Healthcare

Coronavirus Updates Heading into Third Surge During the Holidays

by Scott J. Pearson

I just got off a helpful call with Vanderbilt Medical Center (VUMC) leadership about COVID and the holidays. From a public-health perspective, I feel that I need to pass along the notes that I took. The presenter was Gordon Bernard. He is an Executive Vice President at VUMC and is respected worldwide both as a researcher and as a clinician. He has worked for over forty years as a Critical Care pulmonologist. This information is from his reading over the past nine months.

The situation is that nationally, we are experiencing a heretofore unseen high spike in COVID. The two surges we’ve already encountered seem small in comparison to what we are now facing. In addition to this, we are facing a situation where we have no national strategy and where many Americans approach the holiday season, typically a time of congregating.

  • Prevention
    • Masks and face shields work primarily by forcing the air to make a dead-end U turn around the back edge of the mask to enter the region of the mouth and nose. This increases the time that the virus is exposed to dry air. Since viruses require moisture to live, this means that masks make the virus more likely to die before entering the nose/mouth.
    • There is a dramatic difference between the rate of infection inside versus outside. Outside conditions are much safer because of the expanse in which air can circulate. Inside is much riskier. This is bad news heading into winter months and holidays. Outside conditions still require masks and social distancing, but are relatively safe if those two constraints are observed.
    • An easy but effective test about whether a mask will work is to try to burn one of them. If a mask burns, it’s made of cloth and is relatively ineffective. If it melts, it’s made of synthetic material (plastic) and should work more effectively. The cloth is ineffective, but only the synthetics provide the appropriate filtration.
    • VUMC study of counties in Tennessee: A mandatory mask order cuts mortality by one-half. Rural areas are not passed over (e.g., the Dakotas).
  • Vaccines
    • The vaccines work by a new RNA technology. The vaccines inject RNA into the blood. The RNA are absorbed by your cells. Through the RNA, the cells make protein which invoke anti-COVID antibodies. Normal vaccines usually just inject the proteins into the blood. These vaccines make your body make those proteins. The newness of the technology is why there was uncertainty about the timing of the vaccines.
    • The vaccine will likely be administered in two shots (i.e., with a booster). Immunity will likely be delayed by a few weeks after administration.
    • The FDA will likely approve the Pfizer vaccine this week. The Moderna vaccine will be considered soon.
    • VUMC and other medical centers will likely mandate this vaccination among all its employees.
    • Because immunity wanes over time, this may be a yearly vaccine.
    • The vaccines have been shown to eliminate the virus in 95% of recipients. The other 5% only had mild symptoms. Only one single person who received a vaccine had severe symptoms in both trials.
    • Side effects: Uses different technology than the flu vaccine; therefore, those with issues with the flu vaccine are still safe to receive these. Trials only have seen more mild effects (like a sore arm or small fever) – nothing serious yet.
  • Vaccine distribution
    • Likely in waves. Starting in mid-December. Continuing until April.
    • Wave 1A: Frontline healthcare workers.
    • Wave 1B: All healthcare workers.
    • Wave 1C: Those with comorbidities, like diabetes or hypertension. Also, older adults in congregate care (like nursing homes).
    • Wave 2: K-12 educators, childcare workers, congregate care, all older adults, critical infrastructure workers.
    • Wave 3: Children.
    • Wave 4: Everyone else.
    • Waves 2-4 use nebulous categories, admittedly.
    • Administration will be left up to individual states.
    • Obviously, the logistics of producing the vaccine is enormous. So is the distribution. Think of how to inject 100,000 people a day in a major population center while maintaining masks and social distancing. Likely, the constraint that limits the throughput will be the administration of the vaccine, not the production.
  • Third surge
    • VUMC patient numbers are at an all-time high.
    • 300 VUMC workers have been exposed, most from outside of their job, not inside of the hospital.
    • Masks are proving very effective in the hospital setting.
    • School settings vary in effectiveness, so it’s hard to generalize. Some are good at preventing spread; some aren’t. Best practices: dividing up the classes and forbidding interaction between classes; testing for those exposed. If do best practices, very low risk.
  • Holidays
    • If have 10+ people, increased risk of COVID.
    • It’s “no way safe indoors” (direct quote).
    • Outdoor gatherings are safer. (Still avoid large gatherings with 3,000 strangers.)
    • Closed spaces like cars are dangerous.
    • Worried about relatives’ hurt feelings? Remind them that “you’re saving them.”
    • Think about an outdoor Thanksgiving. Cold and wet conditions are bad. Keep social distancing and masks.
    • No buffet. Have one person serve food after having washed their hands. Be careful sitting at the table.
    • Air and other travel
      • If vaccinated, safe to travel.
      • Filtered air in planes with same filtration system that hospitals have.
      • Biggest risk: getting on and off of the plane.
  • Return to normal
    • When the vaccine has been given (in both doses?), you’re safe.
    • Still think smaller settings. 3,000 strangers will not be ideal for a while.
    • But in polls, 50% say they might refuse vaccination!
    • Even with possibly limited vaccinations, outbreaks will eventually be limited to regions and tracked via the news. This means that if Nashville has a bad outbreak, you’d now.
    • March-April 2021?
  • Treatments
    • Oxygen
    • Remdesivir – FDA approved through VUMC research; “kind of” helps
    • Dexamethasone – steroids help
    • Monoclonal antibodies
      • Two have been studied.
      • One will be available shortly for those who are sick but not hospitalized.
      • 150 doses/week at VUMC – tight distribution.
      • Given through infusion.
    • 120+ trials active at VUMC.
  • Testing
    • Rapid test and at-home tests are coming; currently lack much information about these.
    • Giving blood is safe (always). Those with bad COVID cases are especially desired to be tested via a VUMC study.
    • Once infected:
      • Get tested to be verified for the long term.
      • Get tested to inform others and isolate yourself.
      • Many false positives and false negatives; thus, don’t act rashly.