by Michael D. Cohen MD

The U.S. is experiencing the worst increase in COVID-19 cases, hospitalizations, and deaths since last winter. As I write in mid-August there are more than 150,000 new cases per day and over 1,000 daily deaths nationally. Over 95% of hospitalizations and deaths are among people who have chosen not to obtain the COVID vaccine that is now widely available. This proves without a doubt that the vaccines prevent the most severe disease and death under real-world conditions. If you are already vaccinated, good for you. If not, get the vaccine as soon as possible.

States with the worst ongoing Delta outbreaks (Florida, Louisiana, Texas, Mississippi, Alabama) have the lowest vaccination rates. They have Republican governors who have avoided or actively opposed preventive measures like vaccination and wearing masks indoors. These states are having their worst pandemic yet, with more hospitalizations and daily deaths than ever before. ICU beds for the sickest people are full or close to it. There was recently the first public report of a person who died in the ER while waiting for days for an ICU bed to open up.

In face of the devastation, they are experiencing, people in these states (and elsewhere) are seeking and obtaining vaccines in greater numbers again. The dying are asking for the vaccine (too late) or encouraging friends and family to get it before it is too late. In Louisiana, the demand for vaccines increased to four times the previous rate (400%). Finally! Some are getting vaccinated but are afraid to tell their friends or family because of the intense opposition and condemnation they expect to experience. No matter. Get the shot(s) however you can. They work.

Efforts to mitigate the disaster are underway throughout the nation, but unevenly. Some states, companies, federal government agencies, and others have declared they will require all employees to be vaccinated. Many universities now have vaccine mandates. Some cities, school districts, states, and others have declared mask mandates for everyone entering their public transit, businesses, theatres, schools, supermarkets, etc. That means even vaccinated people should be wearing masks. So far, no stay-at-home orders have been declared in the U.S., as has happened recently in Vietnam, where the Ho Chi Minh City region (13 million people) was in total lockdown for at least two weeks, at the time of writing this.

“Younger, Sicker, Faster”

The people getting hospitalized during the Delta surge are different from those seen earlier in the pandemic. The average age is younger. They are sicker than before and the disease is progressing much faster. In part, this is due to the fact that most of the older population has been vaccinated and is not getting sick enough to be hospitalized. But that is not the whole story. This variant is having a more aggressive clinical impact on the younger, unvaccinated population.

Children too. Earlier rounds of the pandemic largely spared children, especially young children. Hospitals in the South, where the pandemic is most severe now, are seeing greater numbers of children hospitalized than ever before. The children who are hospitalized are sicker with lung disease this time rather than the rare multi-system inflammatory syndrome seen in children last winter. One children’s hospital reported that the average age of children hospitalized for COVID is now five years.

Current predictions are that the pandemic will continue to grow at least through October. As of mid-August cases are doubling every seven to 14 days.

Treatment

The best treatment is prevention: vaccines, masks, avoid crowded places, stay separate from others when in groups, improve ventilation of indoor spaces, hand hygiene, etc.

There are now several treatments available for COVID.

Placing people lying face down (prone) for treatment with oxygen and breathing machines (mechanical ventilation) helps improve lung function.

Remdesivir is an antiviral antibiotic that helps reduce deaths among hospitalized patients.

Anti-inflammatory steroids (corticosteroids) help when given early in the course of the disease.

Manufactured antibodies (monoclonal antibodies) also help when given early in the course of the disease.

One manufactured antibody has been approved recently to prevent infection in people with weak immune systems (or others at higher risk for severe disease) who have been exposed to COVID.

Newer medicines yet to be approved selectively block the excess inflammation (“cytokine storm”) that fills the lungs with fluids and causes lung failure.

“Breakthrough” Infections

Vaccinated people are getting infected with COVID more than expected. No vaccine is perfectly effective, so some infections among the vaccinated do occur. The COVID vaccines were tested to see if they prevent severe disease and death, which they do. They were not tested or expected to prevent all infections. Infections among the vaccinated do not mean the vaccine is not working. Vaccines are working to prevent severe disease and death.

When vaccinated people become infected they are largely without symptoms or have mild symptoms. However, there is accumulating evidence that even asymptomatic people can spread the Delta variant to other people. This is because the amount of virus in the nose and throat is 1,000 times greater with Delta than with the original strain of COVID. Asymptomatic infections in the vaccinated may be part of what is driving the surge among the unvaccinated. That is why even vaccinated people need to wear masks in indoor public places.

A recent study of data from a few states showed that vaccines were protective against infection 55% of the time, protected against symptomatic infection 80% of the time, and protected against hospitalization 90% or better.

Reopening the Schools

Children under 12 are not yet eligible for any COVID vaccine. The only ways to protect the younger children from exposure to the virus and infection are the well-known mitigating behaviors we have been using for the past 18 months: vaccination of eligible students, teachers, staff, contractors, and visitors, masks for all people entering school buildings, keeping distant from others, better ventilation of indoor spaces, exclusion of sick and exposed people, frequent cleaning of toys, tools, shared desks or tables, etc.

Schools in the South have opened and already large numbers of children have been exposed to COVID at school and sent home for two weeks quarantine. Florida and Texas governors have attempted to prohibit mask mandates in the schools, but some school boards have revolted and disobeyed the governors to protect the lives of the children they are responsible for.

Nursing Home Outbreaks

COVID outbreaks in nursing homes have occurred despite high levels of vaccination among the residents (80% in many states). Outbreaks occur largely among the unvaccinated, but also some vaccinated residents are becoming infected. It is thought that these outbreaks are being driven by asymptomatic disease among unvaccinated staff. For this reason, the federal government has declared a vaccine mandate for all nursing home employees.

Vaccine Boosters

Evidence has been accumulating that the immune response to COVID vaccines decreases with time. The third dose of Pfizer or Moderna vaccine has been recommended for people with immune system weakness (immune deficiency) such as those on cancer chemotherapy or after organ transplants. Newer recommendations are for all people to get a booster dose eight months after they completed the initial two-dose series with those vaccines. There has not been enough experience yet with the Johnson and Johnson single-dose vaccine to know whether boosters are needed for people who got that brand.

However, the World Health Organization (WHO) has objected to vaccine boosters in rich countries in order to make more vaccines available to the rest of the world, where most people are not vaccinated and there are vaccine shortages. This strategy would also help protect the population in rich countries by reducing the likelihood of new, more infectious, or more deadly, variants. U.S. authorities say we can do both—boost our population and make more vaccines available internationally.

In the U.S., boosters will start in late September. The booster doses will be free. All people will be eligible regardless of immigration status. Health care workers, older adults, and nursing home residents will get their boosters first.

Clear Plastic Barriers Not Protective

Clear plastic barriers are commonly installed at salad bars in restaurants to block large droplets produced by coughs and sneezes from reaching the food. They are effective for this purpose. Similar clear plastic barriers were installed in places where the public and employees meet face to face such as checkout at stores and supermarkets or anywhere that interviews take place. It is now known that COVID is not primarily transmitted by the large droplets that these barriers block. Rather, COVID is transmitted via aerosols that float in the air for some time and circulate around in a room.

New studies have looked at the effectiveness of these hard plastic barriers against COVID. It turns out they probably don’t help prevent infection and may make the risk worse. By blocking airflow or redirecting flow, barriers may even create zones where viral aerosols are concentrated, making it more likely for people to get infected. They also create a false sense of security that may encourage people not to bother to wear masks. So, stay masked indoors no matter what other measures have been implemented to reduce exposure or infections. 

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