The Piper At The Gates Of Dawn

Spring begins in one week, marking the end of a nightmare of a winter in which several hundred thousand Americans lost their lives to COVID-19.  It appears that we are all moving in a better direction at this time, though we are by no means out of the woods yet.  Will be providing a quick status report today with respect to case numbers.  Also will provide some updates on vaccinations and try to read some of the tea leaves dropped by President Biden this week.

The title for today’s blog was derived from an early Pink Floyd album as President Biden’s address this week was presented as him being the piper advising us of the new dawn coming.  That being said, I find much of early Pink Floyd bordering on unlistenable and decided not to torture you over a cut off the album.  Instead, I offer a cut off the album Meddle entitled a Pillow of Winds.  It was the first song my youngest got to appreciate in the delivery room when born.  So in a way, it is Music to be Born By or a Song in the Key of Life.

A Super Brief Numbers Game

Current Disease Burden

National case numbers have been leveling off for weeks now with little fluctuation.  On a weekly basis there are slightly less than a half million cases being reported.  Death rates continue to decline, though we are still witnessing about 1500 deaths per day in this country from COVID-19.  Expectation is that the death rate will plateau in a similar manner to the case numbers over the next couple of weeks.

Locally, the trends are similar to the national.  New cases in Suffolk County continue to hover in the 600-700 per day range and have been consistently such for a month now.  The percent positive rate on testing has been consistently 4% during the same time period.  The rate of decrease in hospitalized patients has slowed and appears to be finding a plateau in the 350-400 patient range.  Lastly, death rates have appeared to stabilize and are currently between 5 and 10 per day in Suffolk County.

So far, all positive news for you today.

Current Vaccination Status

Nationally we have managed to poke 100 million people to protect them from COVID-19.  One in five Americans has received at least one dose of vaccine at this point.  Of those in the highest risk age range, over 65 years of age, we have managed to provide one dose to 61% of them!!!  Locally, on Long Island, we have immunized 23% of the population with at least one dose.  I could not find the age distribution on those doses, but would assume there is no significant discrepancy from national as the eligibility criteria are similar for much of the country.  Even at current rates of vaccination, over half the population should receive the COVID-19 vaccine by June.  This is not likely sufficient to achieve herd immunity by June, but getting much closer.

On a roll today…two sections in and all positive news!

Al Di Meola.  Guitar virtuoso.  Al is happy to make you dinner and give you a private show.  Seriously, no joke.

Sneak Peak

The Knockdown

Overall, as just presented, the current numbers are encouraging.  We are clearly at the end of the current wave.  A ton of folks, in particular the high risk, have been vaccinated.  Will there be another wave?  Are we done yet?  Ready for a quick whipsaw?

Whipping out my crystal ball, what I envision are significant increases in case numbers towards the end of March leading into April.  Why?  Three reasons.  First, there is variant that is becoming increasingly common and is considered more contagious.  Second, regulations are relaxing that will permit increased opportunity for spread.  Lastly, that relaxation of regulations is starting just in advance of Spring Break.  There are going to be thousands of college kids heading to more temperate climates to eat, drink, and be merry.  They will then return to their respective homes to bring with them a nice tan, their hangover, some venereal disease, and of course COVID-19.

Feeling queasy yet?  We started on such a roll today….

Reversal of Fortune

No need for a sickness bag!!!  On that topic, as an aside, there are apparently collectors of these.

Now here’s your happy prediction for the day.  While I expect the case numbers to increase, I do not anticipate that it is going to result in another catastrophic wave of hospitalizations and deaths.  Keeping in mind that the overwhelming majority of cases that result in hospitalizations and deaths involve the elderly, and that the majority of them are already immunized, the expected increase in case numbers is going to be primarily in folks that do not run a high risk of poor outcome.  Basically, you will see increased case numbers with little change in hospitalization rates or deaths.

More fusion jazz for you today.  The Mahavishnu Orchestra performing Dawn in 1974, Live at Montreaux.

COVID Vaccinations

What’s Available?

All three versions of the COVID-19 vaccine currently available in the United States are beginning to become increasingly available.   Much of the credit for this still goes to the prior administration who guaranteed large purchases of vaccine without knowing whether they would work, simply to make sure that companies were willing to produce massive amounts prior to completing trials.  The current administration gets some applause this week, as it facilitated an arrangement between Merck and Johnson & Johnson to assist production even more.  This arrangement was sought out as Merck has far more experience with vaccine manufacturing and has a larger production capacity at this time.  Imagine….competitors playing nice for the common good.  Could you imagine if politicians could accomplish the same amongst themselves?

While the supply of vaccines is improving, our ability to vaccinate the entire population is still limited by supply.  In anticipation of adequate production eliminating this constraint, it is time to really work through the other parts of the supply chain to ensure that we do not experience bottlenecks that inhibit our ability to deliver every available vaccine to an arm near you (if not attached directly to you).

Tea Leaves

President Biden stated in his address last week that states are mandated to make all adults eligible to receive the COVID-19 vaccine by May 1st.  I am going to take the optimist view regarding this statement, because taken literally it is a recipe for disaster.  The tea leaf reading of this statement is that there will be sufficient production, along with appropriate channels to distribute and administer the vaccine, for all adults in the country by May 1st.

When there are no longer supply or distribution constraints, the vaccine becomes a commodity.  In this case, go to your doctor, your pharmacy, or any other location permitted to receive and administer the vaccine and get it done.  However, while constraints remain, there is a need to prioritize who gets the vaccine based on risk.  If we lack appropriate supply and simply open up vaccinations to the general public, we will diminish our ability to vaccinate those in most need.  As it stands now, there are a ton of young, currently healthy individuals, with low risk for poor outcomes getting vaccinated because they are tech savvy and hammering the government website to get appointments at the expense of elderly folks who lack similar ability or access.

To avoid any misunderstanding, healthy young people should get the vaccine as well.  Just not before their grandparents and those with high risk of dying or contaminating large numbers of high risk individuals (such as your friendly ER nurse).  Those between the ages of 20 and 49 are currently the largest vectors of spread in the United States and Europe.  There is a viewpoint that we should focus on vaccinating this younger population for that reason.  I disagree with it in this case though.  The elderly require a lot less convincing to take a vaccine to save their own life than a 30 year old to save the elders life. Furthermore, it will take fewer doses to protect those that would actually have a poor outcome, rather than trying to cocoon them by vaccinating the vectors of disease.   This strategy would be different if the vaccine worked poorly in the elderly such as is the case with the influenza vaccine, but alas this is a different beast.

The Grateful Dead performing Sunrise in 1977.

Moving On

President Biden stated during his address to the nation that a new online system will be made available to help with scheduling vaccines.  This is an acknowledgment that the current is not sufficient.  To be fair, there was no system in place prior to the pandemic, so I will not completely criticize what is being used, as there were clear time constraints to setting it in place.  Now though is the time to build a system properly that could be used for distribution of any critical item going forward.  My proposal for such would be that people don’t just go and hammer sites looking for appointments.  Rather, they simply sign up.  As supply is available, the system would be designed to reach out, in priority order, to individuals to schedule them.  That way a 95 year old signing  up “late” still gets priority over an asthmatic 21 year old.  Such a proposal also addresses the issue of scheduling large numbers of people months in advance only to cancel them a week prior due to lack of supply.

This week it was also announced that dentists and veterinarians are going to be cleared to administer COVID vaccines.  This addresses potential bottlenecks in the supply chain, once production is not the limiting factor.  That being said, there are a ton of folks out there, such as Peds First Pediatrics, who have been ordering weekly and would love to be part of the solution and have no supply to work with.  Whether non-traditional vaccinators will be needed or not is a matter of debate, but it does show some foresight for addressing the concern, before it becomes an issue.

What About the Children?

For now, the children will remain at risk for becoming infected with COVID-19.  However, as we have been saying for months now, they are not high risk for poor outcomes as defined by requiring hospitalization or having a fatal outcome.  Some speculate there could be long-term effects, but I could say the same about nearly any new illness, food, or other technology.  At this time, there is no data that should be concerning for such.  And just to be clear, I am not suggesting you go old school and try hosting the 2021 version of a chicken pox party.

The clinical trials in children are ongoing and results should be available in a couple of months.  Of note, this first batch of trials is for children 12 years of age and older.  Any conversation for younger children is moot at this time, and will be for the foreseeable future.

Parting Thoughts

This weeks message is one that should be uplifting, especially as we start to push this pandemic towards the annals of history.  We have not yet finished the job, but we are well on our way.   Please continue to maintain your vigilance at this time, especially if you have yet to be vaccinated.  Wear masks, limit contacts, and keep your distance.  If things go as planned from this point forward, summer is going to be a return to something resembling normalcy for all.  Rage Against The Machine is still scheduled for August at Madison Square Garden! By fall, we may be talking about more typical topics like monitoring what’s in your child’s Halloween candy bag that could be a choking hazard, whether we might see our old friend influenza again, and will there be a winter Dead and Company Tour.

Stay safe all and have a great week!

Couldn’t help it.  One cut from the Piper from The Gates of Dawn album with a twist.  Performed live with special guest Frank Zappa.

Post authored by Jason Halegoua PhD, MD, MBA, FAAP.  Jason is the founder of Peds First Pediatrics in 2009, and has been a practicing general pediatrician since completing residency at Schneider Children’s Hospital in 2004.  In addition to earning his medical degree from the Medical College of Pennsylvania, Jason earned a PhD in Molecular Pathobiology for his work contributing to the understanding of the genetic regulation of immune responses to murine leukemia viruses from Hahnemann University in Philadelphia and an MBA in Finance from Hofstra University.