I actually took care of a patient who required admission for COVID this week. It’s the first one I have had in a few weeks. Although we still have COVID patients admitted to the hospital, the numbers are less and less each week. My patient came in with a positive COVID test from an outside facility that had been done earlier in the week and she was having increasing shortness of breath. As I talked to some colleagues in my group, getting diagnosed at another facility and then ending up in the ER is not an unusual occurrence. I think it speaks to the availability of testing which is great but also clearly speaks to the presence of COVID in the community. My patient had excellent insurance, access to the vaccine, but chose not to get vaccinated. The success that we are having around the country is directly related to the success of the vaccine. The CDC reported this week in MMWR that there were just over 10,000 breakthrough cases of COVID in patients among the 101 million persons in the United States that have been fully vaccinated against COVID by April 30, 2021. Based on preliminary data, about 25% of these breakthrough infections are asymptomatic, 10% of the patients were known to be hospitalized, and approximately 2%, (160)) patients died. The median age of patients who died was 82 years old, and approximately 18% of those who died were asymptomatic or died from a cause unrelated to COVID. During the last week of April alone, the country reported approximately 355,000 new cases of COVID. For the sake of making math easy, if you were to estimate 25 new cases per 100,000 population each week, you would expect upwards of over 250,000 new cases in a population of 100 million, in any given week. The fact that there was only 10,000 reported breakthrough cases over 4 months among 100 million people is simply amazing. The CDC recognizes that the number of breakthrough cases is likely underreported given that such a high percentage of people are asymptomatic or those with mild symptoms may not have been tested. This data may end up being the only data the CDC collects on all breakthrough cases as beginning May 1, the CDC transitioned “from monitoring all reported COVID-19 vaccine breakthrough infections to investigating only those among patients who are hospitalized or die.”
I think the vaccine is amazing and is working to getting us back to normal. However, we continue to find some rare imperfections with it. Making the news this week was also an ongoing investigation whether there is a relationship between the mRNA COVID-19 vaccine (Pfizer and Moderna) and heart inflammation–myocarditis and/or pericarditis, particularly in adolescents and young adults. There have been a number of cases reported, predominantly in male adolescents and young adults, 16 years of age or older, and typically within several days after the second dose of the vaccine. Most cases who presented for medical care responded well to medications and rest and had improvement in symptoms. The CDC is investigating whether there is a causal relationship between the vaccine and the symptoms or whether it is just an incidental finding/coincidence that you would see in any large subgroup of the population. It is important to note that these cases are very rare in number relative to the amount of vaccine administered. We can generally make the diagnosis in the emergency department by blood tests and an EKG. The CDC is still recommending the vaccine for all patients 12 and older and I am still planning on getting my son his second dose when it is due in 2 weeks.
I have talked about booster shots a couple of times but of the end of the day, we do not know exactly if and when we will need them. I think it is great that Pfizer and Moderna are working on boosters that may address potential variants. There are a couple recent studies this week suggesting that there are memory cells in the immune system that will remember and be able to respond to Covid far longer than 12 months. There was a study in Nature magazine that show that antibodies decline after people recover from the infection but they seem to plateau and last at least a year. At this point, I think we have to be patient and flexible and watch the science play out. Research is taking place looking at the persistence of immunity levels from the initial vaccine participants as well as looking at the best course for a booster.
Let’s take a second and zoom and on the hospital ER data. My data goes back to the week ending April 22, 2020. This was shortly after we had transitioned testing from the state and reference labs to the hospital and had started using our rapid test for emergency department patients. When we look at our symptomatic patient population (loosely defined as fevers, cough, chest pain, shortness of breath etc.), our percent positive rate has been as high as 50%. It is currently at an all-time low of under 6%. Most of the COVID patients we’re caring for, are more likely coming in like the patient I had this week, with a known diagnosis. We are also at the absolute lowest number of cases and lowest positivity rate among all comers to the emergency department that we have seen since I started keeping data. The other data point that I have kept since the week ending March 5,2020, at the very beginning of COVID, was the disposition of patients who required our COVID isolation protocol. This data was critically important in the beginning because we did not have real-time testing data and it allowed us to get a sense of how many patients each week potentially had COVID and how many were being admitted versus discharged etc. Looking at this data over the last 15 months you can clearly see the surges that took place in the spring 2020 and then this previous winter. The numbers for the past 4 or 5 weeks are significantly below even the post surge lull but not as low as one might expect given the general decline in new COVID cases. That is because we continue to see many patients each day who come in with fever, cough, shortness of breath, etc. Many of these patients have pneumonia or sepsis related to a bacterial source and require admission and treatment. But the numbers of admissions and the percent of these patients being admitted is much lower than earlier this year and allows us to take steps towards getting emergency department operations back to a pre-pandemic system.
Science matters. Get vaccinated. Wear a mask when you’re supposed to. We’re almost there.