With COVID numbers declining, you may be wondering what’s going on in the ER and the hospital. First off, for the middle of flu season, we are not seeing any flu. No cases in the past month and only one case this season. We’re also not seeing RSV, a common virus that causes respiratory symptoms, particularly in kids. This is great. I suspect the reason is multifactorial—increased flu vaccinations last fall, masking, distancing, hand hygiene, and less social interaction. I also suspect that healthcare workers will be in masks for a long time and that many people will start to wear masks routinely during the flu season. ER visits have been down around the country since the pandemic started. People are using telemedicine and their PCPs for minor illness. So what’s coming to the ER are pretty sick patients covering all the typical sick things that we see—stroke, altered mental status, sepsis, trauma, heart issues, issues related to kidney disease, substance abuse and mental health, etc…There are a few things that are really noticeable when looking at our current patients compared to pre-pandemic. First, there’s a large decline in pediatric patients. Kids are not getting sick at school or injured on the playground or in sports at the same frequency. Next, our admission rate (the percent of patients we see each day that require further treatment in the hospital) is up by 40-50%. Our baseline rate is about 20%. Now we’re generally in the 28-30% range. Though our patient volume is down, the number of patients that require admission each month is fairly consistent with before the pandemic. The number of ambulance arrivals is also fairly close. Finally, prior to the pandemic, about 10-15% of our patients were tourists. Afterall, all, every middle school in America basically does a field trip to DC and stays in Arlington. We also used to get a lot of people who were visiting Arlington National Cemetery. I love the tourist patient population. But I can’t remember the last tourist I saw. I hope tourism resumes in DC soon. The hospital side is equally busy. The ICU and hospitalist teams have very high patient numbers. Outpatient surgeries continue. The hospital parking lot is full again.
The COVID numbers are telling a great story. We are past the second surge. This past surge really started towards the middle of November and peaked around January 7th. We then had a couple of weeks of steady numbers before a decline started. The last two weeks have had the lowest number of new cases and lowest percent positive rate since September. The number of patients that require “COVID isolation” status in the ER have dropped to their lowest levels since October and are about 35% of the January peak. These patients are still generally pretty sick and we continue to see about a 45% admit rate from this group.
While public health experts continue to recommend mitigation strategies such as masks and distancing to reduce transmission, obviously most people just want the vaccine to be more available. I continue to see my friends struggle to get themselves or their parents vaccinated. Demand far exceeds supply. There is some optimism that this will be corrected over the next month or two. First, Pfizer and Moderna will be able to increase production from about a million shots a day to over 3 million a day (distributed to the US Government) by late March. Johnson and Johnson has applied to the World Health Organization for emergency use authorization for its vaccine, and is scheduled with the FDA for a hearing, so it’s possible they will be shipping vaccine over the next month or so as well. While it does not look like J&J has a lot of dosages prepared to ship immediately, they expect to up production to 30 million by April and have 100 million by June. Recall, that this is a single dose vaccine that was not as effective as Pfizer’s or Moderna’s but certainly meets the standards by the FDA and will help get all adults vaccinated quicker.
As we get to the second quarter of 2021, the NY Times estimates that America will have about 4 million doses a day to distribute. That’s four times what we have now. I’ve already seen really successful playbooks for large scale vaccination centers, and I hope the government (Feds, state, local) is working on a plan to put the infrastructure in place to scale up vaccination centers.
As we shoot to reach herd immunity by summer, we have a couple of challenges. First, there’s about 15% of the population who say they absolutely won’t get the vaccine. That’s similar to other “mandatory” vaccine rates. There’s another 20% of the population who say they may not get vaccinated. That potentially puts the total of Americans not getting vaccinated at 35% which exceeds the threshold for herd immunity to occur. About half the military have refused the vaccine and about a third of healthcare workers as well. The CDC has to up their game when it comes to vaccine education. Finally, children are not getting vaccinated yet. Studies are underway but getting them vaccinated will be a critical component towards getting back to normal. Although right now, getting vaccinated means you could still be an asymptomatic carrier and you still need to wear a mask, there are huge benefits to the population by getting everyone vaccinated. Vaccinated patients are very unlikely to get COVID (95% less likely). With less patients getting COVID, we’ll see decreased transmission which leads to even less COVID positive patients in the community. With less transmission, we’ll also slow the development of new variants/mutants that may increase infectivity or mortality. And if decreased transmission isn’t enough reason to get the vaccine, perhaps knowing that vaccinated patients have a greatly reduced chance of dying or even needing hospitalization. All of these things together are what will get us back to normal and I hope that each person understands that getting a vaccine is part of their individual responsibility towards mankind in getting us back to normal.
I read an interesting article this week on the infectivity of symptomatic versus asymptomatic patients. Keep in mind that you can transmit virus and infect close contacts 2 days before you’re symptomatic, but a lot of people don’t develop any symptoms. This was a well-controlled study out of Singapore where testing and contact tracing are well controlled. It turns out that asymptomatic patients infect only about ¼ of that total patients that symptomatic patients cause (likely related to lower viral load). I think it speaks to the importance of staying home when you’re sick as staying home keeps symptomatic people far away from others and masks provide the necessary protection for those less contagious, asymptomatic patients.
Finally, lots of people have turned to over the counter vitamins, such as zinc, Vitamin C, and Vitamin D, as treatment options for COVID. The online version of JAMA published two interesting articles recently. First, involved looking at the impact of Vitamin D on the length of stay of hospitalized patients with moderate to severe disease. Unfortunately, a single dose of Vitamin D did not reduce the length of stay compared to placebo in a statistically significant way. Vitamin D also did not impact mortality, admission to the ICU, or the need for mechanical ventilation. The second study looked at the impact of high dose zinc and Vitamin C, alone and together, on whether they reduced the duration of symptoms for out-patient COVID patients. Unfortunately, there was no statistically significant difference in the duration of symptoms among the patient groups. These studies need to be reproduced as that’s part of the scientific method, so as our infectious disease specialist wrote on my post months ago, it certainly won’t hurt you to take vitamins to boost your immune system and it may help. But at this point, you shouldn’t feel obligated to take them as at least in this research paper, they did not reduce the duration of symptoms.
Science matters. Wear a mask. Practice physical distancing.
PS The picture is Taryn, my VP of Outpatient Services, and me with some of the food delivered for the staff today from Nothing Bundt Cakes. We’re really appreciative of the organizations who continue to support the staff.