CMG COVID-19 Weekly Update 7.18.21

New or Updated This Week:
The UK as Harbinger for thEUS (new)
On Vaccine Booster Doses and the Development of an Updated mRNA Vaccine (new)
“Before Hours” Walk-in Availability for Sick Children Has Resumed (updated)
On Office Protocols and Traffic (new)
Status of the Pandemic in the United States and the World (updated)
Status of the Pandemic in the Washington Area (updated)
Statistics – CMG Tests for Active Disease (updated)

Hello again everyone. This is the 68th in a series of COVID-19 updates from Capitol Medical Group. These notices are meant to provide an update on the pandemic, explain procedures we have put in place to best serve you, and provide guidance about protecting yourselves and your families. New and updated sections are so indicated.

In an effort to ensure that this notice reaches everyone in our practice, we are sending it to every patient on file rather than one per family. Our apologies if your family receives multiple copies.

The UK as Harbinger for the US (new)

Roughly 7 weeks ago, cases in the UK started rising as the Delta variant first identified in India took hold. We have been watching what happens in the UK as a potential predictor for the United States since both have relatively advanced immunization programs. Unfortunately, the UK’s experience does not bode well for the United States.

The UK recorded 48,000 new cases on Thursday and 51,000 on Friday. This compares to a baseline of 2,000 cases per day in April and May before the current Delta-driven wave began. The UK’s record for cases in a day is 68,000, set at the height of its winter surge in January. The 7-day average of new cases per day in the UK currently stands at 39,000, two thirds of the way to its winter peak of 59,000.

That peak in weekly caseload was followed two weeks later by a peak in average Covid deaths per day of 1,250. These numbers generate a crude “mortality figure” of 2.1% at that time (1,250 deaths from 59,000 cases = 2.1%). This number is not an accurate mortality rate – there were surely mild cases that went undetected, so the actual mortality number would be lower, and there are other factors that this calculation omits – but this figure can be used for a rough comparison to what’s happening at the moment. Fortunately, the current wave is resulting in far fewer deaths relative to the total number of cases. The current average of Covid-related deaths per day in the UK is 40. Since deaths lag cases by roughly two weeks, the current number of deaths per day can be linked to the average daily caseload from early July, which was 23,000. 40 deaths per day stemming from 23,000 cases per day two weeks earlier leads to a mortality figure of 0.17%. Again, this is not a proper calculation of the true mortality rate, but it clearly suggests that the current wave is leading to far fewer deaths per case than the winter wave.

This decrease in mortality is likely related to the vaccine program in the UK, which began with the oldest cohort and has proceeded to progressively younger cohorts over time. At this point, 53% of the UK’s population (all ages) has been fully vaccinated, and another 16% is partially vaccinated. Because there has been heavy vaccine uptake in the older cohorts, the average age of those contracting the disease has decreased substantially. This has brought the mortality rate down since those who are younger are much less likely to develop severe cases.

The United States is now roughly two weeks into the beginning of its own Delta-fueled wave, so we are 5-6 weeks behind what’s happening in the UK. We feel it is likely that the course of this wave in the United States will mirror that of the UK, though there is reason to fear the situation will be worse in the US. Vaccination rates here are lower – 48% of the US population is fully vaccinated (all ages) and 8% are partially vaccinated – and the vaccine program has slowed dramatically. There are no restrictions on activity in most parts of the United States and a significant portion of the population remains uninterested in or actively hostile to vaccination and other measures meant to limit viral transmission. There is also a higher percentage of unvaccinated adults over age 50 in the US than the UK; this cohort is at heightened risk for severity of disease.

US cases peaked in January at 259,000 per day. This was followed a few weeks later by a peak in Covid-related deaths of 3,340 per day. This yields a winter peak mortality figure (again: not accurate, almost certainly an overestimate, but useful for purposes of comparison) of 1.3%. Currently the US is recording approximately 273 Covid-related deaths per day, which stems from a caseload two weeks ago of 13,300 per day, yielding a mortality figure of 2.1%. If this number were accurate, it would suggest that current cases are leading to deaths more frequently in the US than during the winter surge. This is not likely to be the case – the true number of cases in the US is likely much higher than reported because fewer people with mild symptoms are seeking testing at the moment as they try to “move on” from the pandemic. Nevertheless, these numbers suggest that the US will not see as dramatic a reduction in mortality as the UK has experienced.

If, like the UK, the caseload in the US reaches 2/3 of its winter peak, that would mean 165,000 cases recorded per day. Even if we decreased the above referenced mortality figure from 2.1% to 0.9%, 165,000 cases per day would translate to nearly 1,500 deaths per day a few weeks later. It is hard to think about the pandemic getting this bad again in the United States, but the UK’s experience and that of numerous other countries around the world suggest this is a real possibility.

We feel there is a complacency with regard to the threat posed by Delta in the United States that is misguided. It is true that those who are vaccinated are extremely well protected against severe manifestations of the disease. It is also true that children who are too young to be vaccinated are at very low risk for severity of disease – orders of magnitude lower than older adults. There is also no data to suggest that Delta will lead to worse outcomes in infected children than previous strains. And though it is possible to contract the Delta variant after vaccination – we have begun seeing such cases and will see more and more as time goes on – the overwhelming majority of these infections will be mild. Adults who are not vaccinated, however, and those who do not have fully functioning immune systems, are at significant risk from Delta. If you are in one of these categories, we urge you to seek vaccination and/or revert to full masking and distancing protocols. This variant is extremely contagious and will become steadily more prevalent in the United States in the coming weeks.

On Vaccine Booster Doses and the Development of an Updated mRNA Vaccine (new)

Pfizer last week announced its intent to seek FDA approval for a third “booster” dose of its vaccine. This generated a burst of media attention and uncertainty among the public as to whether a booster will soon be needed. In response, the CDC and FDA issued a joint statement noting that people who are fully vaccinated (meaning two doses from Pfizer or Moderna or one from J&J) are well protected against severe manifestations of the disease. The statement correctly points out that at this stage of the pandemic in the U.S. “virtually all COVID-19 hospitalizations and deaths are among those who are unvaccinated,” and concludes that there is no need for a booster dose at this time. We agree with this view as it relates to people with fully functioning immune systems who received Pfizer or Moderna vaccines. Multiple studies from different parts of the world have consistently shown that the mRNA vaccines from Pfizer and Moderna are 94-96% effective against hospitalization and death across all variants including Delta. We do not yet have comprehensive data on J&J with regard to efficacy against severe disease caused by the Delta variant.

Those who are partially or fully immunocompromised may well benefit from a booster dose of vaccine. Studies on this are ongoing and the CDC is actively investigating this issue. We expect additional guidance on this question in the coming weeks.

Receiving less media attention was Pfizer’s simultaneous announcement that it is working on an updated version of its vaccine tailored specifically to the genome of the Delta variant. In our view this is a positive development. The Delta variant has rapidly become dominant in many countries and will soon be dominant world-wide. A vaccine based on its genome is important for two reasons: maximal protection against Delta itself, and a greater likelihood of protection against future versions of the virus, which are increasingly likely to be derivative of Delta. It will be useful for those around the world who have not yet been vaccinated and for those who may need a future booster dose to have a vaccine available that is as closely tailored to the most recent dominant strain as possible.

“Before Hours” Walk-in Availability for Sick Children Has Resumed (updated)

CMG Pediatrics has resumed its Before Hours walk-in availability for sick children Monday-Friday between the hours of 7 and 8 a.m. Before Hours is meant to provide an opportunity for parents to have their sick children evaluated early in the morning so decisions about school, camp, or work can be made first thing. It is a walk-in service that takes place before the phone system has turned on, so there is no need to call – just arrive at the office between 7 and 8. At 8 a.m. our scheduled day begins, so patients arriving after 8 cannot be seen as walk-ins and will be asked to schedule an appointment later in the day.

Before Hours is meant to provide an opportunity for rapid evaluation of relatively straightforward acute issues such as sore throat, ear pain, cough, fever and the like. It is not meant for appointment types that require a more significant amount of time, such as addressing chronic or complicated issues like ongoing headaches, abdominal pain, constipation, lingering concussion symptoms, etc. For these types of issues we request that you schedule a regular appointment with your provider.

We are able to conduct any type of testing during Before Hours visits, including Covid testing. However, Before Hours is meant for children with active symptoms. If your child is healthy but needs Covid testing for clearance for travel, camp, or other reasons, we request that you continue to utilize our parking lot-based testing program. If you need testing for this reason, please contact the office a day or two in advance.

On Office Protocols and Traffic (new)

Though masking protocols have been relaxed in Montgomery County, we must still require that parents and patients over age 2 wear masks while in our suites. We have many patients who are too young to be vaccinated and a good number of patients and parents who are immunocompromised. To protect everyone from unintentional exposure to Covid and other germs, please wear a mask when you come to the office. Thank you for your understanding.

We also regret to report that with construction ongoing on Connecticut Avenue and more people out and about, traffic around the office has returned to pre-pandemic levels. For in person visits, please take traffic into account and plan to arrive 15 minutes prior to your scheduled appointment time so that you can be checked in, measured and prepared in the exam room by the time your provider is scheduled to see you. Thank you!

Status of the Pandemic in the United States and the World (updated)

The situation in the United States worsened significantly over the last three weeks. Almost 52,000 new cases were reported Friday alone, the most since April 30th and up dramatically from last Friday (35,000). The 7-day average of new cases, number of hospitalizations, average deaths per day and test positivity rate have all increased.

The 7-day cumulative number of Covid-19 cases per 100,000 people in the United States currently stands at 63, up from 28 three weeks ago and compared to 49, 56, and 70 the three weeks before that.

The 7-day average number of new cases per day in the United States is currently 31,000, up from 12,000 three weeks ago and 13,000, 14,000, and 22,000 the three weeks before that. The United States recorded roughly 215,000 total new cases during the week. This represents 6.4% of all new cases worldwide. The United States has 4.25% of the world’s population.

The national test positivity rate was 4.8%, up from 2.0% three weeks ago. This is the highest test positivity rate in over two months..

The number of people currently hospitalized with Covid stands at 21,700, up from 17,000 three weeks ago. The last few weeks have seen an uptick in hospitalizations for the first time in months.

An average of roughly 275 deaths per day were recorded in the United States this week, down from 310 three weeks ago but up 23% from the nadir two weeks ago. As of Saturday morning, the pandemic had killed roughly 608,000 people in the United States.

All 50 states and the District saw an increase in cases over the last two weeks. The current top 10 states (cumulative 7-day case rate per 100,000 population): Arkansas 238, Florida 210, Missouri 210, Louisiana 182, Nevada 161, Utah 112, Kansas 98, Oklahoma 98, Alaska 98, and Wyoming 98. Again, the national number is currently 63 cases per week per 100,000 people.

The per capita numbers in our region (cumulative 7-day case rate per 100,000 population) worsened over the last three weeks: Maryland 14 (up from 4 three weeks ago), DC 28 (up from 7 three weeks ago), and Virginia 28 (up from 14 three weeks ago). DC, Virginia and Maryland are 33rd, 35th and 49th on the list this week.

Many populous nations have higher per capita rates of disease than the United States at the moment. The top 10: Botswana (469 cases per 100,000 population this week), Tunisia 441, UK 413, Netherlands 399, Cuba 392, Mongolia 357, Spain 343, Namibia 322, Colombia 259, and Georgia 259.

Status of the Pandemic in the Washington Area (updated)

New cases reported in DC averaged 28 per day this week, up from 9 three weeks ago and 16 two weeks before that. To this point DC has documented roughly 49,650 cases and 1,146 deaths. New cases in Montgomery County averaged 19 per day this week, up from 6 three weeks ago and 11 two weeks before that. Montgomery County has now recorded roughly 71,400 total cases and approximately 1,577 deaths.

Statistics – CMG Tests for Active Disease (updated)

CMG recorded 8 positive tests for active disease this week. This compares to a total of 6 positive tests over the prior two weeks.