Thanks as always to Dr. Mike Silverman, Chair of the Department of Emergency Medicine at the Virginia Hospital Center in Arlington, for these superb updates!
I do not have the words to describe my feelings about the Tulsa man who targeted his surgeon in Tulsa earlier this week because he was upset with his continued back pain 13 days after surgery. He killed 4 people, including a patient, an office worker, and another doctor, in addition to his surgeon. Certainly, it’s critical to look at the existing gun laws though this case. Although there are a lot of people with undiagnosed psychiatric disease who would never hurt themselves or others, but like many other mass shootings, this shooter probably had underlying psychiatric pathology that was not identified and/or treated, as part of his root cause. Certainly, America can do better.
ER volumes remain very high. Our May numbers finished 24% above our volume last May. That’s great for your investment portfolio but really challenging to manage when it comes to ER growth. Typically, we’ll have a month of super high volumes in the winter, whereas summer volumes tend to be a touch below average. It’s unclear to many of us why volumes are so high. While COVID account for some of the bump, it’s actually only a fraction of the overall volume increase. In theory, there’s not bent up demand for emergency care like there might be for colonoscopies and mammograms, yet across the country, ER volumes are soaring. May was actually our busiest month ever.
Our percent positivity and COVID numbers continue to increase in the ER. We’re at 6 week highs for percent positivity and case numbers for our symptomatic, asymptomatic, and total cases. These are not winter-like Omicron level surge numbers but there’s plenty of COVID around. In fact, the community testing rates are higher than the hospital testing rates.
Whereas last summer felt like a return to normal, it seems like most people are just living their normal lives now. However, Hopkins data shows that the country’s seven-day average of COVID cases is six times higher than it was last year. The 7 day new case average was almost 120,000 as of last Saturday. A year ago, it was about 18,000. However, the 7 day death average currently is 470, which is a decrease from 637 on the same day last year.
Paxlovid has been in the news a lot this week. There are a small amount of patients who have a rebound effect and ultimately requiring longer quarantine due to being contagious. On the other hand, the potential to reduce the need for hospitalization is very important. Tamiflu is an antiviral that has been around for some time that we use to treat influenza. Because of side effects, the drug has generally found its niche among high risk patients with the flu—extremes of age (peds and geriatric), pregnant, immunocompromised, and/or you require hospitalization. I had a couple of friends this week text me and ask me whether they should start Paxlovid for their COVID. I suspect Paxlovid will also find its true niche and now we have some real world data out of Israel to help determine that. Although the study hasn’t been peer reviewed yet, let’s look at the data. The study included over 100,000 patients during the Omicron surge earlier this year. Among patients 65+, only 14 of 2500 patients who received Paxlovid required hospitalization. For this age group, there were benefits to taking the medication whether you had prior immunity (from previous illness or immunization), however there was more benefit if you had no prior immunity. In the non Paxlovid group, about 3 times more patients required hospitalization—762 out of 40315. However, in the 40-64 year old age group, there was no statistically significant benefit to taking Paxlovid regardless of whether you had prior immunity or not. There was an 81% risk reduction in mortality for those 65 and older who took Paxlovid. There was no significant mortality benefit in the younger age group, as mortality risk was very low. I’m sure there will be other studies that help us determine the patient populations who will benefit the most from this treatment option.
Additional data from the Omicron wave shows that those 65 and older had a higher death rate than during the Delta wave last year. In fact, as many 65+ died during 4 months from COVID as was seen during 6 months of the Delta wave. This is despite strong vaccination rates. Death rates from COVID are much higher for those unvaccinated 65+, compared to those vaccinated. And the death rates drop even more with boosters. Yet, about 40% of our elderly population still don’t have a booster, let alone a second booster. For this high risk population, boosters and Paxlovid can make a difference.
OBGYNs have recommended vaccination for their pregnant patients since the vaccination came out. In a recent study, we have data looking at the benefits to the newborn baby when the mother gets vaccinated. During the Omicron phase, women who got a second or third dose of vaccine during pregnancy had a “33% lower risk of a positive test at age 4 months than infants born to unvaccinated mothers.” This was more benefit seen for those pregnant patients who received a booster during pregnancy than their second dose. There are other studies that show that vaccination during pregnancy helps protect newborns from serious illness and risk of hospitalization. Ultimately, it appears that newborns can receive passive protection against COVID through maternal vaccination during pregnancy.
Finally, things still look on track for vaccine approval later this month for those under 5. I know we’ve been close before but the data certainly looks better this time so I’m pretty optimistic.
Coronavirus is not done with us yet.
Science matters. Get vaccinated (or your booster). Keep a mask handy.
Mike
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