Just How Much More Transmissible Is the New Coronavirus Variant and How are the Vaccinations Going? And Some Positive Changes from this Crisis!

Now we are finding out that this new Coronavirus variant is being found in many states as well as in England. Wow! What does all this mean and the larger question- are the vaccines already being given active against this variant? This after I just received my first dose of the Mederna vaccine.

MEDPage’s Molly Walker reported that the new SARS-CoV-2 variant first appearing in southern England has a transmission advantage of 0.4 to 0.7 points higher in reproduction number, also known as R0, compared to the initial strain, British researchers found.

This variant, called 202012/01, has a “substantial transmission advantage,” meaning its reproduction numbers could vary from 1.4 to 1.8, according to a multi-disciplinary team based at Imperial College London (ICL), who published their findings on the school’s website.

Led by ICL’s Erik Volz, PhD, the team found a “large and statistically significant imbalance” in regions where incidence of the variant increased and incidence of the non-variant decreased, and vice versa, which would indicate a change in R0.

Volz and colleagues also noted a larger share of individuals under age 20 among reported cases of the variant versus non-variant cases, dubbing this “a shift in age composition.” They estimated that the variant’s R0 is 40%-80% higher than for the wild-type virus.

For context in the U.S., prior research found seasonal influenza had a median reproduction number of 1.28, while the median reproduction number for the 1918 flu pandemic was 1.80.

This variant already traveled across the pond, with a Colorado man as the first documented case in the U.S. last week, though reports of the variant cropped up in other states over the holiday, including California and Florida.

CDC officials briefed reporters about the variant on Wednesday, noting it appears unlikely to impact COVID-19 vaccine effectiveness, though it may render certain treatments less effective, such as convalescent plasma. The agency says it expects more data on the variant soon.

A preliminary report from the U.K.’s Centre for Mathematical Modelling of Infectious Diseases on Dec. 23 originally estimated transmission may be at least 56% and up to 70% higher. They updated their findings on Dec. 31, noting the frequency of the variant “has grown substantially in all regions of England,” with a 50% or greater frequency in all National Health System regions.

The Imperial College group examined both epidemiological and genetic data, including 1,904 whole genomes from October and December 5 with a genetic background of 48,128 genomes collected over the same period. Notably, they found a “high correlation” between S-gene target failure (SGTF) during COVID-19 PCR testing and frequency of the variant, meaning S-gene target failure could act as a biomarker to detect the variant in the community.

“We see a very clear visual association between SGTF frequency and epidemic growth in nearly all areas … which is reinforced by empirical assessment of area-specific week on week growth factors of [variant] and non-[variant] case numbers,” Volz and colleagues wrote.

They noted a “small, but significant” shift towards individuals under age 20 being more affected by the variant, even after adjusting for several confounders. Any number of factors could account for this: an overall increase in transmissibility of the variant, younger people being more susceptible, or greater symptomatology with the variant.

The group warned that while further research is needed, a variant with increased transmissibility indicates increased public health measures may be needed to contain the virus.

“Social distancing measures will need to be more stringent than they would have otherwise. A particular concern is whether it will be possible to maintain control over transmission while allowing schools to reopen,” the group wrote.

But there continues to be no indication that the variant will resist vaccine-mediated immunity, or that it’s more lethal, except to the extent that hospitals become more overburdened with cases and thus less able to provide high-level care to every patient.

Dr. Marc Siegel: COVID vaccinations will increase rapidly — greatest accomplishment in vaccine history

I think that most of us thinking correctly that all of our most vulnerable populations, beginning with the elderly (who account for over 80% of COVID deaths) should be immunized as soon as possible

Dr. Mark Siegel noted that for the past several months I have counted on my personal protective equipment to create a necessary barrier between me and my patients. Several patients have tested positive for COVID-19, even though they had no clear symptoms at the time of the visit.

But although I will continue to wear PPE, the risk to me and my patients will diminish. This is not because COVID-19 is going away (the opposite is true), but because I have received the Pfizer-BioNTech vaccine.

Ten days after being vaccinated, I am starting to gain some immunity, which probably means that if I do acquire COVID from one of my patients or elsewhere it will be a milder case, although this has yet to be proven.

 What has been shown in clinical trials is that the first shot may offer me just over 50% protection against COVID-19 in advance of my taking the second shot. This is a statistical calculation and by no means a certainty. This means that in the clinical trials those who tested positive for COVID-19 were over 50% less likely to have received the actual vaccine versus a placebo (more than twice the number of COVID cases occurred in the placebo group

With there being a slow rollout of the new COVID-19 vaccines both in the U.S. and around the world, I understand the impulse to give only one dose of the Pfizer-BioNTech, the Moderna, or the Oxford-AstraZeneca vaccine in Britain, in order to vaccinate millions more people in the legitimate hope that this decreases the risk of severe illness and hospitalization at a time when hospitals are overwhelmed with COVID-19 cases.  

But this hope is not purely science. I believe we should keep to the two-dose schedule as studied. Keep in mind that the clinical trials were all conducted with careful dosing regimens and the conclusions drawn are based entirely on these two-dose protocols.

The Food and Drug Administration’s emergency use authorization for vaccinations is conditional. The United Kingdom and its National Health Service are taking a risk in three ways by delaying the second vaccine dose for three months so more people can get the first dose.

First, the degree of immunity may well diminish over the three-month period. Second, there is no direct proof yet that the initial dose alone will decrease hospitalizations. And third, there is no guarantee that the second dose will even be available in three months. Once there is an expectation on the part of the general public that their first dose is in the offing, this demand may get in the way of the second dose for others for several months.

With over 14 million doses of the Pfizer and Moderna vaccines having been distributed in the U.S and just over 3 million doses having been administered here, it is clear that a good part of the delay is occurring at the state level. 

It is crucial that all of our most vulnerable populations, beginning with the elderly (who account for over 80% of COVID deaths) be immunized as soon as possible. 

I expect the numbers vaccinated in the U.S. to increase exponentially in January, as over 40,000 pharmacy sites (Walgreens, CVS, Costco) receive their doses and begin vaccinating.

Keep in mind that by one measure the rollout (albeit much slower than expected) has been a big success. As we have gone from thousands vaccinated in clinical trials to millions vaccinated under the emergency use authorization, the number of significant side effects (mostly allergies) has been extremely small. This bodes well for the future of both vaccine compliance as well as usefulness.

 Whereas more than 1 million Israelis have already received a COVID-19 vaccine (11% of the population, well above the global average of 0.13% according to data from Oxford University), we in the U.S. still lag far behind. 

 But if we think of this as a race, we are losing it will be far too easy NOT to see it for what it really is: the greatest accomplishment in vaccine science in history.

I will never forget the moment of awe and raw emotion when I received my first COVID-19 shot. I intend to receive my second shot on schedule. It will be happening for you soon too.

Dr. Marty Makary decries people ‘cutting in line’ to get coronavirus vaccine

Fox News medical contributor, Dr. Marty Malkary has pledged not to accept vaccine ‘until every high-risk American has had the opportunity to have it’

Angelica Stabile reported that “There’s a lot of cutting in line” to get the coronavirus  vaccine in the early weeks of nationwide distribution, Fox News medical contributor Dr. Marty Makary told “America’s News HQ” Friday.

“Ironically, after all the conversation about Black Lives Matter, here we are with people inserting themselves – people with access, people with wealth, people with connections to the local facilities, and they’re basically saying their life matters more and I think it’s entirely inappropriate,” said Makary, who went on to accuse the Centers for Disease Control and Prevention of being “way too slow” to clarify who should receive priority access to the vaccine.

“It should go to the highest-risk individuals after it goes to nursing homes and front-line health care workers, not all health care workers,” he said. “I’ve taken a pledge not to take the vaccine, along with many health care workers, until every high-risk American has had the opportunity to have it first.”

However, according to Makary, the CDC’s recommendation that “health care personnel” receive priority access to the vaccine has led to the likes of cosmetic surgeons, hospital board members and spouses of health care workers getting the shot “inappropriately.”

I think his assumption is incorrect as evidenced by the next report. We all physicians continue to see patients continuously and are exposed to patients who lie to us because they all believe that their lives are more important then, the physicians, the nurses and our staff. These physicians, nurses and staff then go home with the possibility of exposing their friends and family.

The Fox News medical contributor also questioned the decision by some states to “hold back 50% of the vaccine supply so people could be sure to get a second dose.”

“That was a mistake, in my opinion,” he said. “The strategy should have been give it out to as many people as possible.”

Makary noted that nearly 5% of the U.K. population has already been vaccinated, while not even 1% of the U.S. population has been dosed.

Should Docs’ Spouses Be Higher Up on COVID Vaccine Priority List?

Yes, says ICU physician whose wife got the virus from him and nearly died. Another reporter from MedPage, Cheryl Clark, noted that as frontline healthcare workers around the country line up for the first COVID-19 vaccines, some providers treating the sickest patients, including emergency and critical care physicians, are asking a vexing question: Shouldn’t their spouses also be prioritized?

If they’re not at least 75, or they don’t have serious medical issues, physician spouses aren’t in phase 1a or 1b of the Advisory Committee on Immunization Practices’ recommendations for vaccination priority. They might be considered under 1c, but that may be weeks if not months away.

Denny Amundson, DO, a 70-year-old pulmonary intensivist in California, thinks spouses probably should be moved up the priority list — and the sad ordeal he and his wife have endured makes his case.

Denny Amundson, DO, critical care medicine specialist at Scripps Mercy Chula Vista Hospital. (Photo courtesy of Denny Amundson)

Amundson has been pulling long shifts since March, trying to save the lives of hundreds of patients sick enough to be in the 28-bed ICU at Scripps Mercy Hospital in Chula Vista, California, 10 miles north of the Mexican border. He is the hospital’s ICU medical director.

Amundson’s 71-year-old wife, Stephanie Brodine, MD, a non-practicing infectious diseases physician who heads the division of epidemiology and biostatistics at San Diego State University and runs its school of public health, understood the risks. They took every precaution but continued to live together and “take our chances,” isolating themselves from their six children and nine grandchildren, he said.

He bought an ultraviolet light to sterilize the hospital closets and rooms where he and his colleagues stored their clothing and equipment.

“We thought we’d be safe, following all the personal protection guidelines,” he said, “and we were. For the first eight months.”

On Oct. 18, Amundson started a five-day run at the hospital. The next day, he saw a 74-year-old patient on high-flow oxygen who was going to die if he wasn’t put on mechanical ventilation. The patient was refusing because of all the terrible things he’d heard, that going on a vent meant certain death.

“I probably spent an hour and a half trying to talk him into it,” Amundson recalled. He went into the man’s room three times that day. Though he was properly geared with PPE, the noisy equipment of the man’s high-flow oxygen made it hard for Amundson to hear him.

On several occasions, Amundson recalled, he got very close to the man’s face, “nose to nose with him, except for an N95 and a face plate in between.”

“He had a better than even chance,” Amundson said, citing hospital rates of 60% survival for ventilated patients. “I guess partly because we were close in age, it made me spend an inordinate amount of time with him.”

Still, the man refused. He died later that day.

On Oct. 23, Amundson and Brodine left town. They drove 400 miles north to Yosemite, where they have a second home, a physically-isolated escape in the national forest that’s a mile from their nearest neighbors.

But the day after they arrived, Amundson sensed the sudden loss of his smell and taste. He was congested and started coughing. Two days later, Brodine developed a persistent cough so bad she couldn’t talk.

Amundson remembers no breach in his PPE, but thinking back, he’s nearly certain the time he spent in that man’s room was the cause. The virus somehow got into his nasal pharynx, down into his respiratory tract, and on to infect his wife.

They drove back to San Diego that day and got tested at a commercial lab, which called them that night. “We were both positive,” he said.

Amundson has been off work ever since, saying extreme fatigue cuts his days short by noon, but is gaining more strength every day.

Wife Hit Harder

Not so for his wife, a previously healthy hiker and yoga and Pilates enthusiast with no underlying conditions.

Brodine was so sick, she spent 27 days at Scripps Mercy Hospital in Hillcrest, 11 of them in the intensive care unit, with complications of severe COVID pneumonia. “There was a period of time when all the physicians there — obviously we have friends at the hospital — were concerned for her life,” and some recommended she go on mechanical ventilation, Amundson said.

There was more bad news. Brodine also developed methicillin-resistant Staphylococcus aureus pneumonia. She was treated aggressively with dexamethasone, which can cause bowel disorders. A perforated bowel and diverticular abscess followed, Amundson said.

She’s now been home for the last week, and can move from her bed to the couch with assistance and a four-post walker. Her voice remains raspy and gives out, making it difficult for her to talk. “She’s probably looking at months, if not six months of significant rehabilitation with physical and occupational therapy,” Amundson said.

‘I Brought This Home’

Amundson feels terrible. “The elephant in the room is, I brought this home. I did this to my wife of 40 years. There were lots of periods of time when the tears flowed and we weren’t sure – we weren’t sure she was going to live.”

He wonders if he should have moved out of the house, which they had once considered. “Several colleagues rented trailers and parked them in their driveways,” he said.

Of course, for Amundson and his wife, the question of her access to the vaccine is moot. No vaccine was available in October 2020. But the life-changing experience has left Amundson wondering about other healthcare workers — especially those working like him in the maw of COVID, and who are older, but who think they’re properly protected, only to have this virus sneak up on their families at home.

“We ought to look at maybe prioritizing these people because if you bring it home and give it to a family member who doesn’t know it for the first five days … now, you’ve caused an outbreak of the disease,” Amundson said.

According to the American Medical Association, as of two years ago more than 120,000 practicing U.S. physicians were age 65 or older, an indication that a good portion of their spouses are probably older — and more vulnerable to serious COVID illness — as well, but not old enough to fit into a current vaccine priority tier.

Amundson spent time in Iraq during the war, and has done many things that, in his words, “put you in harm’s way. But to see someone who is really innocent and is only there because of what I do for a living, it doesn’t seem right,” Amundson said.

Chris Van Gorder, CEO of the five-hospital Scripps Health system, sympathized with the issue but noted that vaccines are in short supply. “Being a spouse is not called out right now and I doubt it will be – it’s all individual based,” he said in an email.

Arthur Caplan, PhD, director of the division of medical ethics at NYU Langone Medical Center, suggested that perhaps spouses of providers who work with COVID patients and are older should be ranked higher to get the vaccine. “I would treat them as high-risk elderly,” he said in an email.

Amundson is still trying to regain his full strength, but plans to return to the ICU next week because healthcare workers trained and willing to treat COVID patients are in short supply.

The 116-bed facility was 100% full as of last week, 80% of it filled with COVID-19 patients. In the basement is the hospital’s 28-bed ICU, and 24 of those patients have COVID, all of them on ventilators. Over the last two weeks, the county has averaged more than 2,700 new cases a day. On Dec. 26, numbers in San Diego County of both hospitalized patients and those in the ICU because of COVID broke new records.

Their experience has led Amundson to decide to retire, which he had no plans to do before they both got sick. He’ll return to help with the surge, and train new people to take over when he leaves in September.

Some positive changes amid the COVID-19 crisis

With all the negative reports I wanted to high light some of the positive changes from this pandemic. Dawn Boubds and Wrenetha Julion reported that if COVID-19 is the war, then front-line healthcare workers are our hero soldiers. Sadly, the list of healthcare providers lost to COVID-19 worldwide grows longer and longer. How is it that the country that spends the most per person on healthcare ended up sending soldiers to the battlefield without proper protection (too few masks and caregivers resorting to garbage bags as gowns).

As mental health and public health nurses with over 50 years of combined experience, we are left with the sentiment that we cannot go back to the way things were. Yes, when we signed up to be nurses, we knew what we were getting into. We knew that we would miss family events, such as parties, baptisms and weddings. We were prepared to miss out on spending time with our families. We also knew that we would work long shifts, spending hours on our feet, sometimes without so much as a bathroom break or an opportunity to sit down and eat a meal.

We knew all of this and we did it anyway because caring for patients, families and communities is what we do. But what we couldn’t possibly know is that the COVID-19 global pandemic would strike the U.S. in 2020 and that we could die from it as a result our work. U.S. healthcare will not and should not ever be the same.

Still, despite the tragic losses and seismic industry shifts, there have been some positive developments during this crisis that could shepherd major change. Among them:

Valuing the contribution of healthcare providers, first responders and researchers.

Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, has been one of the most prominent and trusted scientific voices in this crisis. He’s kept the country informed on the evidence-based public health efforts to prevent the spread of COVID-19 and handle the surge of people who are already sick. Fauci and all of our medical experts and researchers—true public servants— deserve support and respect. Healthcare workers and first responders risking their lives for the well-being of others is not unique. What is new today is that their work and dedication are being heralded as heroic amid this pandemic. As a result, healthcare providers and first responders are receiving support in the form of nightly neighborhood serenades in their communities, video messages from celebrities, as well as countless perks from corporations and local businesses—to name just a few gestures of public support.

Probably the biggest thank you would be in the form of student loan forgiveness for front-line healthcare providers. That’s an objective of the movement calling for a Student Debt Forgiveness for Frontline Health Care Workers Act.

COVID-19 offers the public a small window into the daily lives of our healthcare providers and first responders.

Providing insurance reimbursements for telehealth visits without regard to location.

Healthcare visits across the country have quickly shifted online or by phone to patients who do not require an in-person visit. The number of telehealth visits have rapidly increased due to the need to prevent unnecessary exposure to COVID-19. As a result, insurance companies have agreed to reimburse for these visits without regard to the location of the provider or patient (e.g., at home). This was virtually unheard of prior to COVID-19. Before the outbreak, one of the only ways for providers to be reimbursed for telehealth visits was from clinic to clinic—when the provider and the patient were situated in separate clinics.Telehealth visits have increased access to medical and mental healthcare, helped us prioritize and improve workflow and harnessed our triage skills.

Surely, after we have rapidly implemented protocols for these visits—processes that can take years to implement—these efforts must not be lost after COVID-19. Instead let’s keep reimbursing for these visits, offering them from providers’ homes and in patients’ homes whenever possible. All temporary waivers and regulatory changes should be made permanent.

Removing barriers to APRNs practicing at the top of their license.

As the need for more healthcare providers has risen during this pandemic, the pressure to remove barriers to practice for advanced practice registered nurses has become even more apparent. APRNs have been fighting for the removal of these barriers—which vary from state to state—for years. Our scope of practice includes ordering tests, diagnosing, treating and prescribing medications for a variety of health concerns. We have a solid reputation of offering quality healthcare to patients, especially in under-resourced areas. APRNs are often the providers of choice for patients. Despite improving access and offering quality care, barriers to practice such as state requirements for supervisory (restrictive practice) or collaborative (reduced practice) relationships with physicians persist. Some states have already removed barriers to full practice authority and these states are called full-practice states. Other states that have removed some barriers to practice are considered reduced-practice states. Recently, Florida joined 28 other states in granting nurse practitioners full practice authority. California, currently a restricted practice state, is looking to join the ranks of states granting full practice authority.

Since APRNs do not train as long as physicians, many opponents of full-practice authority voice concerns about the safety of patients cared for by APRNs. The data suggests otherwise, because research indicates that APRNs can and do provide care comparable to that provided by other medical providers.

During these dark days of the COVID-19 pandemic it’s crystal clear that APRNs are not competitors of physicians but instead partners in healthcare. Once this crisis has passed, we should continue to expand full-practice authority nationwide for the common goal of access to quality healthcare.

So, the most important thing that we all should take from our discussion is that all continue to practice social distancing, wear our masks and when notified, get vaccinated.

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