BA.2:  Deja Vue all over again?  Or time to pivot? – Michael Fine

BA.2:  Deja Vue All Over Again?  Or Time to Pivot?

By Michael Fine, contributing writer

Editor’s Note: We are about to enter one of those times – to gather with family and friends – and recognize holidays. Easter, Passover, Ramaden. Church gatherings, family dinners, young children all together with older family members. This information is important for you to know. Holiday gathering should not be an “oh, no” thought of dread. This holiday? It doesn’t need to be. If we take the right steps.

Copyright © by Michael Fine 2022

SO, cases were a little up and then down and now up a little again, hospitalizations were down in Rhode Island and are now up a little but down in the US, deaths in the US are down, I can’t tell for sure what is happening to deaths in Rhode Island (because the Department of Health just adjusted the count up to 3,523, up almost 100 in a week but likely a “technical adjustment”) but the weekly count of deaths is between 5 and 10 a week  —  and envelopes remain stationery.  (The last bit references an old joke: escalators are up, elevators are down, and envelopes remain stationery). Yikes. 3,523 deaths in little Rhode Island. At least 500 preventable in the last six months– and more likely close to 3,000 preventable when you compare us to other countries.  But things are better than they were. Way better.

Still BA.2 is here and spreading, with some authorities predicting a 12 percent rise in cases over the next few weeks and wastewater testing suggesting more viral activity all over the East Coast and nation. (I’m not sure what the case numbers really mean any more, with lots of people testing at home and the positives not being reported or counted.) And lots of people are telling me that they or someone they know is sick. In Rhode Island, at least 2,300 are walking around with Covid-19 according to colleagues who are good at these numbers. But I think that’s an underestimate, and the real number is closer to 5000. That’s one in every 200-400 or so people: if you go someplace with 500 people there is a very good chance someone in that crowd will be infected and transmitting disease, and a reasonable chance that is also true of a crowd of 200.

It’s clear that there is plenty of virus around and that we still have robust community transmission.  But it is no longer clear what community transmission means.

As I’ve said before, we should be trying to do two things:  preventing hospitalizations and deaths and assuring the continuity of operations of institutions and organizations.  We are making really good progress on hospitalizations and deaths, at least at the moment, although we need to remember that hospitalizations and deaths lag cases by two to three weeks, so we may still see a small to midsized bump in both in a week or two.

But at least the community transmission we see in Rhode Island, while robust, doesn’t seem to be causing hospitalizations and deaths, at least not now. Other good news: disease transmission in Central Falls, which has had the highest transmission in the nation and the world twice, is now next to nothing, likely because of the combination of vaccination and the immunity that comes from getting infected. It looks like we have herd immunity in Central Falls, at least for the moment. Which means herd immunity may be achievable after all, at least temporarily.

What’s next?  I suspect Rhode Island will have a bump in hospitalizations and deaths from BA.2, which is more contagious than Omicron, and perhaps more kids in the hospital, because data from the UK suggests it hits kids a little harder.  But the vaccine and the recent Omicron surge are likely to protect us from hospitalizations and deaths, even though immunity is now waning.  And the weather is improving, so more people will be outside, which means less transmission.  On the other hand, many people have given up masking, which means more transmission. What’s going to happen?  We’ll have to wait and see. I’m guessing we’ll go up a little in Rhode Island because of BA.2, inadequate masking, and Passover, Easter and Ramadan — and then we’ll go down and have a nice quiet summer.

The good news about immunity is that the vaccines protect better against hospitalizations and deaths than they do against infections, so I’d expect more infections, but not quite so many hospitalizations and deaths.  Except in Florida and Texas, where no one wears masks anymore, and the temperatures are climbing, so more people are spending time indoors to beat the heat.  I’d expect hospitalizations and deaths from BA.2 to climb in those places, particularly in May, June, and July.  See why I like New England?

The bad news about immunity is that it wanes or weakens, over time.  It looks like it wanes quicker for infection than for hospitalization and death, which is a good thing, if immunity has to wane.  But we don’t yet know how long protection against hospitalization and death lasts, and we don’t know if everyone immunized is protected against hospitalization and death equally.  Most likely the at-risk population is also the least well protected.

The best news is that we have effective treatment for Covid-19 now, and it is expensive but widely available.  That’s our best defense against hospitalization and death. This effective treatment makes all the difference in the world, or it least it should.  It gives us a clear pathway to send hospitalizations and deaths from Covid-19 – if we are smart enough to take that road.

In a certain way, we should be thinking about a pivot, about ignoring community transmission, and going back to normal, letting Covid-19 spread during surges, and using that medicine to protect those at risk from hospitalization and death.  I’m just millimeters away from thinking that’s what we should do, because the spread of disease works like a booster for the normal risk population, and actually helps us develop herd immunity as more people become infected and more immune and as those who were vaccinated months ago begin to lose their vaccine acquired immunity — so they may develop better immunity should they get infected. Even exposure to virus without infection is likely to juice up the immune system a little and act a little like a booster.

So, stop all this masking and social distancing stuff?

Not quite.

But.  But.  But…

I so much want to stop it all.  But then I remember that we don’t have a health care system in the US.

In a more perfect world, by this time we’d have an 800 number that the at-risk population could call the moment they got sick, and we’d have test and treat flying squads, so the moment an at-risk person got sick, they’d call the 800 number, a flying squad would come to their house in 15 or twenty minutes  (this is Rhode Island, remember:  no one is more than 20 minutes from anywhere, more or less); they’d get a rapid test on the spot, backed up by PCR and treatment starting right there and then – and we’d prevent most hospitalizations and deaths.

Or maybe we’d just say, call your primary care doctor.  In that perfect world, everyone would have a primary care doctor and we’d be paying primary care doctors to see their at-risk patients the same day (we aren’t) and make sure that primary care doctors had the drugs in their office (they don’t) and can give their infected patients a supply of these amazing drugs so they get started on drugs right then and there.  And maybe we’d be paying primary care doctors to check in with all their at-risk patients once a week, so that at-risk group understood what to do and who to call should they ever get sick.  (We don’t do that either.)

In the world we have, however, twenty five percent of people on Medicare (all of whom are over 65 or disabled) don’t have a primary care doctor.  In the world we have, we haven’t been training enough primary care doctors for fifty years, so many primary care doctors have more patients than they can handle, should everyone over 65 get sick at once.  And that means if you are over 65 and get sick, there might well be no one to take care of you the same day.  And if there is someone to take care of you, test you and find you are infected, you still have to go to the pharmacy.  The pharmacy still has to sort out your insurance.  You still have to sort through copays and deductibles.  You still have to go to the pharmacy when the prescription is finally ready.  And so on and so forth, assuming that you don’t need prior authorization for this or that, that the fancy electronic prescribing system didn’t send your prescription to the wrong place and so forth.  And all that is assuming you can read and write in English, that you have a car or a way to get to the doctor and pharmacy, and that you remember to pick up and take the medication.

(People over 50 and those with chronic disease or who are immunosuppressed under 65 are also at somewhat higher risk – but even fewer of that group has primary care doctors, and too many in that group don’t have insurance at all, a real challenge because Congress is fighting over whether to fund our Covid response.  Without that funding, good luck getting people who are infected to spend $250 to see a doctor to get tested and then fork over $540 for the medication.  At least everyone over 65 has Medicare. Just sayin’.)

So, truth be told, our at-risk population is still at risk, even though we have the tools to protect them. We have great tools. We just don’t have a health care system to make sure that everyone at-risk is actually protected.

Which means that we’ll still have hospitalizations and deaths, as long as virus is circulating in the community.

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Oy vey!  What is a rational human to do?

I think the choice depends on what you want for yourself.

First, if you are, or think you are an at-risk person (people over 50, somewhat. People over 65 a little more.  People over 80 significantly more.  People with severe chronic disease and those who are immunosuppressed, and those with some combination of the above most) you should talk to your doctor and work out a strategy that works for you.  At the current rate of community transmission in Rhode Island, I’d still avoid shopping and events with more than 200 or so people, and I’d mask in public indoor spaces.  If I was doing restaurants, I’d want to eat outside.  I’d have a clear plan about what to do if I got sick:  know who to call to get tested and treated quickly, remembering that all of us are going to get this virus eventually.  I’d pay attention to community transmission, so that when community transmission drops I might loosen up a bit, and when community transmission rises, as it is likely to do in the fall, I’d get more careful again, and I’d stay careful until Covid deaths in RI drop to less than 25 a month  (which is about the mortality we see from seasonal flu) although there is no harm in being more careful yet.

What about boosters?  By now I hope you’ve had the third vaccination, the booster.  If I was being wild and free — eating out, traveling by plane, shopping, going to the theatre, hitting the bars and so forth, I might get a fourth booster now.  If I was at high risk and shopping or traveling at all, I’d get that fourth booster now.  But if I was being careful (masking in public indoor places, avoiding large gatherings, keeping restaurants to outside or not dining out yet) I might wait on the booster until two weeks before travel by airplane or a holiday or event with a bunch of unrelated people, so my immunity is strongest when I need it most.  Vaccinated people who have been infected with Omicron or Delta take note: you probably have four months of protection after the infection, because infection acts like a booster for most people, except those who are immunosuppressed.  There’s no rush to get a fourth booster.  For most of us who are being careful, it makes most sense to get boosted closer to an at-risk event, so your immunity stays robust longer.  If there is another surge, however, I’d go and get that fourth booster as soon as that surge is confirmed.

What about normal risk folks who are vaccinated?  I’d live your life unless there is some event coming up that will be messed up if you get Covid.  If something like that is on the horizon, I’d start the drill – masking in public places, avoiding indoor dining, avoiding large events, and shopping only on-line – about two weeks before that event.  I’m a fan of masking in indoor public places regardless of risk, just to help reduce community spread a little, because we don’t have a health care system in the US.  Why not do for others what you’d want them to do for you?  If we can all chip in and help reduce community transmission a little, why not?  Masking is a pain.  But it isn’t a huge burden.

For the present, as long as community transmission is robust, I’d still same day rapid test everyone coming to large family or community events.  It takes 15 minutes, and it protects everyone.  Important with Passover, Easter, and Ramadan started or coming up.

How about isolation and quarantine?  I’d still isolate for 10 days after testing positive.  See, ‘help protect the community, in a nation without a health care system,’ above.  Same thing is true of quarantine of contacts.  I’d do five days with a rapid test at day five, six and ten.

How about people who aren’t vaccinated?  I think it is time to give up fighting and stigma about vaccination.  All those people have to live with knowing that they wouldn’t take one for the Gipper, that they thought they were too good to take a little putative risk in the interest of protecting their community. (And, my guess is, that they fell for Putin’s social media manipulators, which is where most of the rumors and the myths likely came from.) Let’s give it a rest, and hope they learned something for the next time: we are all in this together, and all of us are about freedom and democracy as one nation indivisible.  We lost almost, almost a million Americans because we were fighting with each other instead of collaborating.  The whole is much greater than the sum of the parts.  We need to do better next time.  You can still get vaccinated.  It’s no big deal.  Or not.  The virus doesn’t care what you think.

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What about schools?

Schools should go back to normal. There is no need for routine testing unless it is to protect a vulnerable person at a family or other event.  That can and should change if we get a variant that increases hospitalization and death, because the spread of such a variant is likely less well controlled by our current vaccines.  If that happens, and I hope it won’t, we’ll need to go back to masking and social distancing to help control spread.  But such a variant is not inevitable.  It is, however, possible.  What about a school that has a classroom or school outbreak, as in more than two people in a class sick, more than two classrooms with two people sick?  I’d bite the bullet and play it straight: go virtual for two weeks in a class outbreak; go virtual as a school for two weeks in a school outbreak.  I’d give up routine asymptomatic testing in schools for the moment:  we manage schools for continuity of operations, not for disease control.  But we must, MUST make sure all staff is fully vaccinated and fully boosted with the fourth booster, and make sure every staff person has a personal plan for testing and treatment should they get sick.

What about testing?

I’d test only before events and gatherings, but I’d do it the same day.  I’m not sure I’d be testing low-risk symptomatic people at all if they have classic symptoms.  I’d just isolate that group.  Symptomatic testing should be reserved for people with mild symptoms – a runny nose with no fever, a mild positional cough with no fever or a mild sore throat, and I’d probably back up rapid testing of that group with PCR.

I do think we need asymptomatic surveillance testing of densely packed populations where Covid-19 has spread easily in the past, and rapid DNA sequencing of a sample of positives.  We’re assuming the rise in positive wastewater testing is BA.2.  But unless we are DNA sequencing a respectable sample of our positives, we’ll never know if a new variant has evolved and is spreading here.

Our failure to do asymptomatic surveillance testing of densely packed populations (we aren’t), and Congress’s failure to appropriate the money we need to control Covid-19 at this point in the pandemic, is very troubling: we haven’t learned a thing.

We need a health care system in the U.S. that cares for all Americans.  We need decent safe and healthy housing for all Americans.  We need a $20 or $25 an hour minimum wage, so people can afford to feed their own kids, and so the CNAs in nursing homes and the front desk folks at health centers can afford to come to work and provide critical health services during a pandemic, instead of working for McDonald’s or Amazon because they get paid better at those places and might actually afford to feed their families.  We need to invest in public health, so we have the resources to respond to infectious disease and prevent outbreaks from turning into pandemics, so we aren’t always playing catch-up ball and so we don’t lose almost a million Americans unnecessarily.  Government needs to be transparent, effective and clear, so people trust one another enough to collaborate when something like a pandemic breaks out. And so, people stop believing all the garbage that Vladimir is sending us on social media, which is designed to divide so he can conquer – I’m guessing that we aren’t seeing cyber-attacks because it would mess up old Vlad’s ability to sow division here, which is his most powerful weapon.

We learned that we are a densely populated world and people travel incessantly.  There are going to be more infectious disease outbreaks because of that, and more pandemics if we aren’t careful, and I promise, the next pandemic will be worse.  Way worse.  Covid-19 is a cold virus.  It ain’t nothing, from the perspective of just how dangerous viruses can be.  It killed a million Americans because we let it.  This pandemic was our first plague – a warning, or, in the language of the Blues Brothers, a message from G-d.  Are we going to wait for the death of all firstborn sons and daughters before we hear the music?

We can listen, and change.  Or we can watch TV.

Michael Fine

Many thanks again to Nick Landekic, who provided me with tons of data and publications over the last twenty-five months, and whose knowledge of Covid-19 is encyclopedic, and to Deborah Faith, MPH, for her unending editorial support.  Thanks as well to the many readers who respond to these emails and help keep me honest. 

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Michael Fine, MD was the Director of the Rhode Island Department of Health from February of 2011 until March of 2015. His career has been devoted to healthcare reform and the care of under-served populations. He served as Medical Program Director at the Rhode Island Department of Corrections; and founder and Managing Director of HealthAccessRI, the nation’s first statewide organization making prepaid, reduced fee-for-service primary care available to people without employer-provided health insurance.

Dr. Fine practiced for 16 years in urban Pawtucket, and rural Scituate, RI. He is the former Physician Operating Officer of Hillside Avenue Family and Community Medicine, the former Physician-in-Chief of the Rhode Island and Miriam Hospitals’ Departments of Family and Community Medicine. He was co-chair of the Allied Advocacy Group for Integrated Primary Care.

He currently serves on the Boards of Crossroads Rhode Island, the state’s largest service organization for the homeless, the Lown Institute, the George Wiley Center, and RICARES. Dr. Fine founded the Scituate Health Alliance.

Dr. Fine is past President of the Rhode Island Academy of Family Physicians, has served on a number of legislative committees for the RI General Assembly, chaired the Primary Care Advisory Committee for the RIDOH, and sat on both the Urban Family Medicine Task Force of the American Academy of Family Physicians and the National Advisory Council to the National Health Services Corps.