Home Coronavirus Friday Night Update from the ER in Arlington, VA: “Trying to wrap...

Friday Night Update from the ER in Arlington, VA: “Trying to wrap our heads around Omicron,” Even as “Delta is still 99% of the sequenced positives” in the US

"The Coronavirus is not done with us yet"

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Thanks as always to Dr. Mike Silverman, Chair of the Department of Emergency medicine at Virginia Hospital Center, for these helpful updates!

This is the longest update I’ve written in while. Prepare for a second drink or read it in two parts (or just skip it). There’s a lot going on this week and I’m also doing some catch up of key articles I didn’t have time to discuss over the last couple of weeks. I’m hoping to answer a lot of the questions I’ve received recently.

What’s crazy to me is that Delta has been around for about 6 months and we’re seeing some great research get published already. Yet, we’re also clearly trying to wrap our heads around Omicron. The virus is moving fast and the scientists are doing an amazing job of rapidly providing info to help us understand the pandemic, to protect ourselves, and to allow healthcare workers the best options when caring for patients.

Like you, my family has had our close encounters with COVID. We’re all vaccinated but we’re out and about and my teenage son is a teenage boy living his life. He got sick a couple of months ago, missed school, was COVID negative, and got better. My wife was sick recently. Although she didn’t have any known exposures, she quarantined like she had COVID until her test came back negative. That leads us to last weekend. I took my son out of state for a soccer tournament. I should have known something was up when he only ate half of his McDonalds hash brown (no judgement please) on the drive up. He got through the first game and then didn’t want to eat lunch. That was weird but he had a little injury and we chalked up the loss of appetite to pain. However, he’d had a potential exposure a week before (the dates made it seem like he was out of the window, but I thought it made sense to test). His only symptom at this point was being tired after a game and not eating. We had a few hours before the next game, so we went driving around the area to find a pharmacy. It literally took going to 3 pharmacies to find a COVID test. I did the test using the back of my truck as my lab. The tests are relatively straight forward but even being a doctor with a lot of lab experience, it still took some concentration. He tested negative. So, he played the next game. Just very tired afterward.

We drove home and then he got a high fever at bedtime. At this point, I’m thankful I’m boosted and was wondering about my own exposure if he ended up having COVID. And how much that would screw up my work if I got sick. So, we did another rapid test the next morning and skipped day 2 of the tournament. Fortunately, the second test was also negative, but since the rapid tests aren’t as sensitive as PCR, we found a place with same day PCR testing. That also came back negative. He missed school Monday but he’s now back to normal. I’ve said a few times that we need to test if we have symptoms. Getting tests at the pharmacy can be challenging (we hit 2 CVS and finally found it at Walgreens). The UK is sending 7 OTC tests to every household in Britain for free. At the very least, almost 2 years into the pandemic, the US still needs to significantly improve our ability to test. It shouldn’t take going to 3 pharmacies to find a kit.

Keep in mind that Omicron isn’t really here yet. What’s going on throughout the US is an increase in Delta cases, likely in response to Thanksgiving travel. In my ER, we see a very clear 6-week trend of increasing COVID cases being diagnosed in the emergency department. We had about 20% more patients who met our symptomatic criteria for testing last week and saw an increase in our percent positivity rate increase to 18% for these patients from a 6-week baseline of 11%. The end result is double the number of positive tests among this subgroup of patients than we have seen the last couple of weeks. We also track utilization of our COVID isolation order set. This allows us to account for patients who have already been diagnosed with COVID and come to the emergency department. Over the past week, we had a 40% increase in the number of patients who required COVID isolation compared to previous weeks. Fortunately, the number of patients who required admission was only up a little bit and therefore our hospital census on the inpatient side has remained relatively stable and on the lower side.

I had a couple opportunities to see vaccination data for our local area. My chief medical officer put together a graph that included Northern Virginia counties and broke down vaccination rate by age. The numbers were really fantastic, and likely accounts for the continued low numbers of patients with COVID who require hospitalization at VHC compared to other areas of the country. I also saw data this week looking at Arlington County. Parents have really done a great job of getting the 5-11-year-old their first dose. About half of this age group in Arlington County have received their first dose. We have phenomenal rates for those greater than 65. Our least vaccinated age group is the 25 to 34-year-olds. This is a challenging demographic as they are typically young, healthy, and do not spend a lot of time worrying about health care visits. However, this group does remain an opportunity to increase vaccination rates in our region.

I do want to give a shout out to VHC Pediatrics. They provide a medical home for children in Arlington, VA that are uninsured or underinsured. Their team of providers and clinical staff pulled together to create vaccine clinics for their patients. To date, they have vaccinated 1600 children—1000 over 12 years old and 600 kids in the 5-11 y.o. group. Way to go.

I first wrote about Omicron 2 weeks ago and said I thought we’d have more info in 2-3 weeks. The data is coming in and while it may not be as clean as we need to have a definitive understanding of this variant, we have a better idea of what to expect. Omicron is spreading fast throughout South Africa and is the dominant variant. Although cases in the US are increasing, Delta is still 99% of the sequenced positives. Here’s what we think we know.

• Omicron appears to be much more transmissible than Delta. Case numbers are exploding in South Africa and the percent positivity rate is very high. We’re learn more about spread as times goes on.
• There is now lab research looking at live samples of Omicron virus with blood samples of people who have had 2 doses of Pfizer and counting the neutralizing antibodies. There are studies out of South Africa, Germany, and Sweden and Pfizer has also released their own data. Whereas Delta had a fivefold reduction in neutralizing antibody response compared to the original virus, Omicron has a 25-40 fold reduction in neutralizing antibodies. This is pretty significant though not as bad as some scientists worried about. This means we’re more likely to see an increase in breakthrough cases. It also means that a booster should offer us more protection since it increases our antibody levels. Pfizer released a statement this week that the booster increased antibody levels 25-fold and will provide enough protection against the Omicron variant (not peer reviewed data).
• An important caveat is that our immune response isn’t based solely on neutralizing antibodies. Our body also responds with B cells and T cells which appear to be less impacted than the antibody response.
• Reinfection rates are higher with Omicron than Delta. Up to 3 times higher for people who have had COVID previously; therefore, natural immunity does not appear to be doing a good job in preventing infection.
• Although indications are that Omicron is not more severe than Delta, the unvaccinated are being hospitalized at a much higher rate than the vaccinated in South Africa. The severity of Omicron is still being reviewed since hospitalizations tend to lag 3-4 weeks behind case surges but the current numbers of hospitalizations not surging is encouraging. Although not a severity indicator, patients are reporting less loss of taste and smell.
• South Africa is also seeing a greater impact to kids <5 years old. They appear to be going to the hospital more frequently than compared to Delta.
• The vaccine appears to offer protection in at least the form of milder disease. Boosters improve your immune response and are believed to be protective against Omicron and future variants.

In the setting of increasing Delta cases and what we think we know about Omicron, I can tell you that I’m worried we’ll see a significant number of new cases in the coming weeks to months. Even if Omicron is milder, there will still be a percentage of patients who require hospitalization and ICU beds and if we have large numbers of new cases, hospitals will continue to be full or exceed capacity. This is in addition to the spread we’re currently seeing with Delta. As we finish up our second year of the pandemic, I have to let you know that healthcare workers are very tired, and we (healthcare as a whole) continue to face staffing/nursing shortages. Get vaccinated. Get your booster. Get your flu shot.

Let’s talk about vaccines and kids. The EUA for Pfizer boosters for the 16 and 17 year olds has been approved. Great news for that age group and I’ll be signing my kid up. However, Pfizer has said publicly they are currently not pursuing research on boosters for kids <16. They have requested an EUA for boosters for 16 and 17 year olds. The American Academy of Pediatrics has no position at this time on boosters for kids at this time. The CDC data shows that those under 18 have the lowest rate of breakthrough cases whereas adults >65 have the highest breakthrough death rates. The rate of hospitalization for vaccinated 12-17 year olds was 0.3 per 100,000 compared to 3.8 per 100,000 for adults.

Before you ask, here’s what I can find on vaccines for kids <5. Studies are ongoing with two age groups—6 months to 2 years and 2-5 years. Approval is expected early during the first quarter of 2022, but data has not been submitted yet. Last Friday, the Pfizer CEO announced that he expects data to be available for kids <5 by the end of the year.

We’re getting into Flu season and I hope you got your flu shot. My wife had an appointment for hers a couple of weeks ago and the pharmacy had run out (she has since gotten one). From the start of the second quarter of 2020 through the end of the third quarter of 2021, I think the hospital lab (which includes the ER patient population) had less than 10+ flu test. In a typical flu season, we will have about 500 to 1100 positive tests at the hospital in a quarter. Although flu season really has not hit yet, we have seen about 30 flu cases over the past month. That’s more than we have had the last 6 quarters combined. Our percent positivity rate on the flu test is low and not nearly as high as we would see during a typical flu surge, however it is much higher than what we have seen since the COVID pandemic began. There have already been a couple of flu outbreaks in the Arlington area, primarily among young adults.

Earlier this week, the “FDA authorized the AstraZeneca {long acting monocloncal antibody combination treatment} called Evusheld for adults and children 12 and older whose immune systems haven’t responded adequately to COVID-19 vaccines (patients with cancer, organ transplants, or those on immunosuprroessive drugs) or have a history of severe allergic reactions to the shots.” It’s estimated that the medication will be appropriate for 2-3% of our population and is intended as a “preventative measure” or pre-exposure—it is not to be used for post exposure treatment or if a patient is diagnosed with COVID. In a company study, there was a 77% reduction in infection over a 6-month period compared to patients who received placebo. Potentially, this medication will allow a lot of people to get out and about rather than self-isolating for safety.

First up, pro-Trump red states are showing a 52% increase in mortality rate compared to blue states. This was CNN analysis of Hopkins data highlighting the correlation between low vaccination rates and mortality by individual states. NPR did an even deeper dive looking at mortality by counties after the vaccination was widely available. Analysis included work with an independent healthcare analyst. They studied 3000 counties across America and found that citizens of counties where Trump received 60+% of votes were 2.78 times more likely to die than counties where Biden received the majority of votes. The counties that were in the top 10% of Trump majorities had death rates 6 times higher than Biden’s top 10% of counties. Four in 10 Republicans are unvaccinated compared to 1 in 10 Democrats. Vaccination matters.

We’ve also seen a lot of data showing that COVID has a disproportional impact on people of color. From an article in Modern Healthcare earlier this week, “In 2020, COVID reduced overall U.S. life expectancy by 1.5 years, according to the National Center for Health Statistics. Black and Hispanic people fared the worst, losing more than three years in life expectancy. White people saw a 1.2-year drop.” I certainly saw the impact of COVID on our Hispanic community, many of whom were in multi-generational living environments.

There was an interesting study out of The Lancet Infectious Diseases that looked at mass indoor gatherings and the risk of COVID. The researchers in France looked at thousands of people who volunteered to participate in the study of a controlled indoor mass gathering that included having a negative rapid antigen test and wearing a mask. There were 4451 attendees and the actual number of COVID cases 7 days after the event was compared to 2257 non-attendees. 3917 (88%) of the attendees and 1947 (87%) on non-attendees came for the 7 day PCR test follow up. 8 of the 3917 attendees tested positive (0.0020) and 3 of the 1947 non-attendees tested positive (0.0015) making the observed incidence roughly the same. Mask compliance was estimated to be 91% which is likely a lot higher than most rock concerts or pro basketball games, but nonetheless probably speaks to the effectiveness of masks and if there is good compliance, we can better understand our risks as we return to large, indoor events.

Anti-COVID medications are being developed by Merck and Pfizer. Both had shown very good preliminary data. Merck released additional data recently. In their 1400 person study, there was a 30% reduction in the risk hospitalization and death compared to placebo. This is meaningful, but Merck initially thought the study would show a 50% reduction. The FDA advisory panel voted 13-10 to approve this product, though expressed concerns that it could cause birth defects if used during pregnancy. Merck’s product is a 5 day treatment which is similar to Pfizer’s though Pfizer is reporting close to a 90% efficacy rate.

From JAMA online, there was an article out of Israel looking at the risk of getting COVID with and without a booster during the delta variant. Researchers looked at over 300,000 patients 40 and over who started the follow up period confirmed PCR negative. Over a 2 month study period, 6.6% of 2 dose patients tested positive compared to 1.8% of those who got a booster. This represents the booster giving an 86% reduction in the likelihood of testing positive.

Also out of Israel, published in the NEJM this week, was a study looking at over 800,000 people aged 50 and over (mean age 68.5) and the risk of death between those who just had the 2 dose “full” Pfizer vaccination series compared to those who also received a booster. Those who received a booster at least 5 months after their second dose of Pfizer had a 90% reduction in their mortality risk. While the risk of death is generally low among vaccinated patients to begin with, I do think the booster is worth it for an additional 90% reduction in the chance of dying.

The attached picture is the 5 year old son of my nursing dyad partner (outpatient AVP Taryn), who has been my ED leadership partner for the better part of the last 9+ years. He got his first dose of vaccine earlier this week.

The Coronavirus is not done with us yet.

Science matters. Get vaccinated (or your booster). Wear a mask.

Mike

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