Another season, another surge.
Since my last post 7 weeks ago, cases have gone way up where I live—but not as high as in other parts of the country. During this time, the hospitals where I work have seen cases go from a handful, or even none, to double digits. Almost all of them are people who have not been vaccinated, for whatever reasons. But a few are folks who have been vaccinated (or recovered from previous infection), yet still became sick enough to require hospitalization. Almost all of them have had some risk factor—immunosuppressed, obese, diabetic, pregnant, advanced age. But the vast majority of the very sick and dying patients are people who are unvaccinated. I have yet to see anyone sick because of vaccination, although they have been reported.
I get many questions about “boosters”—additional vaccinations to enhance immunity. Will they be needed? If so, when? Should we be immunized with the same vaccine or a different one? How do we know if we need a booster at all? At this point, in the USA, boosters are only recommended for people who have previously been vaccinated with one of the mRNA vaccines from Pfizer/BioNTech or Moderna—and only if they have a condition that is considered immunosuppressing. In Israel, they have determined that booster shots are needed for all over the age of 60.
But the really interesting question, that no one has asked me, is: how many times does our immune system need to see either vaccine or infection until COVID-19 is no longer something that changes our lives? How many cycles of exposure to infection or vaccine until our hospitals are no longer overwhelmed, or severe illness becomes a rare event?
So far, the answer to that question seems to be: at least twice, likely more. In Israel, a vaccination rate of 78% in people over 12 did not prevent another surge. On August 13, 2021, the CDC reported a small case-control, retrospective observational study from Kentucky. 246 patients who had contracted COVID-19 in 2020 and became REINFECTED from May to July of 2021 were compared to 492 people who were also infected in 2020, but not reinfected in May-July of 2021 (the control group). Patients in the previously infected group who remained unvaccinated had a 2.34 chance of reinfection compared to the patients who became fully vaccinated after their recovery.
However, also in that study it should be noted that 20% of previously infected people from 2020 were fully-vaccinated people after recovery and ALSO came down with a COVID-19 reinfection. distressing for those unlucky 50 folks who were both recovered and fully immunized. Unclear whether those 50 people were immunocompromised to the extent that even previous infection and vaccination could not protect them. Those people are out there—and they are relying on the rest of us to get this pandemic under control.
One weakness of the study was that a case was defined as PCR positive, with no mention of symptoms. So although they were reinfected, we don’t know if they were hospitalized. We have seen people recovered from COVID-19 hospitalized with infection where I work.
My guess—and really, it is just a guess—is that much of the population will need to have their immune system see vaccine (ie “boosters”) or infection at least 2 to 3 times before viral transmission, and probably symptoms, subside to a level similar to influenza. But remember, we vaccinate a sizable percentage of our population against influenza every year—over 60% of children and almost 50% of adults.
The other phenomenon we are seeing during this Delta surge is that hospitals in areas with low immunization are being overrun to the point where Crisis Standards of Care are being explicitly invoked, as in northern Idaho, or implicitly practiced, as in Florida, Alabama, or Texas. I had written about this during the fall/winter surge last year. Hospitals in COVID-19 hotspots are running out of space and staff. Even hospitals in areas where COVID-19 is under control are losing staff to areas in more desperate shape. The short staffed hospitals also have to start delaying some care as even moderate numbers of COVID-19 patients take up significant hospital resources. When there is Crisis Standards of Care, the usual care you or your loved one might expect at a hospital may not be provided. So please be careful with your personal practices, so that you minimize your need to go to an Emergency Room. But, as always, if you must go, then GO!
What can and should we do now?
The first answer is to increase vaccination uptake, especially in areas where rates are low. I would include the whole world in this effort. The last two surges of virus transmission in the United States came from variants first isolated in the United Kingdom (Alpha/B.1.1.7) and India (Delta). High vaccination rates are the best option to prevent hospitals and emergency rooms from being overwhelmed, as the vast majority of the people in hospital beds and ICUs are UNvaccinated.
The second thing we can do is to reduce transmission generally. Unfortunately, this makes 2021 look like 2020 again, but without the lockdowns.
After 18 months of research and observation, there are practices that we know DO WORK. Most importantly, wearing a mask, especially indoors in areas of high disease transmission, reduces the risk that you might inadvertently transmit COVID-19 to someone else. The largest randomized study to date, of hundreds of thousands of villagers in Bangladesh, showed that wearing any mask, led to a significant reduction in disease transmission. However, two-thirds of the intervention group had surgical masks, and one-third had cloth masks. When divided between cloth and surgical masks, the surgical masks appear to be main the driver of improvement.
Unfortunately, the data is less robust that wearing anything less than respirator level coverage (eg N95) prevents someone from acquiring COVID-19 after they have had a high risk exposure, defined as being in close contact (within 6 feet, for greater than 15 minutes) with an infectious person who is unmasked. When everyone is masked, as in hospitals and airplanes, then high risk exposure is quite rare.
So hang on—we are learning what works. It takes time to learn. It takes time to change practice and culture. We will get there. How quickly, and with how many more lives are lost—or disabled due severe COVID-19—is still the unknown.