I was talking to a physician friend who works at a local university. He was telling me about the massive uptick in cases they had seen on campus, even with vaccinated students. Interestingly enough, our ER data is pretty similar to last week in total numbers of cases. Our percent positive rate is up a bit but the total number of new diagnoses is about the same as last week. Even though cases and hospitalizations are going up nationally, our hospital census is actually a few less than last week. South Africa first reported the Omicron variant on November 24th. While we don’t know exactly where it originated, it does appear that the variant was in the Netherlands as early as November 19th. And it looks like it was around even earlier in November as scientists in S.Africa reported seeing irregularities in test results, which is what prompted the further genetic sequencing.
The first omicron variant in the US was found in California earlier this week. Multiple states are reporting cases, with some people testing positive 7-10 days ago. There were three cases reported in Baltimore today. While some cases have been found in people who were recently in S. Africa, other patients had no travel history. Many of these patients are also vaccinated. None of this should not surprise anyone, nor should it change the precautions that you been taking for the last 6 months. It is still too early to know all of the details around transmission, how sick this variant makes you, and how much protection we have from the vaccine and/or booster. We are learning from other countries and expect to know more over the next couple weeks. South Africa saw a very rapid rise in their number of new confirmed cases, going from about 4400 on Tuesday to 8500 on Wednesday. The positivity rate on Wednesday was 16.5% up from just 1% in early November. South Africa is a population of about 60 million people and has a much lower vaccination rate compared to America. Although this variant contains more than 30 mutations in the genetic sequence, the PCR tests can still reliably detect the virus. These are the tests that we’re using in the hospital and the test that takes about 1 to 2 days to result if you are having it done as an outpatient. The home tests (and many rapid tests at doctor’s offices) are an antigen test, which is not as reliable as the PCR test. It appears that at least some of the antigen test can detect this variant. More info to come in the next week or two.
One question I get asked frequently is what percent of a particular variant are we seeing in the hospital? I cannot answer that question specifically. We are testing for COVID. The state health department collects a sampling of positive swabs from labs and they send these for DNA genetic sequencing. On the national level, through the CDC, this allows for data to be reported, such as 98% of all new cases are the delta variant. Although I suspect that all of the patient’s that we’re seeing in the emergency department that test positive for Covid have the delta variant currently, there is no real way for me to know that. South Africa is reporting that 74% of their genetic sequencing in November was the omicron variant. This will likely continue to increase. CBC director Dr. Walensky said earlier this week that the CDC had been sequencing about 8000 samples per week (at times I definitely didn’t think they were sequencing enough samples). But they are increasing that to 80,000 samples per week, which represents about 1 in every 7 PCR positive cases. Several of the people that have been diagnosed with the omicron variant were selected because of their recent travel history so it’s not necessarily a random sampling.
I also get asked a lot about what I do to stay safe, as well as what you can do to say safe, if the omicron variant surges in the US. On the hospital side, we continue to remain vigilant and protecting ourselves with PPE. We are in masks all the time and generally wearing gloves with patients. Of course, we’re always either washing our hands, or using alcohol based gel, before and after any patient encounter. For patients that are higher risk, we expand our PPE with N95 masks, goggles, and a protective plastic gown. We are essentially all vaccinated and most of the people I work with have received their booster. I feel pretty safe at work.
Funny enough, I had a patient with vomiting and diarrhea recently. Vomiting and diarrhea is pretty routine in the emergency department. I was in my mask and gloves and really did not have a lot of contact with this patient. However, I became very anxious when I reviewed the chart the next day, that he was diagnosed with norovirus. As you may know, norovirus is a horrendous, highly contagious GI illness that causes very significant vomiting and diarrhea, as well as dehydration. I have had it at least once that I know of, and maybe twice, in the last 20 years as a practicing physician, and I was way more nervous about getting norovirus for the next 24-hours than I was about getting Covid from my shift. I was very happy when my 48-hour window of potential illness from norovirus passed.
So, what can you do to stay safe? I know I sound like a broken record, but the obvious answer is to get vaccinated if you are not vaccinated yet. There is still a significant percentage of adult Americans who are not vaccinated. If you are unvaccinated, this puts you at risk for getting Covid and having a worse outcome than if you were vaccinated. It also puts the people you are in contact with at risk of getting Covid. And the more Covid spreads, the more likely we are to experience more mutations in the future.
Now, let’s talk boosters. Again. We’ve been talking boosters for a couple of months and finally the CDC has recommended boosters for everyone 18 and over who is 6 months past their second dose of mRNA or 2 months after J&J. Boosters are critical for everyone who is eligible as immunity wanes over time (which makes you more susceptible to becoming sick with COVID). The booster really supercharges your immune response, and gives you antibody levels that are even higher than after your 2nd dose. The CDC has made boosters available for all because of the risk of omicron. The science supports getting the booster. My wife and daughter have gotten their boosters recently. My son is <18 and about 6 months from his second dose. I anticipate the guidelines will include giving boosters to the 12-18 group soon. I have not seen any data but I’ve read that studies are in progress. The scientists believe that those <18 have a stronger immune response than adults and it’s hypothesized that their antibody levels will remain high longer than 6 months. I suspect we’ll have an answer in the next couple of months. Earlier this week Pfizer announced that they are seeking approval for the 16 and 17 year olds to receive a booster. I would anticipate that the 12-15 year olds won’t be far behind as the data rolls in.
It is possible that there will be an omicron specific vaccine in the future. It’s too early to tell if it’s necessary yet and it likely will take 100-180 days to bring it to market. It is too risky to wait for a “maybe” vaccine that won’t be available for 3-6 months versus getting your booster now.
Besides getting a booster, it still makes sense to wear a mask when you’re in crowded, indoor areas with people you don’t know. Getting together with asymptomatic, vaccinated friends or family is relatively safe. The risk increases when you’re with people you don’t know who may not be vaccinated.
I know it’s winter out and soon I’ll be talking about hypothermia and exposure risk but there was an interesting study published this week on how heat impacts emergency department visits. As a department chair, I’m regularly trying to understand the volume surges that we experience so we can have appropriate staffing. There are some trends that we believe to be true but it’s nice when the research confirms it. Reported in the British Medical Journal, researchers concluded after analyzing “the associations between heat and” ED “visits among more than 74 million adults in more than 2,900 U.S. counties in the warm months (May to September) from 2010 to 2019.” The study revealed that “days of extreme heat (average of 93.9 degrees Fahrenheit) were associated with a 7.8% higher risk of” ED “visits for any cause, compared to days with the lowest temperatures during the warm months.
”Science matters. Get vaccinated (or your booster). Wear a mask. We’re almost there.