Friday Night Update from the ER in Arlington, VA: “There’s certainly a lot of COVID going around the community.”; “I am definitely back in my N95 at work”

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

Friday Night Update from the ER in Arlington, VA

There’s certainly a lot of COVID going around the community. I’m sure you’re seeing it among your coworkers or your kid’s friends. We have seen an increase locally in the community, with 10-15% positivity rates. I’m sure this is true in other industries but there have been at least two medical conferences recently that have led to widespread transmission (one I heard about directly from a physician, the other I read about on twitter). I was at conferences last month and like kids in school, many doctors were happy to go without masks at these large gatherings. COVID wasn’t as bad when I was away last month, but I’d certainly wear a mask if I was going to a conference next week. The new Omicron subvariant BA.2.12 (you may have seen it referred to as Stealth Omicron) may be the most contagious yet. It is believed to be 25% more contagious and is now accounting for almost 50% of the new cases. And, unfortunately, it appears that it’s just different enough that people who got Omicron in January do not have immunity to this new variant.

It’s certainly hard to go backwards and put masks back on, but that’s one mitigation strategy that needs to be considered. Boosters still represent a great opportunity to keep people safe as well. Only about 50% of vaccinated adults (2 doses) are boosted so there’s a lot of opportunity there. If you’re exposed and not boosted, CDC recommends quarantining for 5 days. I’m pretty sure most people don’t follow that recommendation. Boosters were approved (Pfizer) this week for 5-11 year olds. The CDC recognized the growing evidence that two primary vaccinations plus a booster provide the best protection. So this booster should increase the protection for this group. Keep in mind, that only 30% of the 5-11 year old group received the initial vaccine series so that’s a lot of opportunity for vaccinations of this cohort of people. The CDC reported that during the Omicron phase, hospitalizations were twice as likely among unvaccinated 5-11 years than the vaccinated group. And here’s some additional good news, the risk of vaccine associated myocarditis is lower for the 5-11 year old than in the adolescent and young adult population. The rate reported for 5-11 year olds is 2.7 cases per million people compared to 48.1/million 12-15 year olds and 74.2 cases/million of 16-17 year old males.

We are expecting the FDA to meet in June to discuss vaccines for those less than 5.

Let’s take a close look at the ER. Our patient volumes are still super high. Some of this is due to COVID but certainly not all. Our volume is up 12% this month compared to April and about 10% above our pre-pandemic averages. Historically, ER volumes grow 1-2%/year, so 12% month to month is challenging. Definitely, some of the new volume is directly related to COVID cases. The number of patients we diagnosed with COVID who were classified as symptomatic went up 50% compared to last week. The percent positivity rate also increased from 16.4% to 22.4%. It’s the highest number of new cases in a week we’ve had since late January. Our general screening, or asymptomatic patients, also increased by about 50% and the percent positivity went from 3.6 to 6.1% (this is lower than the 7 day positivity rate for the county/state, keeping in mind that the state rate includes symptomatic patients). Overall, this past week in the ER, we had a 9.4% positivity rate. As far as totals go, it’s been since the first week of February that we’ve diagnosed this many people with COVID. And I am definitely back in my N95 at work. The number of patients who are currently hospitalized also continues to increase, but not at the same rate as the number of new cases. Patients requiring hospitalization are a mix of people who have respiratory symptoms and require oxygen (including patients who require ICU care) as well as people who are incidentally found to have covid but require hospitalization for other reasons.

So, this brings us to Monkeypox, which was not on my 2022 Bingo card. Monkeypox is related to smallpox. I don’t think I got a smallpox vaccination as a kid but I do think those a bit older than me might have, First identified in people in 1970 in the Democratic Republic of Congo, the virus had been relatively dormant for decades until it reemerged in Nigeria in 2017. Since there, there have been about 450 cases in Nigeria. Generally, this virus has been traced back to Central and Western Africa. However, in the past couple of weeks, there have been small clusters of monkeypox in the UK, Spain, Italy, and Portugal, and this week, a case was confirmed in Massachusetts, with a possible case in New York. The European cases did not have a link to Africa and the Massachusetts man had been in Canada. Symptoms develop 7-14 days after exposure and are usually similar to the flu—fevers, chills, fatigue, headache, etc but then swelling in the lymph nodes begins and then a widespread rash on the face and body, The official emails I received from medical boards said we should be concerned if we see a rash that looks like monkeypox. By the way, the rash may resemble chickenpox, measles, and syphilis. I see a lot of rashes and didn’t know exactly what monkeypox looked like, until I saw a picture of the rash. Like smallpox, it’s so different than the typical rashes we see in the ER, I’m pretty sure I’d identify it. Mortality has been as high as 10% in the past but over the last several years, it seems closer to 1%.

Coronavirus is not done with us yet.

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

Mike