine. This week, the CDC released a statement based on new analysis of 2500 pregnant women who received the vaccine while <20 weeks pregnant. As an ER doc, I’ve evaluated countless women for potential complications of early pregnancy. About 1% of pregnancies are ectopic (outside the uterus) and these can be life threatening. Most first trimester women who come to the ER are there for bleeding and concerned about miscarriage. About a third of women have first trimester bleeding, making it very common. About half of them will go on to have a miscarriage. While sometimes I can review the labs and ultrasound and provide guidance to the patient on what side of the coin they’re likely to come out on, ultimately its usually outside of anyone’s control. So, when looking at the impact of the vaccine, we need to compare the miscarriage rate of vaccinated patients to the baseline rate. Miscarriage rates among pregnant women who received the vaccine <20 weeks pregnant was 13%, or within the normal range. This analysis and recommendation is great as rates of vaccination among pregnant women are low, yet pregnant women are at higher risk for severe complications from COVID.

One image is a case rate heat map of the US over July 2021. Red is bad. The other image was released via Twitter by Baton Rouge General Hospital and shows the numbers of hospitalized patients by vaccination status. The area is about 40% fully vaccinated though vaccinated patients only make up 10% of the hospitalizations, 5% of the ICU patients, and 5% of the patients on vents.

Science matters. Get vaccinated. Wear a mask when you’re supposed to. We’re almost there.

Mike