A somber milestone on the path to brighter days ahead

https://mailchi.mp/05e4ff455445/the-weekly-gist-february-26-2021?e=d1e747d2d8

U.S. tops 500,000 COVID-19 deaths | PBS NewsHour

Although the nation reached a grim and long-dreaded milestone on Monday, surpassing 500,000 lives lost to COVID—more than were killed in two World Wars and the Vietnam conflict combined—the news this week was mostly good, as key indicators of the pandemic’s severity continued to rapidly improve.

Over the past two weeks, hospitalizations for COVID were down 30 percent, deaths were down 22 percent, and new cases declined by 32 percent—the lowest levels since late October. This week’s numbers declined somewhat more slowly than last week’s, leading Dr. Rachel Walensky, director of the Centers for Disease Control and Prevention, to caution people against letting their guard down just yet: “Things are tenuous. Now is not the time to relax restrictions.” Of particular concern are new variants of the coronavirus that have emerged in numerous states, including one in New York and another in California, that may be more contagious than the original virus.
 
The best news of the week was surely a report from the Food and Drug Administration (FDA) evaluating the new, single-shot COVID vaccine from Johnson & Johnson (J&J), showing it to be highly effective at preventing severe disease, hospitalization, and death caused by COVID, including variants. On Friday, a panel of outside experts met to assess whether to approve the J&J vaccine for emergency use, which would make it the third in the nation’s arsenal of COVID vaccines. If approved, the vaccine will be rolled out next week, according to the White House, with up to 4M doses available immediately.

The sooner the better: new data show that since vaccinations began in late December, new cases among nursing home residents have fallen more than 80 percent—a hopeful glimpse at the future that lies ahead for the general population once vaccines become widely available.

The Burdens Grow Heavier for COVID-19 Health Care Providers

Dr. Christine Choi, a second year medical resident at Harbor-UCLA Medical Center
Dr. Christine Choi, 32, a medical resident at Harbor-UCLA Medical Center in Torrance, prepares to enter an isolation area for COVID-19 inpatients. Health care providers must face daily patient death and suffering.

Soon after the COVID-19 pandemic began last spring, Christine Choi, DO, a second-year medical resident at Harbor-UCLA Medical Center, volunteered to enter COVID-19 patient rooms. Since then, she has worked countless nights in the intensive care unit in full protective gear, often tasked with giving the sickest patients and their families the grim choice between intubation or near-certain death.

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I’m offering this guy two terrible options, and that’s how I feel about work: I can’t fix this for you and it sucks, and I’m sorry that the choices I’m giving you are both terrible,” Choi told the Los Angeles Times’ Soumya Karlamangla about one patient encounter.

While Choi exhibits an “almost startlingly positive attitude” in her work, it’s no match for the psychological burdens placed on her shoulders by the global pandemic, Karlamangla wrote. When an older female COVID-19 patient died in the hospital recently, her husband — in the same hospital with the same diagnosis — soon began struggling to breathe. Sensing that he had little time left, Choi held a mobile phone at his bedside so that each of his children could come on screen to tell him they loved him. “I was just bawling in my [personal protective equipment],” Choi said. “The sound of the family members crying — I probably will never forget that,” she said.

It was not the first time the young doctor helped family members say goodbye to a loved one, and it would not be the last. Health care providers like Choi have had to work through unimaginable tragedies and unprecedented circumstances because of COVID-19, with little time to dedicate to their own mental health or well-being.

It has been nearly a year since the US reported what was believed at the time to be its first coronavirus death in Washington State. Since then, the pandemic death toll has mushroomed to nearly 500,000 nationwide, including 49,000 Californians. These numbers are shocking, and yet they do not capture the immeasurable emotional weight that falls on the health care providers with the most intimate view of COVID-19’s deadly progression. “The horror of the pandemic has unfolded largely outside public view and inside hospitals, piling a disproportionate share of the trauma on the people whose work takes them inside their walls,” Karlamangla wrote.

Experts are deeply concerned about the psychological and physical burdens that providers must bear, and the fact that there is still no end in sight. “At least with a natural disaster, it happens, people get scattered all over the place, property gets damaged or flooded, but then we begin to rebuild,” Lawrence Palinkas, PhD, MA, a medical anthropologist at USC, told Karlamangla. “We’re not there yet, and we don’t know when that will actually occur.”

Burned Out and Exhausted

A new CHCF survey of 1,202 California doctors, nurses, nurse practitioners, physician assistants, and behavioral health specialists confirms that levels of burnout and exhaustion are rising as the pandemic wears on. The survey, conducted January 4 to 14, 2021, is the second in a three-part series assessing COVID-19-related effects on health care providers.

Sixty-eight percent of providers said they feel emotionally drained from their work, 59% feel burned out, 57% feel overworked, and 50% feel frustrated. The poll asked providers who say they feel burned out what contributes most to that viewpoint. One doctor from the Central Valley wrote:

“Short staffed due to people out with COVID. I’m seeing three times as many patients, with no time to chart or catch up. Little appreciation or contact from my bosses. I have never had an N95 [mask]. The emotional toll this pandemic is taking. Being sick myself and spreading it to my wife and young kids. Still not fully recovered but needing to be at work due to physician shortages. Lack of professional growth, and a sense of lack of appreciation at work and feeling overworked. The sadness of the COVID-related deaths and the stories that go along with the disease. That’s a lot of stuff to unpack.”

Safety-net providers and health care workers with larger populations of patients of color are more likely to experience emotional hardships at work. As we know well by now, COVID-19 exacerbates the health disparities that have long burdened people of color and disproportionately harms communities with fewer health care and economic resources.

Women Bear the Brunt

The pandemic has been especially challenging for female health providers, who compose 77% of health care workers with direct patient contact. “The pandemic exacerbated gender inequities in formal and informal work, and in the distribution of home responsibilities, and increased the risk of unemployment and domestic violence,” an international group of experts wrote in the Lancet. “While trying to fulfill their professional responsibilities, women had to meet their families’ needs, including childcare, home schooling, care for older people, and home care.”

For one female doctor from the Bay Area who responded to the CHCF survey, the extra burdens of the pandemic have been unrelenting: “Having to work more, lack of safe, affordable, available childcare while I’m working. As a single mother, working 15 hours straight, then having to care for my daughter when I get home. Just exhausted with no days off. So many Zoom meetings all day long. Miss my family and friends.”

It is unclear how the pandemic will affect the health care workforce in the long term. For now, the damage “can be measured in part by a surge of early retirements and the desperation of community hospitals struggling to hire enough workers to keep their emergency rooms running,” Andrew Jacobs reported in the New York Times.

One of the early retirements Jacobs cited was Sheetal Khedkar Rao, MD, a 42-year-old internist in suburban Chicago. Last October, she decided to stop practicing medicine after “the emotional burden and moral injury became too much to bear,” she said. Two of the main factors driving her decision were a 30% pay cut to compensate for the decline in revenue from primary care visits and the need to spend more time at home after her two preteen children switched to remote learning.

“Everyone says doctors are heroes and they put us on a pedestal, but we also have kids and aging parents to worry about,” Rao said.

Working Through Unremitting Sickness and Death

In addition to the psychological burden, health care providers must cope with a harsh physical toll. People of color account for most COVID-19 cases and deaths among health care workers, according to a KFF issue brief. Some studies show that health care workers of color “are more likely to report reuse of or inadequate access to [personal protective equipment] and to work in clinical settings with greater exposure to patients with COVID-19.”

“Lost on the Frontline,” a collaboration of Kaiser Health News and the Guardian, has counted more than 3,400 deaths among US health care workers from COVID-19. Eighty-six percent of the workers who died were under age 60, and nurses accounted for roughly one-third of the deaths.

“Lost on the Frontline” provides the most comprehensive picture available of health care worker deaths, because the US still lacks a uniform system to collect COVID-19 morbidity and mortality data among health care workers. A year into the project, the federal government has decided to take action. Officials at the US Department of Health and Human Services cited the project when asking the National Academies of Sciences, Engineering, and Medicine for a rapid expert consultation to understand the causes of deaths among health care workers during the pandemic.

The National Academies’ report, published December 10, recommends the “adoption and use of a uniform national framework for collecting, recording, and reporting mortality and morbidity data” along with the development of national reporting standards for a core set of morbidity impacts, including mental well-being and psychological effects related to working through public health crises. Some health care experts said the data gathering could be modeled on the federal government’s World Trade Center Health Program, which provides no-cost medical monitoring and treatment for workers who responded to the 9/11 terrorist attacks 20 years ago.

“We have a great obligation to people who put their lives on the line for the nation,” Victor J. Dzau, MD, president of the National Academy of Medicine, told Jacobs.

Four reasons experts say coronavirus cases are dropping in the United States

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In recent weeks, U.S. coronavirus case data — long a closely-watched barometer of the pandemic’s severity — has sent some encouraging signals: The rate of newly recorded infections is plummeting from coast to coast and the worst surge yet is finally relenting. But scientists are split on why, exactly, it is happening.

Some point to the quickening pace of coronavirus vaccine administration, some say it’s because of the natural seasonal ebb of respiratory viruses and others chalk it up to social distancing measures.

And every explanation is appended with two significant caveats: The country is still in a bad place, continuing to notch more than 90,000 new cases every day, and recent progress could still be imperiled, either by new fast-spreading virus variants or by relaxed social distancing measures.

The rolling daily average of new infections in the United States hit its all-time high of 248,200 on Jan. 12, according to data gathered and analyzed by The Washington Post. Since then, the number has dropped every day, hitting 91,000 on Sunday, its lowest level since November.

A former director of the Centers for Disease Control and Prevention endorsed the idea that Americans are now seeing the effect of their good behavior — not of increased vaccinations.

“I don’t think the vaccine is having much of an impact at all on case rates,” Tom Frieden said in an interview Sunday on CNN’s “Fareed Zakaria GPS.” “It’s what we’re doing right: staying apart, wearing masks, not traveling, not mixing with others indoors.”

However, Frieden noted, the country’s numbers are still higher than they were during the spring and summer virus waves and “we’re nowhere near out of the woods.”

“We’ve had three surges,” Frieden said. “Whether or not we have a fourth surge is up to us, and the stakes couldn’t be higher.”

The current CDC director, Rochelle Walensky, said in a round of TV interviews Sunday morning that behavior will be crucial to averting yet another spike in infections and that it is far too soon for states to be rescinding mask mandates. Walensky also noted the declining numbers but said cases are still “more than two-and-a-half-fold times what we saw over the summer.”

“It’s encouraging to see these trends coming down, but they’re coming down from an extraordinarily high place,” she said on NBC’s “Meet the Press.”

Researchers at the University of Washington’s Institute for Health Metrics and Evaluation, publisher of a popular coronavirus model, are among those who attribute declining cases to vaccines and the virus’s seasonality, which scientists have said may allow it to spread faster in colder weather.

In the IHME’s most recent briefing, published Friday, the authors write that cases have “declined sharply,” dropping nearly 50 percent since early January.

“Two [factors] are driving down transmission,” the briefing says. “1) the continued scale-up of vaccination helped by the fraction of adults willing to accept the vaccine reaching 71 percent, and 2) declining seasonality, which will contribute to declining transmission potential from now until August.”

The model predicts 152,000 more covid-19 deaths by June 1, but projects that the vaccine rollout will save 114,000 lives.

In the past week, the country collectively administered 1.62 million vaccine doses per day, according to The Washington Post’s analysis of state and federal data. It was the best week yet for the shots, topping even President Biden’s lofty goal of 1.5 million vaccinations per day.

Nearly 40 million people have received at least their first dose of a coronavirus vaccine, about 12 percent of the U.S. population. Experts have said that 70 percent to 90 percent of people need to have immunity, either through vaccination or prior infection, to quash the pandemic. And some leading epidemiologists have agreed with Frieden, saying that not enough people are vaccinated to make such a sizable dent in the case rates.

A fourth, less optimistic explanation has also emerged: More new cases are simply going undetected. On Twitter, Eleanor Murray, a professor of epidemiology at Boston University School of Public Health, said an increased focus on vaccine distribution and administration could be making it harder to get tested.

“I worry that it’s at least partly an artifact of resources being moved from testing to vaccination,” Murray said of the declines.

The Covid Tracking Project, which compiles and publishes data on coronavirus testing, has indeed observed a steady recent decrease in tests, from more than 2 million per day in mid-January to about 1.6 million a month later. The project’s latest update blames this dip on “a combination of reduced demand as well as reduced availability or accessibility of testing.”

“Demand for testing may have dropped because fewer people are sick or have been exposed to infected individuals, but also perhaps because testing isn’t being promoted as heavily,” the authors write.

They note that a backlog of tests over the holidays probably produced an artificial spike of reported tests in early January, but that even when adjusted, it’s still “unequivocally the wrong direction for a country that needs to understand the movements of the virus during a slow vaccine rollout and the spread of multiple new variants.”

Where most experts agree: The mutated variants of the virus pose perhaps the biggest threat to the country’s recovery. One is spreading rapidly and another, known as B.1.351, contains a mutation that may help the virus partly evade natural and vaccine-induced antibodies.

Fewer than 20 cases have been reported in the United States, but a critically ill man in France underscores the variant’s potentially dangerous consequences. The 58-year-old had a mild coronavirus infection in September and the B.1.351 strain reinfected him four months later.

No matter what’s causing the current downturn in new infections, experts have urged Americans to avoid complacency.

“Masks, distancing, ventilation, avoiding gatherings, getting vaccinated when eligible. These are the tools we have to continue the long trip down the tall mountain,” Caitlin Rivers, an epidemiologist at Johns Hopkins University, said on Twitter. “The variants may throw us a curve ball, but if we keep driving down transmission we can get to a better place.

CDC presses for schools to reopen with precautions

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The Centers for Disease Control and Prevention (CDC) on Friday released long-awaited guidance on safely reopening schools, emphasizing the importance of having schools open as long as proper safety precautions are followed.

The guidance states it is “critical for schools to open as safely and as soon as possible,” given the benefits of in-person learning.

The top recommendations for doing so safely are universal wearing of masks by students, staff and teachers as well as distancing so that people are six feet apart.

Vaccination of teachers should be prioritized, the agency said, but “should not be considered a condition” of reopening schools.

Schools can adjust whether they are fully in-person or hybrid depending on the level of spread in the surrounding community and mitigation measures in place.

Schools are encouraged to use “podding” to separate students into smaller groups to help make contract tracing easier.

The pandemic’s coming new normal

Photo illustration of the Freedom from Want image by Norman Rockwell with all the participants of the dinner wearing surgical masks.

As both vaccinations and acquired immunity spread, life will likely settle into a new normal that will resemble pre-COVID-19 days— with some major twists.

The big picture: While hospitalizations and deaths are tamped down, the novel coronavirus should recede as a mortal threat to the world. But a lingering pool of unvaccinated people — and the virus’ own ability to mutate — will ensure SARS-CoV-2 keeps circulating at some level, meaning some precautions will be kept in place for years.

Driving the news: On Tuesday, Johnson & Johnson CEO Alex Gorsky told CNBC that people might well need a new coronavirus vaccine annually in the years ahead, much as they do now for the flu.

  • Gorsky’s comments were one of the clearest signals that even as the number of vaccinated people rises, the mutability of SARS-CoV-2 means the virus will almost certainly be with us in some form for years to come.

Be smartThat sounds like bad news — and indeed, it’s much less ideal than a world in which vaccination or infection conferred close to lifelong immunity and SARS-CoV-2 could be definitively conquered like smallpox.

  • With more contagious variants spreading rapidly, “the next 12 weeks are likely to be the darkest days of the pandemic,” says Michael Osterholm, the director of the University of Minnesota’s Center for Infectious Disease Research and Policy.
  • But the apparent effectiveness of the vaccines in preventing hospitalizations and death from COVID-19 — even in the face of new variants — points the way toward a milder future for the pandemic, albeit one that may be experienced very differently around the world.

Details: From studying what happened after new viruses emerged in the past, scientists predict SARS-CoV-2 will eventually become endemic, most likely in a seasonal pattern similar to the kind of coronaviruses that cause the common cold.

  • That’s nothing to sneeze at — literally, it will make us sneeze — but as immunity levels accumulate throughout the population, our experience of the virus will attenuate, and we’ll be highly unlikely to experience the severe death tolls and overloaded hospitals that marked much of the past year.

Yes, but: The existence of a stubborn pool of Americans who say they won’t get vaccinated — as well as the fact that it may take far longer for children, whom the vaccines have yet to be tested on, to get coverage — will give the virus longer legs than it would otherwise have.

  • “This will be with us forever,” says Osterholm. “That’s not even a debate at this point.”

What’s next: This means we can expect the K-shaped recovery that has marked the pandemic to continue, says Ben Pring, who leads Cognizant’s Center for the Future of Work.

  • With the virus likely to remain a threat, even if a diminished one, “those who are more stuck in the analog world are really going to continue to struggle,” he says.
  • Health security will also become a more ingrained part of daily life and work, which means temperature checks, masks, frequent COVID-19 testing and even vaccine passports for travel are here to stay.

The catch: That’s not all bad — the measures put in place to slow COVID-19 have stomped the flu and other seasonal respiratory viruses, and if we can hold onto some of those benefits in the future, we can save tens of thousands of lives and billions of dollars.

  • If the inequalities seen in the early phase of the vaccine rollout persist, COVID-19 could become a disease of the poor and disadvantaged, argues Mark Sendak, the co-founder and scientific adviser for Greenlight Ready, a COVID-19 resilience system that grew out of Duke Health.
  • Sendak points to the example of HIV, a disease that is entirely controllable with drugs but continues to exert a disproportionate toll on Black Americans, who take pre-exposure prophylactic medicine at much lower rates.

“If we go back to ‘normal,’ then we have failed.”

— Mark Sendak

What to watch: Whether the vaccine rollout can be adapted to reach hard to find and hard to persuade populations.

  • The Biden administration announced yesterday that it will start delivering vaccines directly to community health centers next week in an effort to promote more equity in the vaccine distribution process.
  • As the administration rolls out new COVID-19 plans, it needs to “invest in the community health care personnel” who can ensure that no one is left behind, says Sendak.

The bottom line: While SARS-CoV-2 has proven it can adapt to a changing environment, so can we. But we have to do so in a way that is fairer than our experience of the pandemic has been so far.

Where the pandemic has been deadliest

Image result for Ratio of COVID-19 deaths to population Map: Michelle McGhee and Andrew Witherspoon/Axios

In the seven states hit hardest by the pandemic, more than 1 in every 500 residents have died from the coronavirus.

Why it matters: The staggering death toll speaks to America’s failure to control the virus.

Details: In New Jersey, which has the highest death rate in the nation, 1 out of every 406 residents has died from the virus. In neighboring New York, 1 out of every 437 people has died.

  • In Mississippi, 1 out of every 477 people has died. And in South Dakota, which was slammed in the fall, 1 of every 489 people has died.

States in the middle of the pack have seen a death rate of around 1 in 800 dead.

  • California, which has generally suffered severe regional outbreaks that don’t span the entire state, has a death rate of 1 in 899.
  • Vermont had the lowest death rate, at 1 of every 3,436 residents.

The bottom line: Americans will keep dying as vaccinations ramp up, and more transmissible variants of the coronavirus could cause the outbreak to get worse before it gets better.

  • Experts also say it’s time to start preparing for the next pandemic — which could be deadlier.

What happens after a year without the flu?

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Doctors and scientists have been relieved that the dreaded “twindemic”—the usual winter spike of seasonal influenza superimposed on the COVID pandemic—did not materialize.

In fact, flu cases are at one of the lowest levels ever recorded, with just 155 flu-related hospitalizations this season (compared to over 490K in 2019). A new piece in the Atlantic looks at the long-term ramifications of a year without the flu. 

Public health measures like masking and handwashing have surely lowered flu transmission, but scientists remain uncertain why flu cases have flatlined as COVID-19, which spreads via the same mechanisms, surged.

Children are a much greater vector for influenza, and reduced mingling in schools and childcare likely slowed spread. Perhaps the shutdown in travel slowed the viruses’ ability to hop a ride from continent to continent, and the cancellation of gatherings further dampened transmission.

Nor are scientists sure what to expect next year. Optimists hope that record-low levels of flu could take a strain out of circulation. But others warn that flu could return with a vengeance, as the virus continues to mutate while population immunity declines. 

Researchers developing next year’s vaccines, meanwhile, face a lack of data on what strains and mutations to target—although many hope the mRNA technologies that proved effective for COVID will enable more agile flu vaccine development in the future. 

Regardless, renewed vigilance in flu prevention and vaccination next fall will be essential, as a COVID-fatigued population will be inclined to breathe a sigh of relief as the current pandemic comes under control.

“I got the vaccine…now what can I do?”

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A family member in her 70s called with the great news that she received her first dose of the COVID vaccine this week. She mentioned that she was hoping to plan a vacation in the spring with a friend who had also been vaccinated, but her doctor told her it would still be safest to hold off booking travel for now: “I was surprised she wasn’t more positive about it. It’s the one thing I’ve been looking forward to for months, if I was lucky enough to get the shot.” 

It’s not easy to find concrete expert guidance for what it is safe (or safer?) to do after receiving the COVID vaccine. Of course, patients need to wait a minimum of two weeks after receiving their second shot of the Pfizer or Moderna vaccines to develop full immunity.

But then what? Yes, we all need to continue to wear masks in public, since vaccines haven’t been proven to reduce or eliminate COVID transmission—and new viral variants up the risk of transmission. But should vaccinated individuals feel comfortable flying on a plane? Visiting family? Dining indoors? Finally going to the dentist?
 
It struck us that the tone of much of the available guidance speaks to public health implications, rather than individual decision-making. Take this tweet from CDC director Dr. Rochelle Walensky. A person over 65 asked her if she could drive to visit her grandchildren, whom she hasn’t seen for a year, two months after receiving her second shot. Walensky replied, “Even if you’ve been vaccinated, we still recommend against traveling until we have more data to suggest vaccination limits the spread of COVID-19.” 

From a public health perspective, this may be correct, but for an individual, it falls flat. This senior has followed all the rules—if the vaccine doesn’t enable her to safely see her grandchild, what will? It’s easy to see how the expert guidance could be interpreted as “nothing will change, even after you’ve been vaccinated.”

Debates about masking showed us that in our individualistic society, public health messaging about slowing transmission and protecting others sadly failed to make many mask up.

The same goes for vaccines: most Americans are motivated to get their vaccine so that they personally don’t die, and so they can resume a more normal life, not by the altruistic desire to slow the spread of COVID in the community and achieve “herd immunity”. 

In addition to focusing on continued risk, educating Americans on how the vaccinated can make smart decisions will motivate as many people as possible to get their shots.