Thanksgiving is next week. I love Thanksgiving. Food, football, and family. I’ll be spending much of the 4 day weekend in the hospital though I’ll still have a little time to see family. It is possible to safely see family, though in today’s COVID age, there is nothing that is risk free. The first step is decide whether you can accept a little risk. There are things we can do to mitigate risk. First off, if you’re sick, symptomatic, or had a known COVID exposure, stay home and don’t risk infecting your family. I really think many people have forgotten this over the past year. If you’re sick, get a COVID test and quarantine. Next, although it’s a little late to change this, get vaccinated and/or get your booster. If everyone is feeling well and everyone is vaccinated/boosted, the risk of getting COVID is greatly reduced (not zero). The larger the group, the larger your risk. I would consider opening windows or being outside though I can tell you I expect to be indoors with my family, my parents, and my brother’s family. Everyone is vaccinated and several have received boosters. My daughter is regularly tested at school. Doing an over-the-counter test beforehand may identify some asymptomatic people and prevent them for exposing others. It’s a potential layer of mitigation as long as you realize that the tests aren’t as good as PCR tests and even less sensitive for asymptomatic patients. There is obviously a huge desire to return to normal and I expect this to be a very normal holiday in many ways.
Covid cases are on the rise again throughout the country. Our 7-day average is almost 100,000 cases per day. We’re also continuing to lose over a thousand American lives a day to COVID. The 7-day average of new cases is also creeping up in Virginia and in Arlington County. At the emergency department level, we are seeing some of the same. We had more patients require Covid isolation this past week then in any week in the past month. Somewhat unique to my shift last evening was the number of patients who came in because they were already known to be COVID positive and having worsening symptoms. (I don’t think I’ve seen a COVID patient in weeks prior to last evening.) Typically, these patients will not be retested by us and therefore their impact to the data I track is reflected in our Covid isolation data but not reflected in the number of people we diagnose by PCR testing in the emergency department. For patients that we diagnosed, among our symptomatic patients this past week, we had the most patients test positive since the first week in October. We also had an increase in our positivity rate among symptomatic and asymptomatic patients. The increased numbers are not alarming by themself, but it certainly is a reminder that Covid is not gone and that we could see an increase in cases as many have predicted over the winter. The number of patients VHC has currently hospitalized has also increased from last week. If there is good news, is that most of what we’re seeing is milder disease. We are occasionally seeing people critically ill from COVID in the ER, but it’s nowhere near as common as during previous surges.
We continue to see a mix of vaccinated and unvaccinated patients test positive and come to the hospital. In my personal life, I am connected to many vaccinated people who have tested positive recently. I have been talking about waning immunity and the importance of boosters for several weeks now and I am very excited to see the progress being made in allowing everyone 18 and over to receive a booster shot 6 months after their second vaccine. The FDA has announced they’re expanding the emergency use authorization for the Pfizer and Moderna COVID vaccines, allowing all adults to get a booster shot. The CDC’s Advisory Panel met today and just hours ago voted 11-0 to recommend approval of boosters for everyone. It now goes to CDC director Walensky. Getting vaccinated adults a booster does not minimize the importance of getting the unvaccinated their first dose and ultimately getting everyone fully vaccinated. But getting vaccinated patients a booster will reduce the likelihood that they get COVID. It’s fantastic to see the number of elementary aged children who have gotten vaccinated already as well. More than 2.6 million 5-11 years (about 10% of the kids in that age group) have already received their first dose.
Helping us get to the other side of the pandemic is also potential treatments that are likely to get approved soon. Both Pfizer and Merck have submitted EUA requests to the FDA for medications to treat mild to moderate Covid. I gave the details of the Pfizer product recently but briefly, in a large study, the medication was shown to significantly reduce the need for hospitalization and the risk of death. Each of these products will come with a cost. Pfizer’s treatment is expected to cost about $529, while Merck’s will be about $700 per course. Add on that many of these patients will be seen in emergency departments and urgent cares, which will ultimately add on to the patient’s cost. While I think the development of these medications is fantastic and I am really optimistic about the impact they will make in saving lives, we are all better off by increasing vaccination rates. The vaccine is free and shown to be effective. Getting vaccinated cannot only save your life, it will likely save you money.
One of the questions being studied is the impact of the vaccine on viral shedding and transmission of disease. Published this week in Open Forum Infectious Diseases was a study that looked at that. Scientists looked at 880 COVID cases among UCLA healthcare workers. 30% took place in patients who had at least one dose of vaccine. The researchers found that viral shedding was lowest among those who were fully vaccinated and suggest that vaccination could lead to lower transmission rates.
There is still a role for mask wearing, social distancing, and handwashing. Scientists published in this weeks British Medical Journal an analysis from 6 different studies that looked at mask wearing. The researchers found that mask wearing contributed to a 53% reduction in COVID-19 cases. Although I have started to eat indoors at some restaurants, I am still generally wearing a mask when I go to the store. It does not hurt me, and I figure it may keep me and others safe. By the way, physical distancing cuts the rate of transmission by about 25%.
There are a couple of interesting articles out of the CDC’s MMWR this week. First, a study compared ER and hospitalization rates among unvaccinated and vaccinated patients since Delta. Looking at data from Oregon and Washington, “unvaccinated persons with {COVID} were approximately twice as likely to receive ED care or to be hospitalized than were vaccinated persons with COVID.” This led the authors to recommend that we all follow the CDC recommendations for vaccination for everyone 5 and older, including boosters.
Another MMWR report looked at the risk of stillbirth among COVID positive mothers. There are multiple studies showing that pregnant women are at increased risk of severe COVID disease and that COVID is associated with an increased risk for adverse pregnancy outcomes and maternal and neonatal complications. Although stillbirth is very uncommon, it appears that pregnant women with COVID are about 1.9 times more likely to have a stillbirth than pregnant women without COVID. Vaccination before or during pregnancy remains a recommendation to reduce COVID related pregnancy complications and stillbirth.
As an emergency physician, I’ve taken care of countless patients who have overdosed or have substance abuse issues. The CDC reported this week that for the 12-month period ending in April, more than 100,000 Americans died of overdoses, up almost 30 percent from the 78,000 deaths in the prior year.” This is the most overdose deaths in any 12-month period in American history. In the ER, I’ve given Narcan, which can reverse an opioid overdose, and take an unconscious non-breathing patient and return them to normal. Also, as an emergency physician, I’ve prescribed Narcan to use as an antidote for patients who are prescribed opioids or use drugs illegally. There’s been excellent research over the last decade linking opioid prescribing to substance abuse and while I always try to help patients control their pain, I (and most emergency physicians) have become very conscientious of what I prescribe and how many tablets I prescribe. We also have better treatment options than methadone for opioid use disorder patients. If you or someone you love has opioid use disorder, I encourage you get help. There are a lot of resources available.
Have a wonderful Thanksgiving. I hope I don’t see you in the ER.
Science matters. Get vaccinated (or your booster). Wear a mask. We’re almost there.
Mike