July 1st holds a special place in the hearts of doctors. It’s the start of the academic year which means it’s historically the first day of internship and marks the day you advance from one year of residency to another, until you finally graduate on June 30th and become an attending physician on July 1st. We classify the residents by how many years they are out from medical school. Interns are PGY 1 for first Post Graduate Year, and second years are PGY 2, etc…June 30, 1997 was my last day of residency. While I don’t remember a lot of details of the shift, I definitely remember going out to a bar afterwards with other senior residents to celebrate the end of our training. Hard to believe I’m now a PGY 28.
We are down to a very small number of COVID patients in the hospital. At one point last weekend, we briefly had zero patients hospitalized with active COVID. That’s amazing. The emergency department is essentially back to business as usual though we are all still in masks and there is still a lot of COVID testing going on. After 2 weeks in a row of not having any positive tests among our symptomatic patient subgroup, we did see a couple of positive tests over the past week. Fortunately, our percent positive rate among the 400 or so tests that we did in the emergency department this past week continues to remain remarkably low.
I’ve worked a lot clinically (for me at least) the last two weeks. I’ve had a couple of patients who I thought were high risk for COVID but I don’t remember the last COVID patient I saw. I have seen plenty of other emergencies. The acuity (how sick people are) is very high. I’ve had heart attacks, many traumas, sepsis, strokes, plus all the general things that can hurt and could be bad but usually aren’t—headache, chest pain, abdominal pain. We saw a change in the acuity when COVID started as less sick patients (think of the times you went to an urgent care) sought other places to get care (telemedicine has become quite popular plus all the local urgent care centers). As our volume has returned to normal, we’re still seeing a decrease in the percent of our total patients with this lower acuity type of complaint. Yet, that missing volume has been backfilled with sicker people. As an administrator, I think it’s an interesting and perhaps unanticipated outcome from the pandemic. I think telemedicine is here to stay and will play a bigger role in healthcare going forward and COVID served as the catalyst for the growth.
Although things continue to look very favorable regarding COVID within the emergency department and around the hospital, I am concerned about the potential impact of the Delta variant in the US. Recently, there was a small outbreak of the Delta variant in Israel and half of the new cases were among vaccinated patients. This is not saying half of vaccinated patients got Delta. But it does appear that this more transmissible variant can break through the vaccine and lead to positive cases even among the vaccinated at a higher rate than the other variants.
This has led to the World Health Organization recommending the use of masks when indoors even among the vaccinated population. The CDC has not taken this approach. It is important to consider the differences in the opinions. The US has a much higher vaccination rate than most of the rest of the world. With many things COVID, it is important to consider your risk on many levels. First, do you have any past medical history putting you at higher risk of hospitalization or death or death from COVID, or do you live with anyone who is at higher risk of a bad outcome if they have COVID, and/or do you have kids in the house who are not able to get vaccinated. Secondly, what is the vaccination rate in your local area. We have seen much higher hospitalization rates and states for the COVID vaccination rate is low. Keeping in mind that state vaccination rates range from under 40% to over 70%, suggest that there is likely large variability in regions as well. Finally, and this is somewhat correlated with vaccination rates, is what is the new case rate per week per 100,000 population. We have seen this decrease significantly over the last several months but if your local county rate is higher than 10 per 100,000, that puts you in a higher risk area. If you are healthy, vaccinated, and in an area that is well vaccinated, and your area has low new case rates, you are likely still safe walking into the grocery store without a mask. But when I consider that a third to half of the people in the grocery store are not vaccinated and no one is wearing a mask, I am concerned that the Delta variant will lead to an increase in cases. Unfortunately, I just do not think the pandemic is over yet.
As an aside, about two weeks ago, there was an outbreak in a Florida County IT office. Two people died and several were hospitalized. The only person in the office who didn’t get COVID was vaccinated. Vaccines definitely work.
There is a lot of good news from the vaccine literature. A new study published in Nature found the mRNA vaccines “set off a persistent immune reaction in the body that may protect against the coronavirus for years.” This was based on researchers taking lymph nodes of 14 recruits from five different points after their first dose and finding “the memory cells that recognize the coronavirus had not declined” 15 weeks later. “The results suggest that a vast majority of vaccinated people we be protected over the long-term.” There are also early results from a British vaccine study that showed mixing AstraZeneca and Pfizer vaccine led to a protective immune response against Covid. Volunteers produced high levels of antibodies and immune cells regardless of which vaccine was given first or second. Also studied was whether giving a third dose of the AstraZeneca vaccine boosted immunity and researchers found that “the third dose increases levels of antibodies to the virus in the volunteers to a point higher than seen a month after their second dose.” There are other studies that have shown the benefit of giving a third dose of the vaccine to transplant patients (who take medications that make them immunocompromised) so all of this is promising. Finally, announced last night, is that the J&J vaccine appears effective against the Delta variant. This is based on studies looking at blood samples and infected petri dishes and measuring neutralizing antibodies. This is a little different than clinical efficacy (counting the number of real-world people who get sick despite the vaccine) but there is a mathematical formula scientists use to estimate efficacy. J&J is estimated to be 55-60% effective against symptomatic disease and will work well against severe disease. That’s pretty good. Although there are scientists advocating for giving an mRNA vaccine dose to those who got the Johnson & Johnson vaccine, to date, the CDC is not supporting this and there is no research to show that it is necessary. There is obviously a lot more to come on booster shots for all the vaccines but the above studies are all good news.
Have a fun and safe July 4th holiday.
Science matters. Get vaccinated. Wear a mask when you’re supposed to. We’re almost there.