“Shared expectations lead to predictability.”
181. When, where and how to register to be vaccinated as of Jan. 4.
Q: Has anything changed since last week on how we can get vaccinated?
A: No! The current Connecticut vaccination program is still focused on Tier 1a, which includes “healthcare personnel,” “long term care residents,” and “first responders at risk of exposure to COVID-19.” Earlier, the State Health Department estimated this tier included 167,500 people. Bloomberg News reported that as of last week, 149,900 doses have been received in Connecticut. 78,940 doses had been administered (50% of the doses available). The Connecticut Department of Health has not yet updated its procedures for people in the next Tier, 1b. This next group includes “critical workforce” (yet to be defined), “other congregate settings” (e.g., prisons), “adults over age 65,” and “high risk individuals under age 65.” Unofficial sources speculate that this next grouping will begin vaccinations by the end of January. Announcements might soon be made telling where people in the Tier 1b groups can call to make a vaccination appointment. It is not yet known, but each of the above groups may be separated into sequential time blocks. If so, people over age 65 might begin to be vaccinated in the summer rather than in just a few weeks. We’ll soon find out. In addition to local pharmacies, medical offices and health centers, it is expected that large vaccination centers will need to be made available. Planning has yet to consider the scale of effort this project will require! To vaccinate the estimated 3,000,000 people in Connecticut over age 16 by December 31, 2021, it will require more than 8,200 people to be vaccinated (or 16,400 shots to be given) per day including weekends and holidays! To reach herd immunity leading to a “return to normal,” at a more conservative 70% vaccination level, more than 5,750 vaccinated people (11,500 shots) each day will be required! The costs for the extensive full time staffing and support of these vaccination centers for this length of time will be monumental! Stand by! More on Connecticut developing its procedures will be reported next week.
182. Implications from the emerging mutation or variant coronavirus-9
Q: Why are so many people concerned about the mutation found in the UK?
A: In the United Kingdom, a rapid regional rise in the cases of COVID has been taking place over just the past few weeks. This was centered in the southeast area around London, and is spreading rapidly outward. Unlike the United States, the UK routinely does genetic testing of the coronavirus-19 virus sampled from diseased patients. Starting in November 2020, the prevalence of a variant or mutated virus was found. Currently, this variation accounts for 60% of the infections in London. Typically, mutations occur quite frequently, and are the result of incomplete or altered replication of the ribonucleic acid (RNA) as the virus multiplies in an infected person. This mutation has been scientifically identified and given the name: “B.1.1.7.” It differs from the earlier virus in the composition of the “spike protein” that allows the virion to enter a human cell where it replicates into multiple copies of itself, expanding the infection within the patient. The significant result of this particular mutation is an increase in the infection rate by as much as 70%. Each person that carried the earlier virus and gave the disease to 2 people, now if infected with this variant can infect on average about 3.4 others. One factor causing this greater contagion may be the dramatically increased upper respiratory viral load resulting in a greater concentration of the variant virus when the patient exhales. Wearing a mask, and keeping an even greater distance between people are clearly indicated to avoid contagion.
The impact is a rapid increase in the number of cases that require hospitalization within a given period of time. Hospitals that had been discharging patients at the same or faster pace than newly arriving patients now find themselves overwhelmed.
Other factors can cause hospitals to become overwhelmed. People not wearing masks when in public, ignoring warnings to avoid large gatherings – especially indoors, and not following guidance to limit travel over holiday periods are among the other reasons why available hospital resources become stretched. Medical care must be rationed at the point where diversion of ambulances to other hospitals is impossible, and when additional temporary hospital facilities and/or external trained manpower are not available. The Crisis standard of care is defined by the AMA , to address the ethics of rationing medical care. The AMA also defines procedures on how to develop these standards for lesser caregiving. Currently, Los Angeles County and adjacent areas have reached the limit for the normal standard of care. Multiple hospitals there are now implementing this care-rationing process.
The United States is just now establishing a national program of routine genetic evaluation to identify mutations and variant forms of the disease. The variant B.1.1.7. is now identified as being in California, Colorado, Florida and upstate New York. Scientists are now working to determine if this variant has any other implications. To date, the CDC has stated there is no evidence that the variant results in more serious illnesses or deaths. There is also no evidence that the current vaccines will be less effective in preventing infections. Studies are underway to scientifically determine the validity of these and other effects from this new variant.
183. New vaccines with lower effectiveness – private v. public health considerations
Q: Can I choose the vaccine I want to take? I want one that is more effective.
A: If you consider only your personal health, the only choice you will have is to delay scheduling an appointment until a vaccine with a higher effective rate is available. To do so, you will remain unvaccinated until you can find a site that offers your preferred vaccine. Public health considerations are the reason officials are strongly urging immediate use of any vaccine offered when it is your turn to be vaccinated. This contrast is an example of the difference between private health and public health. Personal health would lead an individual to want to receive the Pfizer or the Moderna vaccine with its 90% to 95% effectiveness. But when the AstraZeneca vaccine later becomes available – perhaps in April – it may be rated at about 70% effective. This next-in-line vaccine will be easier to transport and to store. It will only require refrigeration, not a freezer or cold-chain ultra-cold equipment. More people can thus receive this future vaccine in a given period of time than the two mRNA vaccine products currently being used. This gives the public greater protection by rapidly decreasing the number of people who are contagious. That is the goal of public health. Most authorities recommend that any approved vaccine should be taken as soon as it becomes available for people in each of the priority groups. The delay by deciding to wait for a higher efficiency vaccine actually places the unvaccinated person at greater risk than the less effective protection immediately taken.
184. “Living room spread” of COVID used to illustrate its contagion
Q: We want to “get back to normal!” Why not visit often with a few of our best friends?
A: One reason for the explosion of the number of cases is the “vigilance fatigue” that everyone is experiencing to limit contagion from infected people. Many have already developed the “habit” of wearing a mask and maintaining social distance when leaving the home. But with the emergence of the variant virus, vigilance against indoor contact is becoming more important. One physician, Dara Kass, MD published online a case study about a man who was tested for COVID-19. Dr. Kass is an Associate Professor of Emergency Medicine at Columbia University Medical Center.
After testing negative for COVID-19, this man decided to visit his family including his parents and siblings. The following day, his mother had her own parents come for dinner. They were frequent visitors, and were considered part of the same “bubble” or cohort. Everyone felt comfortable being together indoors without masks or social distancing. A day later, a nanny arrived to spend the day tending to a younger child.
“However, the older brother who came to visit actually tests positive after developing symptoms. The mom and the entire family began developing symptoms themselves. It wasn’t long before mom tested positive herself and everyone begins quarantining.” It turns out that the most serious health implications fell upon the nanny, who became critically ill, and who had no health insurance. “Dr. Kass highlighted this case as a clearly delineated instance of ‘living room spread’ and how this is one of the most seemingly harmless, but actually pernicious ways that COVID-19 keeps surging up again after leveling off for a few weeks or days.” One has to remain vigilant about how family and friends might actually be contagious, even if they live at home with their family or are frequent visitors. Wearing masks indoors and keeping distant from others are habits worth developing in the months ahead!
