Friday night update from the ER in Arlington, VA
COVID is here, again. Although we’ve continued with our weekly COVID task force phone calls, today was the first COVID leadership team teleconference with our medical staff in months. We provided department udpates, talked about outpatient testing, and current treatment recommendations. Things have been stable and we really haven’t needed this meeting over the last few months, but the COVID situation has changed. The picture is from our meeting. Front row on the left is Dr David Lee, our new chief medical officer. I’m to his left. On the right is the director of our ICU, then the head of infectious disease, our lead hospitalist (who is presenting), and on the far side of the table is the new president of our medical staff. It’s an amazing group of physicians that I consider myself lucky to be working with.
This has been a crazy week so the word count for this post is closer to the very long posts I did in the spring. Thanks in advance for following, reading, and sharing.
Let’s dive into my data. We are doing significantly more testing than during the spring surge. Our overall percent positive rate is higher than the summer and fall and approaching spring levels. Our total number of positive cases diagnosed each week are hitting the spring levels. Some of these positives are being found in what we call asymptomatic patients. The hospital has been testing asymptomatic patients prior to surgeries, outpatient procedures, and women delivering babies, and have found the asymptomatic positive rate in this “healthy” group of patients to have basically doubled over the last couple of months. I used to estimate that about 2% of the general population was COVID positive. Now I think that number is closer to 5%. When I look at our symptomatic patients who require testing, we’re seeing the highest numbers since mid-summer, with positive numbers hitting close to springtime levels. In this patient population, we’re seeing the highest percent positive rate for 2 weeks in a row since late May. We continued to see an increase in the number of patients who require our COVID isolation procedure. The last two weeks have been our highest numbers for back to back weeks since May. We’re still 25% + below our spring numbers but our slope since early October on this curve is clearly increasing. Our admission rate for this patient subgroup remains high. While not as high as last April, it’s definitely higher than the summer and well above our baseline overall admission rate. COVID is here and we need to do everything we can to flatten the curve.
The new Eli Lilly therapeutic agent, bamlanivimab, is arriving at hospitals in the state. This is a very expensive medication that will initially be covered by the government. It’s meant for high risk patients that don’t require hospitalization with the goal of helping to keep this group from requiring hospitalization. I expect it to be in extremely limited supply. We don’t know how much we’re getting or how often we’re getting resupplied. It’s approved for “emergency use only” (which seems to me to be a couple of steps above experimental since we don’t have great data on it yet) with some side effect risk, but as we get experience with it, if it’s as good as the preliminary research, it has the potential to really help reduce hospitalizations. This treatment will typically be given through an outpatient infusion clinic. The biggest challenge right now will be figuring out how to get it to patients and making sure we have enough.
The CDC is warning us not to travel for Thanksgiving. I heard that it’s estimated that the average Thanksgiving get together will decrease this year compared to last year. However, it’s only from 10 people to 9 people so it sounds like a lot of people are not going to follow the CDC recommendations. I realize everyone wants to see their families. I have had several friends recently tell me their plans have changed and they will do a quiet Thanksgiving without family. I hope more people make this call.
If you must see family, please wear a mask. Data released by the Federation of American Scientists shows that if states were countries, we would have 19 states among the hardest hit countries in the world based on cases per million residents. Leading the way are North and South Dakota where masks have not been mandatory. It doesn’t take a rocket scientist to see that masks work. They protect you and those around you.
I know a lot of people are thinking they can get tested and bring their negative test to their Thanksgiving dinner with family. But testing provides a false sense of security. I rely on the testing but it’s far from perfect. I continue to see patients who I think have COVID and even if their test results are negative, we’ll often keep them on isolation. The testing is less accurate in asymptomatic patients since your viral load may be lower and not trigger the positive finding. Additionally, the testing tells me where you are today but doesn’t tell me where you will be tomorrow or the next day. There is a latent period between exposure, being contagious, testing positive, and being symptomatic. You can get exposed yesterday, test negative tomorrow (and the next day) and then test positive the 3rd day and be symptomatic the 4thor 5th day. It’s a crazy smart and challenging virus so while a negative test provides a little reassurance, it’s not a guarantee that you’re actually negative and won’t be transmitting the virus to your loved ones.
I thought the big news this week would be Moderna releasing info about their vaccine that it’s 94.5% effective. That’s amazing. It appears that the patients given the Moderna vaccine had zero symptomatic infections. Overall, vaccine patients had 5 infections while the non-vaccinated study group had 90. Then Pfizer said they analyzed more data and their vaccine is actually 95% effective and they’re applying for FDA approval this week. Both vaccines use a new technology based on messenger RNA, so it doesn’t surprise me that they achieved similar results. The Pfizer vaccine requires the deep -80C freeze. The Moderna vaccine requires -20C which makes transportation and storage easier. (There’s about a 6 month wait to get the super cold freezer right now) Dr Fauci appears to be giving the thumbs up to the vaccines as safe and effective. Although I’m waiting for experts like the Infectious Disease Society of America (IDSA) to weigh in once all the data is published, I’m relatively optimistic about the vaccines. It’s possible that healthcare providers will have the chance to get vaccinated in the near future. I’ll likely take it when offered. However, here’s a few things we have to keep in mind. Vaccines are only effective when people are vaccinated. Ultimately, we’ll need about 70% of Americans to get vaccinated and that’s a tall order that we don’t come close to achieving with the annual flu vaccine. Next, none of us will likely have a choice as to what vaccine we get. Vaccines will be distributed by the government and we’ll likely get what we get. And if you get one that requires a second dose, you’ll need to get that same manufacturer’s product at the right time. Pfizer and Moderna’s vaccines the second shot on different schedules. Finally, although vaccines will roll out in the near future, it will take until summer of 2021 before the last cohort (young, healthy people) are able to get vaccinated. This means mask wearing and COVID restrictions well into next year. But I think the light at the end of the tunnel could be school starting next fall and life returning to normal. We’re 9 months in with likely another 9 or 10 to go, but at least we now know the end point.
In other news, the FDA approved an at home test for COVID. It’s a fairly straight forward test made by Lucira Health where you can collect your own nasal swab, place it in a vial, wait 30 minutes and get a light-up display showing whether you’re positive or negative. I’ve heard it will require a doctor’s prescription and be priced at about $50 but if it’s pretty accurate, it could certainly make testing more accessible. The cost and requiring a prescription may limit access to much of the population so hopefully those aspects will change.
And in a sign that researchers are throwing everything but the kitchen sink at COVID, JAMA published a study online that looked at an antidepressant (Luvox) in non-hospitalized patients with mild symptoms and within 7 days of onset and found that none of the patients who took the study medication developed severe breathing problems or required hospitalization. About 8% of the placebo group got worse with 2/3 of them requiring hospitalization and 1 patient requiring a ventilator. It was a small study, far from changing practice, and referred to as “hypothesis generating.” But perhaps this will lead to a larger study and if reproduced, would certainly offer a cheap, safe, available option with oral medications for patients with mild disease.And on the flip side, the World Health Organization has released a statement on Remdesivir, which has been one of the staples of medications we’ve been using for months, advising against its use in “hospitalized patients, no matter how severe their illness may be. As current evidence does not suggest Remdesivir affects the risk of dying from COVID-19 or needing mechanical ventilation, among other important outcomes.” With that said, it is FDA approved and there’s no evidence that it clearly doesn’t work (some studies have shown reduced hospital length of stay), so I suspect we’ll continue to see it used for hospitalized patients for the time being.
Governor Hogan put some restrictions in place this week in Maryland. Virginia seems to typically be a week or so behind Maryland so we’ll see what next week holds. Possibilities include restrictions on visitors in hospitals and possibly limiting outpatient surgeries. COVID is bad and getting worse. Death counts will start to climb even more in about 2-3 weeks. Wear a mask. Enjoy your turkey. I hope you have a quiet Thanksgiving.
Science matters. Wear a mask. Practice physical distancing.
Mike