by Michael D. Cohen, M.D.

Widespread community transmission of COVID-19 disease continues in the U.S. New records have been set daily for numbers hospitalized, numbers in ICU and deaths. Total U.S. deaths were over 400,000 as of January 18, 2021.

All preventive measures undertaken by individuals to protect themselves and others must continue.

A new strain of the virus was identified in the United Kingdom. The UK strain infects people more easily and has spread around the world. Ireland was having the most rapid acceleration of infections that epidemiologists had ever seen in a human population. It is expected that the UK strain will soon come to dominate infections in the U.S.

So far, health authorities believe the current vaccines will be effective to prevent severe disease due to the UK strain. Because of the increased infectiousness of the UK strain, some public health authorities are recommending more effective N-95 type masks rather than surgical or cloth masks.

The Connecticut Department of Corrections did a study of infections and severity of COVID-19 in its state prisons and jails. The department looked for risk factors for infection, hospitalization, ICU admission and death. Risk factors identified in the Connecticut prison and jail population may not necessarily be the same for other populations. Top risk factors found were:

• Risk factors for infection: Dormitory housing, Hispanic ethnicity, and older age.

• Risk factors for hospitalization: Heart disease, dormitory housing, and older age.

• Risk factors for ICU admission: Heart disease, autoimmune disease, and older age.

• Risk factor for death: Older age.

The strongest predictor of infection was dormitory housing. Housing assignment is the only important risk factor they identified that can be modified in congregate living facilities. You cannot change your age, ethnicity or chronic illness. But people with those risk factors can be moved out of dorms into single cells to try to better protect them from infection. Better still, move everyone out of dormitory housing to single cells.

Medical Care

• Viral load predictive of severe disease

Viral load is a measure of how many viruses are circulating in the body. A high viral load means there are a lot of viruses in circulation. A new study has shown that people with a high viral load early in their illness are more likely to become severely ill. This information may be used, along with age, chronic illness and obesity, as another predictor of risk of severe disease. It may help inform clinical decision-making to use available medicines earlier in the clinical course of the disease, especially for otherwise healthy younger people.

• Human serum with antibodies to coronavirus prevents severe disease

Serum is the liquid portion of the blood after red cells, white cells and platelets have been removed. Serum from people who recovered from COVID-19 contains large quantities of antibodies (high titers) to the pandemic virus. The new study looked at patients who were given high titer human serum early in their illness, at time of onset of symptoms. Follow-up of the patients showed that high titer human serum given at onset of symptoms helps prevent severe COVID-19 disease. Previous research gave high titer serum to hospitalized patients who already had severe disease. It did not help people who were already very sick. The newer study shows it does work when given early rather than late in the disease course.

• Two drugs that suppress the immune system approved in the UK

Two medicines routinely used to treat arthritis to suppress the immune system have been approved to treat COVID-19 in the UK. Studies showed better survival among severely ill people hospitalized with COVID-19 who received the drugs. All patients were already receiving dexamethasone (a corticosteroid that also suppresses the immune system) and remdesivir (an antibiotic active against coronaviruses).

Prison and Jail Staffing

• Closing prisons due to illness among guards

In early January The New York Times reported that California, Missouri, and Pennsylvania have closed prisons due to widespread COVID-19 disease and quarantine among guards. Transfer of prisoners out of closed facilities can cause increased crowding at the facilities that are still open. Transfer of prisoners who are infectious with asymptomatic COVID-19 can cause more widespread disease in receiving facilities and their local communities.

• National guard mobilized to staff prisons

The same New York Times article also stated that Ohio and New Hampshire have mobilized national guard units to staff prisons with too few guards available due to COVID-19 illness.

• North Carolina court order

The North Carolina prison system is under court order to test guards every two weeks and test prisoners prior to transfer. COVID-19 testing of guards before work and prisoners before transfer should have been routine from early in the pandemic.

• Health professionals leaving practice

Stories are starting to appear about doctors, nurses and other health professionals leaving the profession due to burnout. Too much death, overworked during the health crisis, and too much risk to their own family have taken a toll on health providers’ emotional health. Also, health professionals have been desperately urging their neighbors to implement preventive measures like masking, separation, avoiding crowds etc. In areas where they have been subjected to hostility and threats from local anti-maskers, some are choosing to move away from that environment permanently. The end result of both these trends will be fewer doctors and nurses available to work at prisons located in rural areas.

Coronavirus Vaccine

Everyone needs to get the COVID-19 vaccine when it becomes available to you. It is safe, effective and there have been very few dangerous side effects.

As of mid-January, about 31 million doses of the Pfizer and Moderna vaccines have been distributed in the U.S. and about 12 million have been administered nationwide. The rollout has become chaotic, to say the least. Many states have not finished immunizing front-line health care workers, people in nursing homes and those 75 and older. Immunization of essential workers was beginning when suddenly the Trump administration changed policy and allowed the vaccine to be given to anyone over 65 years old. Scheduling web sites crashed as more than 7 million people tried to get appointments for vaccination. States and the new Biden administration will be putting up mass immunization sites, but the bigger problem soon will be vaccine shortage.

A severe allergic reaction (anaphylaxis) occurred for 21 people out of 1.9 million doses given. This is the only serious complication of vaccination observed so far. The reactions occurred within 15 minutes of the vaccine injection and were treated promptly and effectively with an injection of epinephrine. All 21 recovered without further complications.

Most immunization centers routinely observe patients for at least 15 minutes after injecting the coronavirus vaccine. Generally, it is routine to have epinephrine available to treat a severe allergic reaction if it does occur. This experience re-emphasizes the requirement for clinical observation after the shot is given and the requirement for epinephrine to be available at every vaccination site.

Reopening Outdoor
Sporting Events

Masking with social distancing at an outdoor event where everyone was screened for COVID-19 infection prior to entry may turn out to be relatively safe. But we don’t know that to be true unless it is studied in an organized way.

In order to determine if an outdoor sporting event could be safely opened to limited numbers of fans, New York State and the NFL Buffalo Bills organization agreed to carry out a trial in early January.

The playoff game between the Bills and the Colts was held January 9 at the Bills stadium in Buffalo. Limited numbers of fans were allowed in the stadium with no symptoms and negative coronavirus test results within three days. Free rapid testing was available in the stadium parking lot for three days prior to the game.

On game day, no partying was allowed in the parking lots. About 6,700 fans were allowed into the stadium. While in the stadium and parking lots, fans were required to be masked and distant from others who were not from their own household.

The New York State Department of Health had planned to follow up with the fans who attended the game in the two weeks following to see if any got sick from exposure during the game. No conclusions were available yet from this follow-up phase.

One weakness of the game-testing protocol was the use of rapid tests. These tests were shown to be accurate and given emergency FDA authorization for use with people who are showing symptoms of disease. They were not shown to be accurate or authorized for use for mass testing of people without symptoms. Nevertheless, they are being widely used in that way.

The distinction is important. There may be relatively few false negatives (infected person has a negative test) among people who have symptoms of disease when they are tested with a rapid coronavirus test. But there may be a much higher rate of false negative tests among those who are infected but not yet feeling any symptoms of disease. Those people may be infectious to others, yet not showing enough virus antigen in their nasal secretions to give a positive test result.

People who show no signs of illness but are infected and able to transmit the disease to others have been the source of much of the disease spread throughout the pandemic. Rapid tests miss some of those. How many true positives are missed depends on the specific test product technology, and how common infection is in the population being tested. These factors need to be studied and understood before we rely on rapid tests to screen people for infection prior to air travel, or before coming to work in a nursing home, meat processing plant or prison. It may provide a false sense of safety if too many infected people are found to have negative tests and allowed to work or travel.

Stay Safe

Even with widespread testing of people without symptoms, it is still necessary to continue to wear masks, stay separate, avoid crowds, avoid time indoors with others and all the other preventive measures we know so well. This is even more true now than before, due to the highly infectious new UK strain of the virus. 

Michael Cohen was the medical director for the New York state juvenile justice system for 20 years and previously provided medical care for incarcerated adults at the New York City Rikers Island jail and at Greene CF in Coxsackie, New York. For 10 years, he participated in a support group for people with diabetes at Great Meadow CF in Comstock, New York. With the group, he co-authored the Prisoner Diabetes Handbook published by Southern Poverty Law Center and distributed by Prison Legal News. Heal the sick. Raise the fallen. Free the prisoners.

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