Yesterday marked the 1-year anniversary of the World Health Organization declaring Coronavirus a global pandemic. Since then, over 530,000 Americans have died. A few key definitions are worthy of review at this point. An epidemic is a sudden increase in cases in a particular area. When COVID started, it was an epidemic in Wuhan, China. We’ve also seen epidemics of SARS and other infections before. A pandemic is when the disease has spread across an entire country or the world. We’re still in a pandemic.Endemic is when a disease or infection is regularly found among a certain people or part of the world. While completely eradicating Coronavirus around the world is ideal, it’s unlikely to happen despite the vaccine. So public health officials are hoping we can reduce numbers from pandemic level, perhaps it will be epidemic in certain parts of the world where vaccine delivery is difficult, but ultimately get to very low levels of disease where we coexist with it (endemic).
Let’s turn to the volume at the hospital and the ER: The hospital census has a few less patients with Covid admitted currently than we did last Friday. That’s good news and parallels hospitalization numbers around the country. In the emergency department, we seem to have plateaued about a month ago in our decline in the number of patients that require Covid isolation and in the number of patients we diagnosed with Covid based on testing. We then had several successive weeks of increases in these metrics, which raised concerns. However, over this past week, we did see a slight decline in the numbers of patients who require Covid isolation. We also saw a flattening in the number of patients that we diagnosed with Covid. Even our percent positive rate is down to touch. With the amount of vaccination taking place among the nursing home patient population and the 65+ year old patients in the county, at some point, we expect to see a decline in ED visits and hospitalizations related to Covid. Attached is a picture from a Tweet I saw earlier in the week looking at daily case numbers, hospitalizations, and deaths in Indiana among those 70+ years old. There is a very clear relationship between increases in the percent of the population being vaccinated and all of these key metrics (new cases, hospitalizations, deaths in the same age group) starting to decline. As expected, you see a greater decline in the number of new cases and then a decline in the number of hospitalizations and ultimately a decline in deaths. It’s data like this that clearly show how impactful the vaccine can and will be and that there truly is light at the end of the tunnel.
There is a new potential treatment that has been recommended by the Infectious Disease Society of America and NIH that is being incorporated into treatment plans of our most critically ill patients. Tocilizumab is a recombinant humanized anti-interleukin (IL)-6 receptor monoclonal antibody approved by the Food and Drug Administration (FDA) primarily for rheumatologic disorders. Based on research published in early February, the medication is best for critically ill patients requiring ventilatory support and/or those who respiratory status is rapidly declining. This is definitely not a treatment for every hospitalized patient but may help prevent some of the sickest patients in the ICU from dying.
The biggest news this week is that the CDC announced guidelines for activities that vaccinated people can do without a mask. This is a huge step in helping people feel normal. It also continues to recognize that COVID is present, variants may continue to infect people, and that vaccination does not replace public health mitigation strategies completely yet. (A friend and colleague told me today that he recently had COVID despite being fully vaccinated) First, the recommendations start with being fully vaccinated defined as 2 weeks after your second Pfizer/Moderna dose or 2 weeks after your J&J vaccine (immunity a month earlier than with Moderna). Next, it depends on whether you’re with vaccinated or unvaccinated people. Sitting indoors without a mask with a small group of vaccinated friends who aren’t sick is fine. Visiting your healthy, low risk grandchildren without masks is also fine. The CDC still recommends masks when in public, in large groups, or when around people who would be high risk if they got COVID. My take is they think the vaccine greatly reduces your risk of getting or giving COVID (asymptomatic transmission in a vaccinated patient is likely very rare) but leaving some wiggle room to protect those who are unvaccinated AND high risk (age, past medical history, etc.) Finally, we have to consider the impact of the variant strains. Although cases have flattened, the percent of variants nationally has risen to >20%. We don’t fully know the impact of the variants on vaccinated patients and that’s why, for now, we need to continue to mask when we’re in risky environments.
There’s even more out of the CDC with their MMWR March 5th report showing that masks work. This analysis showed that states who issued mask mandates had a reduced number of cases and a reduction in death growth rates (picture flattening the curve or slope) within 20 days of implementation. And then when states loosened restrictions by allowing on-premises dining (not categorized by indoor versus outdoor), there were increased case rates 41-100 days after implementation and increases in death growth rate 61-100 days after implementation. The bottom line appears to be that mask mandates and restricting on-premise dining at restaurants can reduce case and death rates. Hopefully we’ll remember this for our next pandemic.
There was a studied published in JAMA online last week looking at the mortality of hospitalized patients between March and August of 2020. The good news is that our ability to care for critically ill COVID patients improved and we saw a marked reduction in mortality among hospitalized patients over time. In hospital mortality also correlated with age with only 1.4% of 18-29 years dying but increasing to 26.6% of those over 80 years old.
Vaccine production continues to ramp up and my take is that it’s getting easier for people who qualify to get appointments. By May, every adult should be able to get a vaccine. There are still a few people who are worried about allergic reactions, so let’s consider a big study out of Mass General Hospital (which is Harvard). Among 65,000 employees getting mRNA vaccines, only 16 (0.025%) had anaphylaxis and all recovered. 98% had no sign of acute allergic reaction. That’s pretty reassuring.
Science matters. Wear a mask. Practice physical distancing.