The CDC is very concerned about a fourth surge and are reporting that the daily number of new cases are up 10% compared to a week ago. Hospitalizations and deaths are continuing to climb around the country as well. I spoke with a colleague of mine who is the medical director of a busy Baltimore emergency department and she was also very concerned about a fourth surge. It would seem that volumes are up across Baltimore emergency departments, COVID admissions are up significantly, and hospitals are pretty full. Based on traffic and the amount of people traveling for spring break, I’m certainly concerned about what the next few weeks could look like. With that said, my local volume remains relatively stable. We continue to see COVID in all age groups, though our hospital COVID census is similar to last week. In the ED, the number of patients who tested positive for COVID and our percent positivity rate is pretty flat compared to last week. That’s relatively good news though I worry about a Baltimore surge and how it could impact the rest of the DMV. Despite COVID diagnoses being flat, we had our second straight week of increasing numbers of patients who require our “COVID isolation” status. Remember, these are patients who present with COVID like symptoms and also includes patients who are known to be positive, since those patients aren’t reflected in our new case diagnosis rate.
There’s lots of vaccine info below so keep reading.
I went into my local CVS this week and was very happy to see them offering vaccines. This is new in the last couple of weeks and speaks to the increased availability of the vaccine. I am definitely seeing more of my friends and even younger adults have access to the vaccine. Vaccine availability is continuing to increase. Both Maryland and Virginia are rapidly moving to Phase 3 allowing anyone 16 and older to get a vaccine. I’m optimistic that hospitals will start receiving it on a regular basis again as well. This may be our best way to help get the homeless and other vulnerable populations vaccinated and who otherwise would have trouble arranging for an appointment (we’re not there yet but I think it is one way we can continue to help down the line).
If we want to attack the virus among the group responsible for high spread rates, we need to find a way to get the college-age and young adults vaccinated. There will likely be plenty of opportunities for this age group over the next month. At my house, the biggest risk of bringing COVID into the house is probably from my teenage son. He attends school in a hybrid fashion and although cases have occurred at the school, my sense is that the kids do a really good job of wearing a mask and having some distance between each other. However, he is still a teenage boy, many months away from being old enough to get vaccinated, and probably does not always follow the rules when he hangs out with friends. Getting this group vaccinated will also be critical to reducing spread and helping us achieve herd immunity. Pfizer released unpublished data this week looking at the vaccine’s effectiveness in 12-15-year-olds. They enrolled 2200 teenagers into a trial where about half got the vaccine and the other half got placebo. Pfizer reports that there were 18 cases of COVID reported among the teenagers in the placebo group but none in the vaccinated group, showing 100% effectiveness rate. That is a great starting point though we will certainly want to see the full results and then will want to see a real-world study. One of the other endpoints that came out was what kind of antibody response these teens achieved with the vaccine. And more good news there. These kids achieved high levels of neutralizing antibodies, similar to the levels in older teens and young adulthood been vaccinated. Pfizer has also just begun looking at how well the vaccine works in children ages 6 months to 11 years old. And while that data may be months away, it does look like Pfizer will apply for an emergency use authorization of the vaccine for 12-15-year-olds in the next several weeks.
I frequently get questions about how many patient’s we’re diagnosing with COVID after they’ve been vaccinated. Looking at our ED, talking to friends and colleagues, and even looking around the hospital, the short answer is not many. But better than my own personal experience is what the research shows. The state of Minnesota reported this week that they’ve had 88 “breakthrough” cases among the >1.4M people who have received at least one COVID vaccine. That’s pretty reassuring. We also have two recently published studies looking at “real world” data for the Pfizer and Moderna vaccines. The CDC published results from a study called HEROES-RECOVER on March 29. The study looked at 4000 healthcare personnel and essential frontline workers in 8 locations across the United States with a mix of unvaccinated, single dose vaccination, and fully vaccinated patients. This is a great study because they not only had a control group, they also looked for asymptomatic infection. The participants were asked to complete weekly COVID testing for 13 consecutive weeks which included self-collected nasal swabs. They sent their samples to a central lab for PCR testing. The study found that among the unvaccinated group, there were 161 infections. After partial vaccination, more than 14 days from the first dose, 8 people were infected. After full vaccination, 14 days from the second dose, 3 people were infected. This equates to 90% effectiveness after full immunization and 80% effectiveness after partial immunization. That is very reassuring. I talked about rates per 100,000 population last week. If our current rate is 50 per 100,000, a 90% reduction would bring us to 5 per 100,000 which would allow life to go back to normal. The study is important because it shows real world data, including impact from the variants that are out there now, and also includes swabbing of asymptomatic people. There were some limitations to the study, and we do not know all the outcomes including who was hospitalized or not. However, the bottom line is that the vaccine works, and everyone should be looking to make their appointment to get vaccinated.
The other real-world study was released March 30 and came out of Israel using the Pfizer vaccine. This study is important because real world vaccination does not always replicate the exactness of a clinical study when it comes to vaccination scheduling and handling logistics. This study was an observational study that looked at all people vaccinated from December 20 through February 1st and they were matched to an unvaccinated control. This was a huge study with over 3 million people involved of which about 48% were vaccinated. While there were some bigger effectiveness differences between the first and second dose, fully vaccinated people had a 92% effectiveness rate for asymptomatic infection, 94% reduction in symptomatic infection, an 87% reduction in hospitalization, a 92% reduction in severe disease, and because there were no deaths among vaccinated people, a 100% reduction against the risk of death. These are phenomenal numbers that certainly support the original findings of the randomized trial and shows that vaccinations appear to decrease both asymptomatic and symptomatic COVID infections and the related morbidity and mortality.
Next up, Pfizer released info on their original study group. They report protection against symptomatic COVID is 91.3% at 6 months after the second dose and no COVID cases in the vaccine group of a South African trial suggestion protection from the B.1.351 variant. I’m also seeing just a little bit of info on the very first Phase 1 Moderna patients who are coming up on a year from their first vaccination and are now getting a booster shot. We really don’t know how long the vaccine will be good for and since I’m coming up on 3 months, I’m happy to hear it’s good for a while longer. I’m also looking forward to all of the info that will be coming up over the next 6 months.
Finally, on the vaccine front, I want everyone to keep in mind that we need to achieve global vaccination to really end the pandemic. While things in America are likely to be significantly improved by the time school starts this fall, we have an international economy and the world is pretty small, so we will be talking about COVID for a while and should be hoping that world leaders come together to help the countries that need it.
Monoclonal antibodies have also been in the news. Administration of them is typically an outpatient procedure arranged by the primary care physician for patients who meet certain criteria but do not require hospitalization, so I do not see a lot of patients getting these. But there are a couple large centers around the area that are doing them. What came out that caught my attention over the last couple of weeks is that the main one we have been using, Bamlanivimab, (affectionately known as our BAM protocol around the hospital) has been shown to be ineffective against the California and Arizona variants. These variants are not common in our area, but they have been identified. The infectious disease Society of America has since come out with the recommendation of a combination monoclonal antibody that we refer to as BAM-E for Bamlanivamab+ Etesevimab.
Science matters. Wear a mask. Practice physical distancing.