There is a colossal supply and demand mismatch when it comes to the vaccine. My understanding as of earlier this week was that Virginia had over 300,000 dose requests a week and had only 105,000 doses to allocate. The state has tremendous capacity to administer vaccine–just look at the capacity that both VHC and INOVA have. But with no vaccines given to the hospitals, we can’t reach our maximum distribution effort at this point. I do expect this to be rectified over the next few weeks but the sooner we get people vaccinated, the sooner lives are saved. Both VHC and INOVA had to cancel vaccination appointments. This is because the state is controlling vaccine distribution and administration through local health departments and no longer supplying vaccine to the hospitals. Hopefully, the state will have high capacity vaccination centers up and running in the near future.
The good news about the vaccine comes on the efficacy side. We have seen a decline in the number of our vaccinated staff who test positive. We do have staff get exposed and we’ve had some test positive after the first round of vaccine, but I’m not aware of anyone testing positive 10 days or longer after the second dose (which is when full immunity is expected).
Earlier this week, VDH confirmed the first case of the UK variant in the state. This variant has up to a 70% increased transmission rate and may cause more severe disease (still being reviewed). Certainly, public health experts are concerned that it will lead to another surge in March. The South African variant was found in South Carolina earlier this week. Two people in different parts of the state who had no travel history. This variant is clearly in the US. The big concern is that the vaccine may not be as effective against it. Every delay in controlling the virus spread leads to the potential of more variants. Viruses mutate as they reproduce so reducing spread (reproduction) decreases the chances of additional mutations. This is a real concern.
There is some good news on the COVID volume front. The number of patients that we have in the hospital is down another 10% from last week. Our overall, hospital positivity rate is up a touch compared to last week but much lower than a few weeks. In the Emergency department, our COVID isolation numbers are down 10% or so as well. There are couple other things to note. We did have a little increase in the number of symptomatic patients who tested positive compared to last week. The total number is still in our pre-Thanksgiving range and much better than December and earlier in January, but it was the first uptick in this patient group in a few weeks. The percent positive rate among symptomatic patients is also up a touch and is not as low as it was in the pre-Thanksgiving. However when we look at all of our testing across the emergency department, our percent positive rate is down for the third week in a row and is in the pre-Thanksgiving range, and the actual number of COVID patients that we diagnosed is almost half of what it was a month ago. This is also similar to the pre-Thanksgiving range.
I had a couple interesting things occur during my shifts this week. First, I had several patients who tested positive before Christmas and although never requiring hospitalization or even a trip to the ER, become so symptomatic that they came to the emergency department. I was a little surprised since we do not typically see people get that much worse a month after their diagnosis. One of these patients was very sick and required high levels of oxygen and admission. The others were less sick but coming to the emergency department and ultimately getting follow-up with a pulmonologist was appropriate. As I spoke to one of the pulmonologists about a patient, he remarked that they were commonly seeing patients a month out from their diagnosis who are still short of breath. This is just another example of how different this disease is from the typical winter flu. The other thing of note is just how many patients I continue to see who test positive who tell me they are quarantining well. When I talk to patients, I typically ask them how the quarantine is going, if they have any known exposures to COVID positive patients, and I usually talk about their work situation if appropriate, as that also lets me assess their risk. I continue to see people who tell me they quarantine very strictly but then go on to add that they did take a trip to go see their grandchildren or other family or friend. On further conversation, it is not unusual to find that the patient’s children and grandchildren may have traveled to something like a soccer tournament out-of-state which is not a low risk activity. After that, it is usually not long before they tell me their family member tested positive for COVID but it was a couple days after their visit. One of the problems with COVID is that someone can be contagious a solid 2 days before they are symptomatic. Therefore, making plans with family who are asymptomatic is not necessarily safe. Finally, it’s still not unusual to have critically ill patients come to the ER, get diagnosed with COVID pneumonia, require admission to the ICU, and we expect them to die because of the severity of the disease we see in the ER. COVID is still causing critical illness and death.
There has been a lot of talk this week in the news about wearing multiple masks to increase your protection. Now that masks are in good supply, it is certainly a worthwhile conversation. This conversation is in large part triggered by the increased transmission rate of the new variants (UK, South Africa, and Brazil) while also looking for ways to reduce transmission in general. I think the first question comes down to what your exposure risk is? If I was traveling on an airplane or mass transit, I would definitely wear an N95. But I can also tell you that I do not wear an N95 (or any mask) when I am outside walking my dog because I do not get close to any people. Most of our day-to-day risk is obviously in between those 2 bookends. If you and the people you are with, are wearing a high-quality surgical mask, you are likely to be well protected if your duration of contact is not long. An N95 allows you to have long-term close proximity contact much safer. N95’s fit much better and are tight around the face and don’t have gaps like other masks. At the hospital, we undergo “fit testing” to make sure we wear it correctly and have full protection (many people have shaved off their beards and mustaches a year ago to achieve proper fit). If you’re not wearing an N95 or similar mask, wearing two masks does enhance the fit of the first layer, increases your protection, and likely provides additional cover over more of your face. Inherently, double masking makes sense and offers enhanced protection. We typically wear surgical mask over our N95’s at work to protect the N95. When we are in high risk environments, we know our surgical masks becomes contaminated and it is cheaper to replace the surgical mask than it is to replace an N95. At work, I don’t really think of the surgical mask as adding a ton of coverage over my N95. I do think of it as giving my N95 more life and keeping me from touching a dirty mask and contaminating myself. If it offers additional protection, then great. I don’t go to a lot of crowded places and therefore feel pretty safe in a surgical mask. However, it probably makes sense to add a good cloth mask over your surgical mask, particularly in crowded places, to enhance safety. Dr. Fauci and the CDC are recommending double masking. I think if you can find some KN95’s, about $1/mask in bulk at Costco, there is additional benefit in wearing them. We still need to do everything we can to reduce the risk of transmission and get this virus under control.
I have been asked about schools reopening for the better part of 6 months now. At the risk of opening up a can of worms, here’s my take. It is always easy to look back with hindsight and see where we could have done things differently. When the pandemic started last year, I was completely in favor of closing schools to keep her kids and teachers safe and reduce transmission. I was not surprised when most schools choose not to reopen in the fall and thought that was a good decision. We were expecting a second surge, there was no good data to suggest that returning to school was safe, and there was no vaccination in the immediate future. One of the hot topics last summer was about cheap, rapid, saliva-based testing that could be done daily to assess whether people were safe to go to school or work. It seemed on the edge of a breakthrough and then hasn’t materialized. Testing was also a bit of a mess (and arguably still is). Although I believe that opening schools needs to be made at the local level based on public health parameters, there are a variety of factors that we have learned that make opening schools more realistic now than 6 months ago. First, we have data that suggest that there is not a dramatic increase in community transmission of COVID between teachers, kids, and their parents when schools are open. That is actually great news. Secondly, many of our teachers are already vaccinated and many more have plans to get vaccinated in the near future. Keeping the teachers and the school support staff safe is critical. COVID is overwhelmingly a minor cold for most kids and they also tend to have lower viral loads, so having teachers safe with vaccination is a huge step. Finally, there does appear to be the financial support and the lessons that come with time about how to space out students, create hybrid learning environments, and keep everyone safe. There was a very good article in JAMA online this week that summarized the different research studies and emphasized the importance of masking, physical distancing, improving ventilation, and being able to do contact tracing. Other countries that opened or kept schools open throughout the pandemic, often closed their restaurants and bars, which are larger factors of transmission. No one wants to completely shut down again but there may be choices that need to be made to keep overall transmission at an appropriately low rate. We are still above the target positivity rate of 5%. The CDC is recommending that schools should be the last shutdown and the first to reopen whereas bars and restaurants are the reverse of that. These are tough societal choices politicians must deal with that I hope are guided by public health recommendations. School systems also must consider where we expect the pandemic to be over the rest of the school semester. Although things clearly look better now compared to 2 weeks ago, our numbers are not at the low levels that we saw over the summer and we’re expecting another surge in March because of the UK variant that may cause more significant disease. And so, while I am in favor of trying to get schools reopened, it has to be done strategically, following best practice guidelines to insure student, staff, and community safety. And I do hope that schools allow an option for all virtual students who may be immunocompromised or have family members at higher risk.
Science matters. Wear a mask. Practice physical distancing.