COVID-19 Update 4/7: Cases, Vaccinations, Side Effects, AstraZeneca, and More

In this week's COVID-19 update, Dr. David Pong discusses the plateauing of COVID cases, the continued increase in vaccinations, vaccine safety, AstraZeneca and blood clots, and more. Watch the full video below and read on for a transcript.

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COVID Cases Plateauing

Right now, we've been on the downslope of COVID disease activity. Our peak was back in January and early February. We had a very high number of cases, hospitalizations, and deaths, both here in Virginia as well as across the country. And thankfully we've seen a pretty dramatic fall through the springtime months. 

Anyway, a little bit of flattening now. The numbers since about mid-March, we've seen a seven-day moving average in Virginia of about 1,300 new cases. And that's been pretty steady 13 to 1400. It turns out if you look at hospitalizations and death, we're seeing similar kinds of changes...a plateauing.

And of course, we don't really want to have plateauing at those numbers. We'd like to see continued drops. So the seven-day moving average and death rate and hospitalization rate, unfortunately, continues to, instead of continuing down, has started to plateau a bit in Virginia. We can actually see that across the country, although in certain parts of the country, we're seeing flare-ups.

So right now, if you go to the Johns Hopkins map and look at the past 30 days, we can see increasing activity in different states, particularly in Michigan and in Texas. For those of us in the mid-Atlantic, it's worrisome that we're seeing some activity both in New York, New Jersey, Pennsylvania, North of where we are, but also down in Florida to the South. And of course, with I-95, they're connected and they go right through us.

So we are seeing some increased activity. Some of that is due to everybody getting kind of tired of continuing to take the public health measures that have been so helpful. Masking and handwashing and such. Some of it is due to some of the new variants we're seeing in the virus.

We know that the South African variant and the UK variant seem to be more contagious. They seem to cause more sickness in the people who do get infected. And we're seeing some variability in the protection we get out of the vaccines.

Generally speaking, the vaccine protection is still quite high. And without a doubt, I would recommend getting vaccinated now as opposed to waiting for somehow a better vaccine to come. They will come actually, but they'll come in the form of boosters. And all of the major companies right now that have vaccines available to us will be having updated vaccines to account for that.

But we are seeing some increase in disease in the areas where we're doing genetic testing of those variants. We're seeing increasing numbers of them in both the South Africa and the UK variant, particularly.

And again, with higher transmissibility and higher infection, we're starting to see younger people ending up in the hospital. If you look at those trends, it makes sense, right?

We vaccinated our older populations more effectively and our younger folks are the folks who are still out in the world trying to reopen businesses, keep things going. But those are the people that are relatively unprotected and yet the people who are now being exposed to a virus that's a bit more contagious.

So we are seeing again a flattening of some of the curves rather than continued downward trends.

Vaccinations Continue to Rise

In the face of that, we're vaccinating, and we're finally seeing a fairly rapid rollout of vaccination. Just a few weeks ago, we were saying that we're vaccinating at about 2.5 Million doses a day. We're now up to about 3 million doses a day.

And if you look across the country, we're at somewhere around 110 million people who've received one dose. Somewhere around 63 million who've received a full vaccination series. That's about 19% of the population, them being fully vaccinated.

In terms of the population over 65, we're at something like 57% of the population fully vaccinated and 76% of the population who received at least one dose. So we've done quite well in the older population and so if you're hanging out with a bunch of 65 plus-year-olds, a lot of your folks likely have gotten into that herd immunity range.

If you're hanging out with folks in their thirties and forties, it's unlikely that they've done that at this point, but we're catching up.

And in fact, as part of that, Virginia is moving from a Phase 1 to Phase 2 on April 18th and everybody 16 and older, if you are getting the Pfizer vaccine, or 18 and older, if you're getting the Moderna or the Johnson & Johnson vaccine, would be eligible.

And currently, in Virginia, you can pre-register now. As of April 4th, you could begin pre-registration for vaccination essentially of all adults. Wonderful news. And as you've heard me say before, and I think you've heard Dr. Bishop say for sure, that we strongly encourage vaccination when you're able to do it.

How to Think of Vaccine Efficacy and Side Effects

The vaccines are not perfect. And it sounds kind of dumb to say it that way, but I think sometimes we expect perfection out of medicine and we expect perfection out of drugs and vaccines.

And I think we get surprised when we don't get the outcome we want. Remember these vaccines at their best are showing something about 94% or so of protection, but that means 5% are getting vaccinated and still are susceptible.

So it's important to remember that not only are they not perfectly effective, they also can have side effects. I always like to think about this in the context of the disease though. It kind of reminds me of when people will have concerns about taking statin medications for lowering cholesterol.

I think people who have high risk, someone who has known plaque in their arteries, someone who's diabetic, someone who's got multiple risk factors, if you look at, statistically anyway, the likelihood of them eventually having a heart attack or stroke, it's very high. For someone my age, who has two or three risk factors, the likelihood of an early heart attack or stroke is probably on the order of 50-50, where it should be down around, statistically and population studies, down in the 20% range.

And so in those high-risk individuals, I think putting them on a statin makes a lot of sense, and yet people are really are reluctant. They're worried about side effects. They're worried about the possibility of having some untoward effect in the distant future.

I think we see the same thing in concern about vaccination for COVID, and while the vaccines are not perfectly effective, they're certainly better than almost any vaccines we've ever had. We always use the comparison of the flu vaccine, which in any given season is 40 to 70% effective.

And they have side effect profiles that actually similarly, from a safety profile, look really quite good. Anaphylaxis in something like four or five people for every 9 million doses. We have a lot of reactogenicities, so sore arms and a few days of achiness, but in terms of safety, in terms of ending up with an actual medical complication, the risks are quite low.

AstraZeneca & Blood Clots

There has been some new news that's kind of interesting, and worrisome. If you've been following vaccines, the AstraZeneca vaccine has had some concerns raised about blood clotting.

And there was a piece put out yesterday on Reuters where the European Medicines Agency has come out saying that they believe there is an association or a link between AstraZeneca's vaccine and a rare clotting disorder that involves the cerebral blood flow.

This is something that involves a large vein kind of in the center of the head called a cerebral venous sinus. And they have seen 44 reports out of 9 million people in the European area that have developed this, and that's higher than you would expect in the standard population.

They don't yet know if there is a cause and effect relationship, or if it's an association, but not a direct cause, but it's definitely continuing to get more study. Now, again, we should keep it in perspective, 44 out of 9.2 million. You know, there's a lot of things we do in our lives that are a whole lot riskier than that. You know, driving to the grocery store is a higher risk of having an event than 44 in 9.2 million.

But that's a thing that's continuing to be monitored. Not going to spend a lot more time on that because we don't have access to the AstraZeneca vaccine in this country. And actually, if I had to guess, we may not, or at least we may not in this cycle. I think between the number of doses of the mRNA vaccines and the Johnson & Johnson vaccine that we have available, I don't know that we'll be approving the AstraZeneca vaccine in this country, in this cycle.

Novavax Conducting Crossover Study

Now another new vaccine that we don't have yet in this country is from a U.S. Company called Novavax. And they're doing some interesting new work in their studies. You know, it's always been kind of a question if you're doing a vaccine trial in the middle of a pandemic, is it ethical to have a group of people who never received the vaccine?

In a study, you've got the active folks who get the vaccine and the placebo arm who don't, and is that okay? And I would comfortably argue it's not. My argument is that the illness is bad. We're seeing people having both out of the acute illness, but also some of the longer-term complications really having a challenging time with acute COVID. And so I think it's hard to argue that it's an ethical thing to do as we go further and further into the pandemic to do a vaccine trial, where you have a group of folks who never get the vaccine.

So Novavax has started doing in their trials what's called a blinded crossover. So the trial keeps going, but partway through the trial, they do another round of shots, and people who received placebo, in the beginning, are given active vaccine midway through, and people who got vaccinated at the beginning are given placebo shots.

And then, of course, you look at what happened in between the shots and you look at what happens after the second round, and it should be able to give them a nice sense of the protective value of the shot.

It also gives them a sense of what happens if you boost. They have an arm in it where they're actually giving an extra dose of active vaccine, so it's a nice way to do a trial.

I think it holds nicely with some of the ethical considerations around trying to do vaccine trials during the pandemic. And I think it is exciting to think that we'll have another vaccine that we'd be able to add to the three active ones now.

Don't Fumble on the 5

I guess the main point I'd want to make today is, you know, one of my patients recently was diagnosed with COVID, and he said in his note to me telling me about this acute diagnosis and symptoms that he was so frustrated because he felt like he'd made it to the five-yard line, meaning he'd run 95 yards down the field only to fumble the ball on the five.

And that he was very frustrated because it's likely, as we said a minute ago, that with the vaccine rollout, it's likely that he'd be on the list to get vaccinated in the next few weeks. And in the next month or six weeks, he would be fully vaccinated. And yet he's in the midst of acute COVID.

It reminds me of a bunch of ideas. I really strongly encourage those of you who are interested in vaccination to please sign up and get vaccinated. I think vaccinated people together are able to comfortably spend time together without masks. In our own practice, when we have business meetings among a group of vaccinated people, if everyone in the room is comfortable, we take the masks off. Currently with my own patients, when we're in a room together, if we're both vaccinated and we're both comfortable, we take the masks off. I think that, by the same token, when I walk down a hallway here, everyone has a mask on. When if I go into a place where there are other folks who may or may not have been vaccinated, and I don't know that, I think it makes sense to have a mask on.

I think it makes sense to wash hands. I think it makes sense to continue to maintain distance. Socially, if I'm with a mixed group of people where I don't know who's been vaccinated and who hasn't, I would recommend being outdoors. There really is very good science around all of these things.

The protective benefit of masking, the protective benefit of handwashing, and the protective benefit of some distance and being outdoors. And until you're vaccinated, I think it would make sense to really continue to work those efforts.

The Washington Post had an interesting kind of a fun article. It had a link to a tool that was built by a team at the T.H. Chan Public health School that tried to help people see what their risk looked like if two unvaccinated people got together for a meal. And they have based their statistical calculations on a fairly high-risk situation, remember the old Diamond Princess cruise ship, but they looked at what happened when you put unvaccinated people in a room where one person asymptomatically has the disease and the other person does not, and what factors would affect transmission.

They actually put some numbers to it. And it clearly shows that if you're masked up, if you have distance, if you open the windows, if you move it outside, you can dramatically lower the risk such that if two of us are unmasked for three or four hours having dinner in a room the size of my office, I probably have a 90% chance of getting infected from the other person if they're asymptomatic and can transmit, if they have the virus in them.

If I take the same two of us and we move outdoors, we sit six feet apart, and we have our masks off only to eat, that that number drops to something between 5% and 10%.

So if between now and getting vaccinated, you want to get together socially, I mean, we're blessed in the mid-Atlantic, right now the weather is very good. At least it is Richmond today. But I mean, generally speaking, we're headed into a warmer part of the year.

I really encourage continuing to think in terms of relatively small groups and being outdoors until we get more and more of the population vaccinated.

Try not to fumble the ball. Try not to end up getting acute COVID on the eve of being able to get vaccinated and get protection.

Vaccines and Side Effects, Part Two

I believe the vaccines are very safe. And yet, you know, recognize that there certainly are folks who will have allergic reactions. There are other acute reactions that are happening with some of the vaccines.

Ashish Jha, who is at Brown, was giving a podcast talking a little bit about that and his reflection was that, in coming up with guidelines for the FDA, they looked back at all the previous vaccines we've had, and almost without exception, if there was going to be a serious side effect from vaccination, it would show up within two months of the person being vaccinated.

And that was part of the FDA's hesitation initially was waiting for a couple of months after the people in the vaccine trials had completed their vaccine series to see if anything showed up in those thousands of people. And it really has shown that the vaccines that we have available are very, very safe. So I do encourage vaccination. I encourage continuing to pay attention to the preventive health measures you can take a while waiting for vaccination. And once you're vaccinated, and if you're in a situation with other vaccinated people, I think that you can really let your guard down and feel pretty safe about that.

The caveat to that I think is going to be watching what's going on in your community, around you. The numbers, if they were to start rising, for example, as they are in Michigan right now, I think one has to think about that and be aware that what may be happening around you is the rise of a variant of the virus that may be more transmissible than what you have seen so far and may be able to get through the initial blockade put up by your vaccine.

All of the major companies are working on boosters that can address the new variants and some of the vaccines, for example, Johnson & Johnson, may actually be pretty good against the South African variant and the UK variant.

Herd Immunity Target

"About herd immunity: in the light of declining mitigation within a mitigation fatigued population. Do you have an estimate of how much vaccination to reach national regional herd immunity? I know that this is a moving target in the sense that we need more vaccination if we do worse at mitigation."

The numbers that I keep seeing are somewhere around 70%. So as I alluded to earlier, if you're with a bunch of 65-year-olds in Virginia, you probably have a rough chance of 70% that those folks have been vaccinated and the likelihood of transmission within the group is certainly lower. So I think those numbers are probably still reasonable to think about. Again, what I would be watching to try and help me think about that is what's going on in the community around me.

Right now we're at a fairly low, although unfortunately stable, level in Virginia. If that starts rising, my assumption is that something's happening either with behavior or with the transmissibility and infectivity and all of the virus. So maybe again, a variant. And if I saw that happening, I would be more cautious. I would put the mask on in more situations. I would be more cautious about getting mixed groups of people together.

Vaccinations vs. Variants

"I see the CDC director said today that the B.1.1.1.7 Is now the dominant strain across the nation. Studies I've seen suggest pretty strongly this variant is significantly more transmissible and more virulent. With vaccination at a record pace, who is winning the race between vaccination and the spread of the variants?"

Great question. I think right now it's a regional answer. While I think the B.1.1.1.7 and to a lesser degree, the 1.1.3.5, are in places across the country, I think that in terms of rising infection rates, we see that more in pockets.

So right now, for example, in Michigan, in Texas, in the Northeast. I think those areas the numbers are actually kind of daunting. Both the number of cases, but also the proportion of those cases that are in one of these two new variants.

I think that if you look at us nationally, actually, I think we're right at kind of the, what I hope is the turning point. Meaning I hope that we're able to continue a high pace of vaccination. And if we can stay focused on mitigation strategies over the next few weeks, I think we may actually see that continued downward trend again. This is also the opportunity where we could turn and go up again.

That's one of the most frustrating things about this particular virus is because of the asymptomatic and presymptomatic transmission and it being a respiratory virus that is aerosolized and can be transmitted, that combination means that it doesn't take very many infected people to infect another whole group.

As your question alludes to, the key is vaccination. To get enough people in the room unable to receive the virus. So I guess I'm not really answering your question terribly well, but my sense is that we're not in a position where I can tell you we've crossed through that inflection point, and either we missed, and there's a rise going on, or we're succeeding.

I think there are places in the country right now where it feels like we missed, and I don't know how long it will take to catch up let's say in Michigan. I think in Virginia right now, if we can hold on and continue to vaccinate at the pace we're going or faster, I think we can actually avoid a surge here. I think the weather is clearly on our side. And I think that our rate of vaccination will only increase.

Vaccine Passports

"What's my take on the pros and cons of using vaccine passports? Dr. Bishop explained his skepticism. What's your perspective?"

You know, if we had a system where everybody was getting vaccinated equally, in a sense that equal access to vaccine, if we had equal comfort level, the vaccine hesitancy as well as the ability to actually get the vaccine if you want it, if everything was equal, I think you could make reasonable argument for doing a vaccine passport.

I think it's sort of like the idea of, in my family, we were contemplating whether or not we'd be comfortable with a big family get together this summer, but if we didn't know if everyone was vaccinated, would we feel like we were creating a risk situation?

Kind of like if you get a group of people together and you let them drink too much. It feels like, are you creating a situation where there could be bad outcomes? And is it wrong to do that?

You know, in a sense it would be like having to require a vaccine passport to come to my family reunion. I actually like the idea of people knowing their vaccine status, sharing it, and decisions being made openly. I struggle with a true vaccine passport when we live in a society where not everyone has had access to get the vaccine equally. I think then it would be an unfair thing because of the kinds of limits that might be imposed. So I'm not a huge fan of that.

Vaccine Nationalism

"What's my take on vaccine nationalism? It looks like it may take years to vaccinate the world's population, and perhaps this won't happen at all without significant investments by the wealthier countries. This raises the prospect of a replication in unvaccinated countries generating variants that will trouble the rest of the world. How concerned should we be about this? What might we do to address it?"

I think that's a huge problem. I said the last time I was here, I think one of the biggest problems we have is that the number of infected people in the country and in the world is enormous. And every one of those people is an opportunity to create variants to create viruses that are able to elude the immunity we get from acute COVID, the immunity we get from vaccination, and the treatments we have.

So the faster we can get the world population vaccinated and lower the case rates across the world, absolutely the better for us here. The challenge is we live in a very mobile world. You can see the risk by how this whole thing got started, right?

I mean, if we go back to the beginning, it was an an isolated thing happening in one part of China, best we know, is the beginning. And it really didn't take very long before it was everywhere. And I think the problem with not vaccinating and managing the disease risk everywhere is that problem. That idea that it can then come back from anywhere and spread rapidly through the world.

So what can we do? I think we have to be willing to see ourselves as part of a world partnership. That means that our investments can't be just for our own benefit. I think you could see the same idea.

What if there was only enough vaccine to just vaccinate my family? How would that work? And I think you could see the same thing, if no one else in Richmond got vaccinated and only my family did, it's just a matter of time before variants come up in the population around us that we are not immune to. It fails.

Of course, they'd come with the pitchforks before that, but it fails. Anyway, I think what that requires is we have to be willing to invest financially. We have to be willing to make choices that recognize that the benefit of everyone, float everybody's boat, kind of an approach.

Yes, it makes me a tree-hugging, left-sided liberal, I guess, but I do think that in situations like this if we don't do that, then we run the risk of not getting what we really want, which is a highly functioning, integrated world where we're all safe again, or we are safer.

And I think that the examples we can see in our own communities, in our country, are exactly the same as what you'd see across the world.