500,000 COVID deaths. We crossed that threshold earlier this week. It’s really unbelievable to me where we are compared to a year ago. In reviewing my calendar and emails, my first COVID meetings were 52 weeks ago today. We met with the county in the morning and then with our infection prevention team in the afternoon. My first email to my group specifically on COVID was the next day, on Saturday morning. We were starting travel screens and had outlined the appropriate work up patients would need to undergo before trying to obtain a COVID test. Until early April, testing was controlled by the County Health Department and very few patients qualified for a test. Now, we do about 400 rapid tests a week in the ER. My recollection is that by this time last year we had already seen American patients who had been evacuated from China come in to get evaluated for COVID. By March 5th last year, we had already implemented our “COVID isolation status” and had seen 20 patients over the week that required the isolation order.
Let’s turn to this week. I definitely saw COVID patients this week when I worked in the department but overall, they represented a small percentage of the patients that I saw. COVID numbers are generally low around the hospital. The hospital census has declined about 20% since I reported it a few weeks ago. COVID is infrequent enough in the emergency department that I stopped carrying my phone and keys in a plastic baggie to keep the Covid germs off of them. My keys are back in my pocket and my phone is out and about (though I do seriously scrub it down at the end of the shift). I may not have been the first person to put my phone and car keys into a baggy last spring though I am probably the last one to stop using the baggy to protect them. Our COVID testing volume was interesting. We had a bump in our positive cases among symptomatic patients for the first time in 3 weeks. Our percent positive rate in this subgroup of patients was also the highest it has been in a month. However, we had very few positive patients that underwent our general screening testing and our percent positive rate for this population was about 2% (these are typically patients who require a COVID screen for admission or transfer but otherwise don’t have any symptoms where we are considering COVID as a possible diagnosis. Our overall number of positive cases and percent positive rate for emergency department patients this past week was up a touch compared to the previous week but still below the numbers we saw in January. What’s interesting about the increase we saw in COVID patients this week is that the US and the world also saw a slight increase in new cases over the past week after weeks of steady decline. At the hospital level, I can attribute it to normal variability, but the ER may also be the canary in the coal mine for what could be spread attributable to the new, highly contagious variants.
A new variant identified by researchers in New York is increasing in frequency in both NY and throughout the northeast. It appears to be less responsive to the body’s natural immune system and to monoclonal antibody therapy. It may also be more resistant to the antibody response triggered by the vaccine. The new mutation represents about 13% of new cases in NY. There was also a new variant identified in California. This variant wasn’t found in September but now represents about half of the new cases in California. It appears to be more infectious due to the mutation allowing it to bind cells better. Additionally, it may also cause more severe disease as infected individuals have an increased risk of requiring higher oxygen for treatment. All of this is to say that despite having less COVID in the community and in the hospital over the last month, and having a vaccine, we are not done with COVID and still need to use the basic mitigation strategies of masking, distancing, and hand hygiene.
The CDC’s MMWR reported this week on COVID spread from an indoor gym during August. Among 81 attendees of a Chicago exercise facility’s indoor high-intensity classes, 55 people developed COVID. 40% of the people with COVID attended class on or after the day symptoms began (yes, they went to class sick). Most people were not consistent with mask use among the attendees, including 84% of people with COVID. This highlights that masks should be worn during indoor exercise, even when you’re more than 6 feet apart and that if you’re sick, you should quarantine, and not to go out with other people. Exercising outdoors with others does appear safer than exercising indoors.
Israel has done an amazing job of vaccinating its population. One recent study looked at over 600,000 vaccinated Israelis and found that only 21 of them contracted COVID that required hospitalization. That’s about 3.5 per 100,000 citizens. At that rate, COVID becomes a very manageable disease that we can live with as a society. For comparison, during a typical flu season, 150 out of 100,000 people are hospitalized. I have to agree with several articles I’ve read recently suggesting that we’ll never completely eliminate COVID and that we need to learn to control it so that we can live normal lives again.
The Johnson and Johnson vaccine cleared a big hurdle this week as an FDA review found it safe and effective. This was a key step towards getting emergency use authorization and ultimately vaccine into arms. An EUA is expected in the immediate future, (like this weekend). As a reminder, the J&J vaccine “had a 72 percent overall efficacy rate in the United States and 64 percent in South Africa, where a highly contagious variant emerged in the fall and is now driving most cases.” Additionally, the vaccine “showed 86 percent efficacy against severe forms of Covid-19 in the United States, and 82 percent against severe disease in South Africa.” While these numbers are not quite as good as the other vaccines, the vaccine appears very effective against the variants. And perhaps most importantly, the J&J vaccine has been shown to reduce severe illness, hospitalizations, and death as much as the Pfizer and Moderna vaccines. My recommendation is to take the first available vaccine you can get. There will likely be boosters down the road for all of the vaccines but getting a vaccine right now helps ensures everyone’s safety, including your own.
The hospital business continues. Even before COVID, one of the leading causes of in-hospital mortality is sepsis (infections). We have a team within the hospital that focuses on the quality aspects of sepsis. Our department spent a lot of times in the weeds of sepsis care this week with the goal of continuing to reduce in-hospital mortality. And finally, after more than 2 years in the making, we had our state survey to become a Level 2 Trauma Center this past Wednesday. We are awaiting official notification/certification from the state to come later this spring. Although we’ve always taken care of trauma patients, becoming a certified trauma center helps ensure that we provide the highest quality care to our community. I’ll write more about the trauma journey later this spring.
Science matters. Wear a mask. Practice physical distancing.
PS The picture is me from about midnight last Sunday night. I had worn my mask for 9 hours straight and you can definitely appreciate the tight fit caused by the rubber bands. The indentations in my scalp were even more pronounced once I removed my surgical cap.