Home COVID-19 Friday Night Update from the ER in Arlington, VA: “Bivalent…COVID booster will...

Friday Night Update from the ER in Arlington, VA: “Bivalent…COVID booster will be available in the near future”; “As trigger laws about abortion go into effect in several states, I really worry about the situations my emergency physician colleagues will face”


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!

As trigger laws about abortion go into effect in several states, I really worry about the situations my emergency physician colleagues will face. If fertilization defines life, and you can only intervene when a mother’s life is at stake (and some of what I’m reading means imminently at stake), what happens when you diagnose a patient with an ectopic pregnancy (1% of all pregnancies) but the patient has normal vital signs and bleeding isn’t too bad? Do you wait for the patient to crash before you take them to surgery rather than intervening early? These are non-viable pregnancies, and some could have been treated medically, avoiding surgery for the patient, while they’re still stable. It’s going to be challenging and potentially impact the outcomes for some patients.

COVID remains stable. Numbers are constant. It remains a part of our daily work with numbers and rates similar to last week. By now, I hope everyone has bought a pulse ox at home ($25 on Amazon gets you a good one) so you can monitor your oxygen levels. Also, keep some rapid tests at home. The COVID patients I saw this week ranged from very mild to moderate symptoms. Fortunately, none were critically ill.

There’s a few interesting things that came out this week about COVID.

The virus has gotten more efficient over the time. Published in JAMA online, the “incubation period from infection to symptoms or first positive test” has decreased over time. “With the Alpha variant, the incubation period was about 5 days, which fell to 4.5 for Beta, 4.41 for Delta, and 3.42 for Omicron.” Those over 60 and kids have had longer averages. Interestingly enough, COVID has longer incubation periods than other upper respiratory tract infections, which typically average 1-3 days. This is the kind of data that drives the CDC recommendations about testing 5 days after exposure though wearing a mask for 10 days after exposure rather than quarantining.

About 40% of people hospitalized with COVID this spring were vaccinated +/- boostered. The virus has changed to make the vaccines less effective in preventing disease, but vaccines and boosters saved lives. In hospital mortality was initially 10% prior to vaccinations, but is now in the 3-4% range.

The CDC is also reporting an increase in hospitalizations among children <5 years old from spring into summer. This age group had about 20 hospitalizations a week in April and that climbed to 100 a week by July. Pfizer is reporting that their vaccine is 73% effective in protecting kids <5 during the omicron phase. As we go back to school, talk to your pediatrician about vaccination if your child is not vaccinated yet. I’ve been to some pre-season school events, and everyone seems to have mask fatigue.

One of the challenges of COVID has been understanding who actually has immunity. We have tests that can accurately measure immune responses for many infectious diseases (rubella, hepatitis, etc), and scientists are working on developing a test that will accurately measure COVID protection. A study published earlier this week presented a test that would detect neutralizing antibodies against COVID using just a finger stick for blood. While this still needs large scale testing and regulatory approval, it shows that COVID will continue to keep scientists busy, trying to develop technology that will help manage the virus.

Finally, on the COVID front, it appears that a new COVID booster will be available in the near future (hopefully mid-September for Pfizer and October for Moderna). This is a bivalent vaccine, meaning it’s developed to fight two different versions of COVID. Half of this vaccine will be the original vaccine while the other half will be designed to target the BA.4 and BA.5 variants. BA.5 is responsible for 90+% of new cases and is pretty different than the initial virus. For those who love diving into the weeds, Dr Eric Topol published a detailed article on this new version earlier this week. I retweeted it earlier today. Find me on twitter @drmikesilverman. The original bivalent vaccine was targeted against BA.1, tested in people, and appeared successful. However, as that was getting ready to roll out, BA.4 and BA.5 were taking over. The FDA wanted a vaccine that would target the new variants. As initially hoped with the mRNA technology, scientists were able to quickly pivot and change the vaccine to target the new versions. This is really amazing. But in order to get it the public, the new version has not been tested in people yet. It has been tested in mice and shown to be effective. There is precedent for this. The flu vaccine is quadrivalent and is tested in mice each year. Dr Topol doesn’t seem concerned about the safety risk of bringing a vaccine to the public without human testing. We have enough experience with the mRNA technology to know it’s safe. We also had human testing with the BA.1 version. However, Dr Topol isn’t sure that the immune response will be as good in humans as it was in mice since COVID is very different from influenza A. There is some uncertainty about how our immune system will respond given our previous vaccines and illness history. However, there’s likely to be continued benefit. Dr Topol does point out that the booster rate in the US is about half of our peer countries, with only 32% of our population having received a booster, and aggressive messaging by the CDC about boosters needs to occur. He also is looking forward to the results of a large study that used a nasal vaccine and is optimistic that nasal vaccines will be beneficial.

Finally, as a [reminder], the funding for free vaccines is running out so this will likely be the last chance to get a government subsidized vaccine.

I still haven’t seen my first case of monkeypox but it’s on the radar. It’s in all 50 states, there are 12,000 cases in the US and 45,000 cases worldwide. There have also been 12 deaths reported worldwide, all outside of the US, and these are being investigated. The good news is that we still have testing capacity. Recall, that testing early in COVID was very limited and challenged containment. Also, there is plenty of medication available to treat it (though medication is experimental and is reserved for patients with specific clinical conditions).

Coronavirus is not done with us yet.

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



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