COVID-19 11/18: Vaccine News, Cases Increasing, and the Holidays

Dr. David Pong filled in for Dr. Bishop on this week's COVID-19 update and discussed the recent exciting vaccine news, the rise in cases across the country, how people can be safe during the holidays, and more. Watch the video below and read on for a recap. 

Numbers Rising in U.S.

It's a pretty sobering time. Right now in the United States, there have been more than 11 million cases of COVID-19 and more than 250,000 people who have died from this disease, and a growing number of people who are suffering from various lasting injury and effects of their infection that we still have a lot more to learn about.

As of July 13th, the Virginia Department of Health reported that the seven-day moving average of COVID-19 cases, the positive rate was about 7.4%. It's been rising about one percentage point every eight to 10 days lately. We're now seeing between 1,500 and 2,000 positive tests per day in Virginia. And about a month ago, we had about 975 people who were positive in hospitals. And right now we're at about 1,400. So significant change in the last month.

In South Carolina, the seven-day case positivity rate is 15%. It's 15% in Georgia as well. And in Maryland, the case positivity rate increased from 3% to nearly 7% in the last month. So in all of our locations, the proportion of those being tested, who are positive, the absolute number of cases is growing rapidly.

I think my biggest concern is that this is happening ahead of when many of our children are coming back from college, when they've been away. It's happening ahead of the coldest weather, which will force us to be inside.

And it's happening ahead of the holidays. Right now about 40% of folks in a recent Pew survey said that they intended to gather inside their homes with people from other households to celebrate the holidays. And that's likely to push the numbers higher unfortunately.

Exciting Vaccine News

Now clearly there's some good news right now in the news. You've all seen recently that Pfizer has released initial preliminary data and, now today, formal data of their big trial showing that their vaccine is more than 90% effective in preventing those who get the vaccine from getting COVID-19. And it appears to also diminish the severity of the disease in the few people who did get infected. We have that combined with the other mRNA vaccine, Moderna, where they have nearly 95% prevention rate and also will be able to release their vaccine probably by the end of the year.

It's exciting because we think that these are much higher effectiveness rates than expected. The vaccines both require two doses. The expectation is that you'll get one dose and then a few weeks later, get the second dose. And by about a month from the first dose, you would have your protection in place.

There are some hurdles right now. Vaccine production has been going on kind of in anticipation of these being successful vaccines. And so there are millions of doses and yet there will not be enough doses for every person in the United States to be vaccinated in this first wave. There are also hurdles in terms of distribution. The Pfizer vaccine requires very cold storage and many practices like ours are ramping up our ability to store at the minus 90 degree storage that's required.

The Moderna vaccine looks like it can be stored at more typical settings and maybe easier for most facilities to store. There are distribution issues also that have to do with getting a vaccine that has to be kept very cold out into all the settings where it will be needed.

PartnerMD has taken all the steps we can with the various state departments of health that we work with to make sure that we will be able to provide vaccines as soon as they're available to us. By now I believe that the CDC and the state departments of health are governing the distribution of vaccination for COVID-19. The intention is to vaccinate frontline health workers, those in congregant living settings, such as nursing home settings, and those at highest risk for having severe outcomes.

It's likely that practices such as ours will probably be in a second tier for being able to distribute vaccine, but we'll know more as as things continue to unfold. We have recently added to our website, if you now were to go to partnermd.com/covid19-vaccines, it should take you to our best information and timelines as this continues to evolve and I would refer you there. And of course, we'll be happy to talk about questions and answers as we go forward today.

Containing COVID While We Wait for a Vaccine

My last kind of prepared ideas is then — how do we contain this rising wave of COVID while we wait for vaccines? While we wait for access? I'm reminded of those videos that show up in my feed from time to time where you see the person who's approaching the end of their cycling race and they get excited and they raise their hands up at which point they crash ahead of the finish line and people go past them.

And this is not the time, now that we have the vaccines, this is not the time for us to take our eye off the ball and to stop with the protective activities that have helped us so far. Right?

So I assume that if you're watching this program, you already believe that COVID is real. You recognize the threat that it presents. You've been wearing your masks when you're indoors with other people outside of your household. You're keeping distance from other folks and you're washing your hands and keeping your hands away from your face.

That stuff is still really important, very important that we continue that. It is likely that we will not, most of us will not likely have access to vaccines until we get into the spring of 2021. And do not let your guard down. Wouldn't you hate to be someone who got COVID on the eve of the vaccine being available?

Remember Your Why

Going back, when I think about how I'm going to help protect myself, my coworkers, my family, I always have to first remember why I'm trying to do that. We get to the point of the decisions we make cognitively. We think about the different things that we're going to do or not do for weeks.

Now, my wife and I have been thinking about and rolling around arguments of how we could manage to get a group of folks together for Thanksgiving and how we could safely do it. A lot of cognitive work, but ultimately we'll make that decision emotionally. We make our decisions by how we feel. And it's very important then to remember why this stuff matters to you, not just why it matters in terms of the bigger picture of the numbers, but why it matters to you.

The numbers are huge. We know that right now the number of people killed by COVID is equal to all of the people in Richmond. It's equal to half of Atlanta's population. It's equal to four times the population of Greenville, seven times the population of Owings Mills. So it's a lot of people. And yet the people that matter most to us are the people in our lives, our families, our coworkers, our children.

So I encourage you, as you think about how you're going to craft the time you spend between now and getting adequate vaccination together, that we think about who those people are and how important is it to us that we are not the ones responsible for giving this away, right?

The numbers are very important, but they don't really reflect what it feels like to realize that you're the person who infected their family.

I have the terrible memory of having thrown a dinner party many years ago where I didn't cook the lamb chops thoroughly. And of the 10 people who were there, four people got sick and thankfully, no one was hospitalized and nobody died. But you know, I still carry that. The idea that I didn't take enough care in what I was doing, but that I caused people to get sick, and of course, there's something like COVID, it would have, of course, just be worse.

Holiday Advice

Many of you know that I am a Thanksgiving kind of guy. I love having my big extended family filling my little house laughing, singing, telling stories, dancing, eating all day long. And we're not going to do that this year.

It's, as I said earlier, my wife and I have been thinking about this for weeks and we've come to the realization that what we want is to bring everyone together. And what we know that we can't do is bring everyone together.

And so it's time to get creative, and we all need to get creative because we have to feel good about what we're trying to do. And I really encourage you to really think about how to make your get-togethers as safe as they can be, and yet hopefully be able to yield the emotional results you want for getting together for the holidays.

So it's time to get creative. Is it possible for you to get folks together outdoors? It's really clear in the data that being outdoors with other folks is significantly safer than being indoors. Remember not only is this virus spread by droplets, but it's also spread by aerosolized, inhaled virus. And the longer we spend indoors sharing the air, the more likely it is for someone in our midst to be able to give us the virus.

So outdoor events are better. And if it's possible to be able to have, let's say, a fire pit or an outdoor heater, you may be able to make that make that more doable.

For some people it's going to work better to actually be in separate homes. We have all gotten tired of doing this sort of Zoom interaction. And yet it may be that the safest thing is to eat separately and yet connect through something like Zoom.

Or maybe after you eat, we could all gather in a park and take a walk. Maybe you could throw a football together, but not being under one roof piled into one room, having that big table of food and big table full of people would be better.

Consider a Pre-Holiday Quarantine

If you need to be under one roof, right, if there just isn't a good alternative, one thing that is very protective is can you quarantine? If between now and Thanksgiving, you truly quarantine, stay in your house, minimize almost no contact in the outer world. Can you do that?

And if so, actually, if you're asymptomatic at the time Thanksgiving rolls around, the likelihood of transmitting the virus is very, very low. It's in fact a better strategy than trying to test your way out of this. We've talked about that before, and you can see it at the national level. The people around the president and the vice president used testing as the way to avoid transmission. And yet they can't test often enough.

Testing is unfortunately not accurate enough to ensure that we will not transmit the virus unwittingly. So quarantining is incredibly effective if you can manage it. It's just hard. But if you can, that would be ideal.

If you have to be under one roof and not everyone can quarantine, is it possible for households to each sit at their own table? You can spread them apart so that the folks who live under my roof can be in one part of the home and someone who lives out of state and has come in could eat at another table and keep those tables separate.

Again, the transmission rate goes down significantly if you do that. If you're having people eating with you, consider having one person serve. That person should have on a mask and have on gloves, but that would minimize the risk of people congregating around the good food, right?

It would minimize the risk of having people sharing utensils, where potentially someone could cough on a spoon, and then that could be the vector.

So again, I really encourage you to be thoughtful about it, to take the moment and truly, really think about that. It's a pretty tough pill to swallow, at least for those of us that just really love Thanksgiving.

But to my mind, it's a lot better if we curb some of the things we do for this year's celebration, so that we give everyone the best chance of being happy and healthy and here to celebrate next Thanksgiving.

So I do encourage that. Remember the website, I mentioned partnermd.com/COVID19-vaccines to continue to get information there.

Storage and Transportation of Vaccines

"Do you have a sense of how significant are the storage, transportation and other logistical issues of vaccination dissemination? Is the country capable of dealing with these issues?"

It's a mixed answer for the Pfizer vaccine, actually, it's very challenging. We priced some of the freezers that would be necessary just to be able to hold the vaccine. And there were about $5,000 each right now. So many locations in the country will have trouble with that.

I do believe that way ahead of us thinking about this, of course, the folks at Pfizer have been thinking about this, and I think it's likely that the Pfizer vaccine will be able to be distributed and stored, but it probably will be of best use in larger facilities where that vaccine, a lot of it at one time, could be shipped and then used in one location. It won't yield a lot of of separation and handling it won't do very well there.

We're fortunate. It appears that Moderna's vaccine does not require the same level of of refrigeration and likely can be shipped the way many vaccines are done. And there's a very robust network for doing that. We don't know enough about the details of the of the non-mRNA vaccines, but they probably will look similar to some of the other vaccines we've had in the past and probably will be easier to ship. So I think it's likely that we will be able to manage that. The vaccine that one individual, either practice or individual person has available to them, may vary depending on where you are though.

Return to Normalcy Once Vaccinations Begin?

"What stages and over what timeline do you expect us to experience greater normalcy once vaccines are approved and have begun to be disseminated? Do I have any specific expectations?"

You know, granted my standard disclaimer that I'm not an epidemiologist or virologist, and I am probably a little on the negative side.

I think that it's likely that we will see a lot of people, particularly people in situations where they have a higher chance of transmitting the virus, so our essential workers, our healthcare providers, our EMS. Folks working in hospitals and in nursing homes. People who are driving buses. School teachers.

I mean, the places where groups of people spend time and the folks who need to be in those situations, I actually think a lot of them will be able to be vaccinated as we get into the spring and summer months of next year. And that will certainly help. We don't yet have a firm idea of how long a vaccination or how long immunity will last for vaccination.

We assume that it will last for, like a flu shot, for example, for a season, at least. It'll get us through a year. Perhaps it will go longer. So my sense is that next winter we will still be wearing masks and thinking about the extra care we take to minimize the risk of of transmitting flu and COVID.

But by then, we'll have a fair amount of our population who were in those roles, where it's easy for them to transmit the virus, vaccinated. I actually think it'll likely take us another season to be able to get enough vaccination where we could consider taking the masks off. I don't know, right, but that's my best guess.

What happens if people don't get the vaccine? 

"Surveys show that a significant percentage of the US population are wary about being vaccinated with one of these new vaccines. Perhaps as many as 40% say now they don't intend to be vaccinated. Presumably more folks will want to take the vaccine. If safety data is good, but if some significant proportion of the population declined to be vaccinated, how would that affect the return to normalcy?"

I think, in the way that I was describing earlier, I think that like most vaccines, like the flu vaccine, not everybody needs to get it, but we do need to get enough people vaccinated to be able to get the likelihood of an infected person coming against someone who is vulnerable...That has to go pretty low for us to be able to have that herd immunity that we see as so protective.

So I do think we are going to have to get you know, somewhere in that 60 or 70% of the population immune, to be able to have that sense of normalcy, that sense of being able to go out without paying as much attention.

Now, we're lucky, right? The 90-95% effectiveness of the vaccine will help us dramatically. The CDC and FDA, all originally set a bar around 50%, right? You'd have to vaccinate almost twice as many people to get the same number of immune folks.

So we're fortunate a higher effectiveness vaccine will help. I'm hopeful that a lot of the folks who are worried about this will find it easier to consider vaccination once they see that a larger swath of the population is safely able to be vaccinated. I'm hopeful that that will go better.

Should you open the windows and turn off the fans? 

"If indoors with others and with everyone wearing masks, I assume windows should be open. Should air conditioning or heat be turned off? Should the fan from the furnace be on or off? And after others leave, how long would it take to get the air clean in the house?"

I think that yes, if possible, having the home open, having air circulating is very valuable. I would leave the fans on. I think what we're trying to do is take the air in the home and push it out. And so the fans on all of the devices I think would be on.

Of course the challenge if you live somewhere good and cold is going to be can you manage to have the heat running that long? Or can you have a cold house? But I think that it, to the degree you can have windows open, fans running, possibly HEPA filters running, all of that should reduce the risk.

I don't know how long you have to leave things going to clean the air. It's all about air flow. So if you buy a HEPA filtering device, you can look at the recommendation for room size and how long it takes to turn over the air in the room. You can possibly find information about that with your HPAC unit.

But if I had to guess, it would be something on the order of a couple of hours. I don't know the last time any of you burned something in your oven, but it takes a little while to get the smell out. So it's probably on the order of that.

Immunity After Recent COVID Illness?

"Do you think my 18 year old niece who had COVID about three months ago should be somewhat immune right now? Trying to determine the risk she might bring to her family and mine over Thanksgiving since she's active outside the home due to work in school."

Boy, do I wish I could answer that. The statistical answer is yes. I think it's likely that she has some degree of immunity. It's really hard to measure that. Right now we're unable to do quantitative antibody testing, and until we can do that, it'll be hard to measure the antibody mediated immunity.

We believe that there is cell-mediated immunity and are starting to explore the possibility of measuring that. That's an exciting idea. We've not really done that in clinical medicine much. But if we are able to manage or to measure cell-mediated immunity, that will be exciting because we think for many of these viruses, that is the mechanism where most people will have their durable immunity.

So the real answer, unfortunately, is I don't know. The statistical answer is probably. Probably three months ago, the niece would would actually have some degree of immunity that would be somewhat protective.

Outdoor Dining and Gathering Under Large Tents? 

"Outdoor dining and gathering under one of those giant tents that's mostly enclosed to keep heat in... Same issue as being indoors?"

Yeah, actually I think so. I think what I would do if I was setting up a tent is I wouldn't put the walls up or perhaps you put one wall up, but you got to have some air flow. If you don't have air flow, you're not really accomplishing what you want to. I suppose it's likely better than indoors, but if you have four walls up in a tent with a doorway, I wouldn't trust that. I think you might as well go indoors and open your windows. And that way it'd be a little bit warmer.

Contagious Children

"Do we have any information about how contagious children are? There were some reports earlier on that we thought they weren't as contagious as adults? Is there any more on that?"

I apologize if I'm out of date, I actually think that the virus likely moves easily between children and adults. I think that what we have seen is that, particularly the middle schoolish child, the older elementary school and middle school, young adult kids seem to have a lower risk for getting acutely ill with COVID.

But I don't know that they have less risk of actually carrying and transmitting the disease. Now that aside, we have been fortunate.

It appears that school settings, public schools, private schools, locally for the primary school, appears to be a lower risk than what we were concerned about. It seems we're not seeing the rise in cases being from kids being in school.

Let me say that differently. The rise in the positivity rates in communities in the schools seems to parallel what's seen in the community, suggesting that that rise is due to what's going on in the community more than it's due to what's going on in the school.

When we look at the college-age kids, it appears that whether they're in class or just doing remote learning, but in the town where their college is, so they've left home and they're in their college town but doing remote learning, seems to give them similar rates of infection to kids who are actually in the classroom.

So it's about being in the town and probably in the bar and at the parties where the risk is. I actually don't think that it's any safer in terms of kids transmitting to adults. I think we have to assume that everybody can be infectious. And the more folks have exposures, the more I would assume that their risk for transmitting is higher.

Excellent. So I don't have to do all the work. So Kristin is replying to Kim and perhaps you can all see this. Anecdotally, my four-year-old's class had an exposure with everyone wearing masks and no one in the class, including the teachers, got it. Everyone was tested.

And this is what we saw in a story that came out about the hairdressers who wore masks and none of their clients were infected. It really is true that if we're wearing masks and if we are having our interactions being fairly brief with people the risk is quite a bit lower.

And we're still seeing people without infections in our offices. I did two physicals today where I and the client are masked up and we were sitting far apart. We have some air cleaners running, but the risk is still relatively low.

Toddlers Transmitting to Adults?

"Any information about toddlers transmitting to adults? Is it the same as school-aged children?"

Again, I believe it is. I'm embarrassed. There may be better information about that than what's in my head, but I would not assume that it is safe for me to be around toddlers and school-aged children. If those toddlers and school-aged children are around other people, it's basically the same as all of us.

I would say the more people I'm around, the higher the likelihood I could acquire the infection and therefore transmit. And it goes back to what I was saying earlier about quarantine. That if you need to get people together from different households for the holidays, if it's possible for all of the people who are coming to be able to quarantine effectively for 10 to 14 days prior to getting together, it really will lower the likelihood of transmission.

I say 10 to 14. If your group of people does not include any people who are older, sicker, higher risk individuals, you probably could cut it down a little bit.

Certainly if we were getting my standard group together, we would do a full 14-day quarantine of everyone who showed up because we have some older folks with some health conditions that I wouldn't really want to have bouncing some kids on their lap this year.