I haven’t been blogging much recently. Call it Covid fatigue. Influenza and RSV seem to have peaked and gone away, but Covid remains. Not a day goes by that I don’t get a call from a patient who has Covid or has questions because a family member does. (Three cases in the last 2 days). It just doesn’t seem to go away like the other respiratory viruses that are seasonal. The hospitals are full, but they aren’t all Covid patients. Staying at least overnight in the emergency room prior to being able to get a bed seems to be the norm. This Q and A with an ICU director was interesting. Most of the Covid patients that they are seeing have underlying conditions and haven’t been boosted. If you are 50 years of age or older, you should certainly consider getting a bivalent booster. People who have had a booster are now wondering what the recommendation will be on getting another. That is the article that follows from US News and World Report.
An ICU Doctor on How This COVID Wave Is Different
Last week, 3,171 COVID deaths were reported in the United States. In the past seven days, an average of 13 COVID deaths were reported each day in Los Angeles County, California, the country’s most populous county. Although this February’s death rate is lower than that of the previous two, COVID patients are still fighting for their lives.
Isabel Pedraza is the director of the intensive-care unit at Cedars-Sinai Medical Center in Los Angeles, overseeing the care of some of the hospital’s sickest patients. Someone treated in her unit may have had a heart attack, been in a traumatic accident, or be battling COVID on a ventilator.
Pedraza told me that this winter, her unit is seeing fewer COVID cases than expected. (Patients with non-life-threatening COVID cases—the majority of those in the hospital—are treated by her colleagues “on the floor,” where they aren’t monitored quite as closely.) As for the patients who do wind up in the ICU with COVID, she told me, treating them is much less stressful than when the virus first arrived. By now “it’s a lot less chaotic,” she said. “It feels like we have a path and an algorithm, and ways that we know we can save people.” At the same time, Pedraza said, more people are coming into her unit severely ill for other reasons—such as kidney and heart problems—than before the pandemic began.
Pedraza offers a first-person perspective from a hospital ICU and shares why she wishes people would be a little more considerate of others, even when mask mandates aren’t in place.
Isabel Pedraza: The most striking thing to me is that, although they’re not anywhere near the peak that we had in 2020 or early 2021, the numbers of sick patients generally that we’re seeing in the ICUs are definitely much higher than we saw pre-pandemic. But we’re not seeing as much COVID as we expected.
But we are definitely getting some patients. It’s usually people who are most at risk for severe disease: the elderly, people who have lots of medical conditions—liver disease, kidney disease, heart disease, obesity, diabetes, cancer, immunocompromised, all of those things. The past few people I’ve had have been unvaccinated. But you also see people who haven’t received the bivalent booster, or who received their third or fourth dose maybe a year ago and have a lot of other organ disease.
Today, the people in the ICU are the sort of the people that you would expect to see there, as opposed to two years ago, when you had plenty of people who really had no known risk factor for being there.
Nyce: How does this year compare with the past two years?
Pedraza: It’s a lot less chaotic. We are treating patients now with a lot more evidence. In the beginning, everybody was sort of trialing different therapies to see what worked best. And then we started to get data late in 2020 that helped show that things such as steroids actually have a mortality benefit. So it feels a lot clearer and a lot calmer, and a lot less anxiety provoking than it did at the beginning.
We have a lot more patients who are not COVID positive who are coming in really sick. The numbers in the unit are much higher than they were pre-COVID, and everyone is extremely ill.
Nyce: With respiratory viruses?
Pedraza: Everything. It’s not just respiratory viruses; it’s a higher level of acuity for all illnesses. It’s not just here—we’re seeing it across the country. I’m not sure what the explanation is for that.
Pedraza: It’s everything we would normally see in an ICU, just greater in numbers and more severely sick—somebody with a history of congestive heart failure coming in with an exacerbation of that heart failure, somebody with liver disease coming in decompensated, somebody with end-stage kidney disease coming in really, really hypertensive. This is a lot more than we’ve seen. And I don’t know if that’s just the backup from people not going to doctor’s offices in the past couple of years or something else.
Nyce: You were saying that some of your patients in the ICU are unvaccinated. What is it like treating them?
Pedraza: Well, by the time you get to the ICU, patients are patients, and people are seeking help. And it’s really not the time or the place to pass judgment. And COVID is not unique: I certainly, in past years, have had patients dying of influenza who have the same guilts. I’m sure that on the floor, it may be a different thing. In the ICU, the cases are a lot more extreme.
I also see patients in the long-COVID clinic that we’ve set up here, and I’ve had a good number of patients who have suffered significant problems with long COVID and still don’t want to get a vaccine. It’s weird to have people seeking you out to help them with their symptoms or with saving their lives, people who listen to your medical advice and trust you there—but who think that you’re lying to them when you tell them a vaccine could be lifesaving. It’s a bit demoralizing.
Nyce: Has the progression of the illness changed at all this winter? Any changes in when you’re getting patients coming to the ICU or how long they’re there for?
Pedraza: They still follow the same timeline as to when they end up developing the lower-airway disease. Omicron is thought to have less propensity to go into the lower airway, so maybe that’s part of the reason we’re not seeing as many people end up in respiratory failure. But there are a lot more patients on the medical floor than there are going to the ICU.
Nyce: We started this pandemic with a big emphasis on supporting health-care workers. How is staff morale now?
Pedraza: I think it’s easier now because there isn’t that sense that you’re risking yourself and your family every time. At least now you’re vaccinated; your family is vaccinated. A lot of hospitals, including this one, have tried to provide psychological or well-being services [to their staff]. I think people are just tired because it doesn’t seem to let up quite as much as we wish it did.
We lost a lot of staff, especially nursing staff, as did every medical center across the country. I think this was probably because of the level of moral injury that was sustained, because while the rest of the world was making sourdough bread, they were spending their days—especially nurses who were at the bedside—watching people die, despite everything they were doing. Then to have people so angry about being asked to do the minimum possible to protect their fellow Americans—I really think it burned a lot of people out.
Nyce: What do you wish that the general public knew about what it’s like to treat COVID and other respiratory diseases this winter?
Pedraza: It can feel disheartening to know that certain things are preventable. If someone had just been vaccinated, or if the people around them had been vaccinated, or if somebody had worn a mask, maybe the transplant patient would still be alive, or maybe the person fighting cancer would still be alive. You wish that people would think about the way their actions have real-world effects on others.
Nyce: Obviously, there are people who believe anti-vaccine disinformation. But setting that category of people aside, I’m curious: What would you say to the people who are sort of in the middle, who are like, “Life has to go on”? Who are not necessarily radicalized—maybe they’re vaccinated and keep up to date with their shots. But they’re also like, “We have to enjoy one another’s company. We have to combat the loneliness epidemic.”
Pedraza: I wish that we could go back to a time where we could just follow public-health recommendations. I certainly don’t judge people when I’m out and about for not wearing a mask, because it has not been a recommendation yet. In the hospital, people get upset because they’re asked to wear a mask—that I have less tolerance for. Or on a plane—that is such an easy place to give other people your illness or to catch an illness.
I wish that, in the absence of a public-health department recommending masks, people would just think more of others. If you’re in an Uber or someplace where you’re really close to people, you don’t know what those other people are dealing with. You don’t know if they’re undergoing chemotherapy or if they have a loved one at home who’s sick.
And I definitely would love it if people would not be judgmental of people who are wearing masks. We’re not a bunch of—what do they call it, snowflakes? I have actually been wearing masks since 2019, because I have been treated for breast cancer.
Nyce: How do you think you’ll remember this winter versus the other seasons of COVID?
Pedraza: It feels like we have a path and an algorithm, and ways that we know we can save people. A couple of years ago, even last year, there were still questions. We went from not having any idea of how to manage this to really having good ways of managing it, and being able to improve outcomes.
Nyce: It’s got to be so wild to be on the front lines of that, while it’s happening. I can’t imagine what it was like—to be building the airplane while flying.
Pedraza: That’s a very good way to put it—flying the airplane while learning how to fly. It was a once-in-a-lifetime, thankfully—hopefully—experience.
Nyce: And now it feels like the airplane is pretty much built? With maybe some pieces still missing around long COVID?
Pedraza: Yeah. It feels like you know how to fly the plane, and you’re pretty sure how to keep people from falling down the chute. And you can’t understand why some people are voluntarily jumping off the plane. But at least you know how to get people safely on the ground if they choose that. And, I guess the analogy would be, there’s the frustration of seeing some people being pushed out of the plane by people who don’t care about getting them sick.
Early Updated COVID-19 Vaccine Recipients Left Wondering: When’s the Next Booster Shot?
The U.S. tried something new about six months ago. Federal health agencies authorized and recommended an updated COVID-19 booster shot that matched the coronavirus variants that were circulating at the time. Some Americans were quick to line up to get the latest shot.
But as the weeks rolled into months, just under 16% of the population eventually joined them. The low uptake forced health officials to focus their attention on the vast majority of Americans who hadn’t gotten the shots rather than the few that did.
Now the group of Americans who eagerly lined up when the booster was first offered are asking questions. Namely, when can they get their next shot?
“It’s one of the most common questions I’m asked right now, with varying degrees of urgency, particularly among the immunocompromised who are especially concerned because there is still quite a bit of COVID out there,” says Dr. Peter Hotez, the dean of the National School of Tropical Medicine at Baylor College of Medicine.
Federal health officials are eyeing a switch to an annual COVID-19 booster shot beginning in the fall, but some Americans are hoping to get their next shot sooner than that, citing concerns that the efficacy of the shots starts to wane after a few short months.
It’s a significant number of Americans who want to know. According to a recent survey from the Kaiser Family Foundation, 15% of all adults said they are waiting on the Centers for Disease Control and Prevention to issue new guidance on the next shot. If the survey were extrapolated to real life, it would mean that more than 38 million Americans are waiting on federal guidelines for another booster.
Among adults who received the updated booster shot, more than half say they are waiting on guidelines so they can be eligible for another booster. The vast majority of updated booster recipients – 86% – say getting another COVID-19 booster shot in the future is important or a top priority of theirs.
A CDC spokesperson said that the agency recommends only one updated bivalent booster shot at this time, adding that the majority of Americans haven’t yet received the shot. She said that updated data is expected to be shared during a meeting of its vaccine advisory committee next week.
“CDC will continue to monitor COVID-19 disease trends, variants, and vaccine safety and effectiveness to inform future vaccine recommendations,” the spokesperson said in a statement to U.S. News.
Hotez, who also serves as the co-director of the Texas Children’s Hospital Center for Vaccine Development, says he has raised the issue with leadership at the Department of Health and Human Services. He says that even if federal officials don’t want to issue a recommendation for people to get a second updated booster, they could at least authorize the shot so that people have the ability to choose for themselves.
A second booster shot is important, Hotez says, because there is still a “significant” level of COVID-19 transmission from the omicron subvariant XBB.1.5. Most of the U.S. is experiencing a high level of coronavirus transmission, according to CDC data.
Additionally, he says that it’s hard to predict what comes next with COVID-19.
“We always want to spike the ball and say, ‘We’re done.’ And I don’t know that we can say that just yet,” he says.
Booster shots are “probably best reserved for the people most likely to need protection against severe disease – specifically, older adults, people with multiple coexisting conditions that put them at high risk for serious illness, and those who are immunocompromised,” Dr. Paul Offit, a pediatrician who is also a member of the Food and Drug Administration’s vaccine panel, wrote last month in the New England Journal of Medicine.
Immunocompromised Americans are in a particularly tough spot after the FDA last month pulled its authorization of Evusheld, an antibody treatment that was used as a pre-exposure treatment for people at high risk for severe COVID-19.
But it might not be prudent to try to prevent infections in young, healthy Americans with booster shots, Offit said.
“In the meantime, I believe we should stop trying to prevent all symptomatic infections in healthy, young people by boosting them with vaccines containing mRNA from strains that might disappear a few months later,” he wrote.
Still, the latest data from the CDC found that the updated bivalent booster shot does provide protection against the now-dominant XBB.1.5. A study the agency published last month found that efficacy against symptomatic infection varied by age range, with people ages 18-49 seeing the highest level at 49% and people ages 50-64 seeing the lowest at 40%. Americans 65 years and older saw 43% vaccine efficacy against symptomatic infection with XBB.1.5 and XBB.
When the FDA last month proposed the shift to annual COVID-19 boosters, it noted that “two doses of an approved or authorized COVID-19 vaccine may be needed to induce the expected protective immunity for those who have a low likelihood of prior exposure (the very young) or those who may not generate a protective immune response (older and immunocompromised individuals).”
The FDA’s vaccine advisory committee met last month to discuss the potential annual booster strategy and touched on the idea of two vaccines per year for certain groups. The agency’s top vaccine official Peter Marks noted that immunocompromised people got an additional COVID-19 shot as a part of their primary series.
“Whether that translates into two vaccines per year … I think that’s something that we’d like to have a discussion of and use the best available data that we have,” Marks said. He added that there is a “real spectrum” among immunocompromised people ranging from “modest” to “tremendous.”
But the vaccine experts didn’t come to a strong conclusion on the strategy, instead saying that the committee needs more data to figure out exactly who would get one shot per year and who would get two.
Another updated booster authorized anytime soon would be the same composition as the first one, which was targeted against omicron subvariants BA.4 and BA.5 as well as the original coronavirus strain.
While the mRNA technology used for the Moderna and Pfizer vaccines is easily adaptable to new strains, vaccine manufacturers and federal health officials haven’t made updates to the shot.
“We really have not taken advantage of that performance feature of the mRNA vaccine because in theory we should have the XBB.1.5 version by now,” Hotez says.
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