Dear Patients of Sansum Clinic,
It has been a little more than a year since the COVID-19 Pandemic changed everything. Even though the pandemic had started in China at the end of 2019 and there were scattered outbreaks affecting the United States in the winter of 2020 – recall the cruise ships without a place to disembark and the clusters of cases in Washington State and the initial wave of cases around New York City - in California, it was in March 2020 that the shutdowns began and cases started to appear.
A bit more than a year later, we’ve been through a series of shutdowns, economic devastation for many, school closings, social dislocations for everyone and several surges of COVID-19. In Santa Barbara County, according to data from the New York Times there have been 33,926 cases (1 of 13 people in the County) and 448 deaths (1 of 997 people in the County) related to COVID-19. (I’m using the New York Times dataset to compare other areas on an apples-to-apples basis.) At Sansum Clinic, we have diagnosed 2,356 cases of COVID-19. Our hospitalists and ICU doctors have taken care of more than 300 cases of people ill enough to be hospitalized, many critically ill. We have administered 15,870 doses of COVID-19 vaccines. We have been through a lot and have learned a lot.
I thought it might be a good time to take stock of where we are and what we are concerned about a little more than a year into this crisis.
STATE OF THE PANDEMIC LOCALLY AND LOOKING WITH A WIDER VIEW
Locally, the cases of COVID-19 have been dropping over the last few months. Below is the most recent data from our testing at Sansum Clinic. Even though the dataset is not huge, it has been very consistent and has reflected quite faithfully what is happening in the community.
Sansum Clinic COVID-19 testing, by week:
The Santa Barbara County Public Health Department website (on April 25, 2021) is reporting a 1.8% positivity rate, a low rate, consistent with our data.
While the news is clearly good locally, it is important to realize that the news is not the same in the rest of the country. Below is a map from the New York Times (April 25, 2021), showing the variation in disease activity by county throughout the US. There is nothing so unique about Santa Barbara that we can assume that what is happening where things are bad cannot happen here.
On a statewide basis, California is among the states doing the best with a case rate of 6/100,000. As you can tell from the map, Michigan is currently doing the worst with a case rate of 54/100,000 (a nine-fold difference from California).
The “UK Variant” (technically B.1.1.7) is the most common variant circulating in Michigan (and much of the country). As you have heard, this variant is more contagious and more virulent than the original form of the coronavirus that causes COVID-19. The population of Michigan is only a little bit less vaccinated than the population of California. It is not the small difference in vaccination rates that accounts for the huge difference in disease activity. Fortunately, it seems as if the tide may be turning in Michigan, but the situation there should tell us that we need to be vigilant and not declare victory yet.
Besides the regional variation in cases, what else is different from earlier in the pandemic?
An important new trend in COVID-19 in the U.S. is the age distribution of cases, particularly the age distribution of people being hospitalized. Earlier in the pandemic, the majority of people hospitalized were older, typically above age 65. Recently, as the graph from the CDC website (April 25, 2021) shows, the national overall rate of hospitalization has gone down from the winter peak, but the percentage of those hospitalized who are younger is going up. Some speculate that it is because those over 65 are generally more likely to be vaccinated than younger people. Others speculate it is because those over 65 tend to be more cautious in terms of COVID-avoidance behavior. I suspect both of those explanations are true.
It is worth mentioning what is going on in India right now. India is in the midst of a horrible surge, with hundreds of thousands of new cases a day and a health system barely able to provide even basic care to many. There appears to be a variant there that is highly contagious and more virulent – a story we have heard before. As is the case in many countries with fewer financial resources, the vaccine rate there is only a fraction of that in wealthier countries. Again, using the New York Times dataset, India is reported to have vaccinated 10% of its population, about 20% of the rate in the United States. A combination of a highly transmissible variant in a densely, unvaccinated population is a recipe for the disaster that is unfolding.
VACCINATION SUCCESSES AND CONCERNS
The fact that there are three effective vaccines in use in the United States and that about one half the adult population (those over 18) have received one dose or more of an effective vaccine is remarkable. The chart below from the CDC tells the more complete story – note the difference in those fully vaccinated by age, and recall the shifting age demographics of hospitalizations noted above.
Locally, according to the New York Times dataset, the County of Santa Barbara has fully vaccinated 38% of those over 18 and 69% of those over 65, better than the national average. Despite a slow start, owing to a real shortage of vaccine, the County has done well. The hospitals in Santa Maria and Lompoc have been effectively vaccinating the northern part of the County. In the Southern part of the County, Cottage Hospital has done a tremendous job of getting the community vaccinated, operating a very high-volume drive-through vaccine operation. The Public Health Department, in addition to steering all of us through unfamiliar terrain, has managed to be one of the most important vaccinators throughout the County. Sansum Clinic has also been jabbing along since the beginning of this, working on nights and weekends because our buildings are full during the day. We have provided 15,870 vaccines to date. Our local pharmacies have been helping, too. It’s been a true team effort.
While the adoption of vaccination up to this point has been encouraging, we are seeing signs of change that are concerning. There is evidence of greater vaccine hesitancy. Three weeks ago, if we opened 500 vaccination spots in the upcoming days, they would be filled in a few hours. Recently, we and the others operating large volume clinics, have spots going unfilled. Again, there are tens of thousands of people in SB County now eligible who have not been vaccinated. We have not reached the greater than 80% (at least) level that is needed for effective “herd immunity.” Despite that, we and others are not filling all of our spots.
Last week, the New England Journal of Medicine published data from Israel about the effectiveness of vaccines. While we already knew much of this from the randomized trials that led to the Emergency Use Authorizations of the current vaccines, the randomized trials involved tens of thousands of people. This data looked at hundreds of thousands of people in the “real world.” This data was based on the Pfizer Vaccine, the one primarily used in Israel. Below are graphs of what happened in the days after more than half a million people were vaccinated compared to a control set of those not yet vaccinated. By two weeks after just one dose, the lines diverge – the red line is for those not vaccinated, the blue line for those vaccinated. The shaded area around the line is the confidence interval – a measure of the confidence in the validity of the reported result. Most of the cases in those vaccinated occur before day 28, before the second vaccine (at day 21) has had a chance to work fully. Regardless, the differences in outcomes are dramatically improved in the vaccinated group. Just as in the randomized trials, in the real world, it appears as if the vaccines work (assuming the others will show similar fidelity to the trial results).
NEJM, April 15, 2021.
Another concerning trend we are seeing is people not returning for their second “booster” dose of an mRNA vaccine. Recall Moderna and Pfizer both are mRNA vaccines, each licensed to be a two-shot series. Our most recent vaccine clinic had an 8% no-show rate for the second dose. We did not see that previously. Everyone showed up for their second dose until recently. Whether people have heard that some people have symptoms after the second dose or if they feel that “I get enough effect from one dose” they are taking a chance that they should not be taking. Some people do feel poorly as their immune system responds to the second dose, which is ironically a sign the vaccine worked. Those reactions usually last less than 48 hours. A single dose of the mRNA vaccines has not been studied to know if it works over time.
The pause on the Johnson & Johnson (J&J) vaccine has likely also contributed to the hesitancy we are seeing with the other vaccines, even though the mRNA vaccines are different in mechanism and the rare clotting side effects which sidelined the J&J have not been seen in those. The J&J vaccine has now been put back into service. As you may know, about 1 in 1 million people vaccinated have developed serious blood clots, with the J&J vaccine, some of which have been fatal. Disastrous side effects cause us to give those side effects greater weight than the frequency of them should cause us to do. It is human nature to do that. But it is important to keep in mind the frequency of that problem. The CDC website lists the chance of a lightning strike of a person to be 1 in 500,000 in a given year. This awful vaccine side effect is about ½ that frequency. The chance of an unvaccinated person getting COVID and then getting a clot or dying as a result of COVID-19 is much greater than the chance of getting a clot from the J&J vaccine.
SO, WHERE ARE WE NOW?
Summarizing the situation locally and nationally, things are going well locally – in our County and our State. But, there are parts of the country (and the world) in which the disease is still very active. The fact that younger people, those least vaccinated and most active, are increasingly those being hospitalized in the United States should tell us of the importance of vaccination and the importance of not jumping too quickly to a declaration of complete victory over the pandemic.
There is abundant evidence that vaccines are safe and effective. There is growing evidence that outbreaks are occurring and will continue to occur when we believe the herd is immune, before the herd is immune, which is likely what happened in Michigan or when a surge strikes and the population is not remotely adequately immunized and the fire burns through the dry brush with no fire breaks - as is happening now in India.
What can we do?
Get vaccinated. If you have started with a two-shot vaccine, get both.
To get vaccinated, most vaccine sites in our County are using the MyTurn system to make appointments. The site can be reached at myturn.ca.gov or by calling 833-422-2455. Some pharmacies use their own scheduling systems, but most including Sansum, Cottage and the Public Health Department use MyTurn.
Talk with people who might be reluctant to get vaccinated. Here are some links to sites that can provide help with those discussions:
Once you are vaccinated, it is still recommended that you follow all safety protocols including wearing a mask, social distancing, avoiding large gatherings and non-essential travel.
Remember, we are all in this together. Thank you for choosing Sansum Clinic – and please know, we’re all smiling under our masks.