Joe declares victory over Mother Nature: Covid Report, September 2022 – Michael Fine

By Michael Fine

Is the Pandemic over? And if so, why are people still getting sick, and what should I do today and tomorrow about masking, vaccines, isolation and living life?

© 2022 Michael Fine

Ok. First the local Covid news, which, for Rhode Island, is pretty darn good.  We are most of the way through BA.5.  Hospitalizations went up 50 percent but from a reasonably low baseline and have started to drop again, and deaths haven’t jumped (yet though, remember deaths lag hospitalizations by a few weeks, so we could still see a few more.)  Better than that, there have been about 15 deaths in August and between 20 and 25 in October (still 15 and 25 too high but about the mortality rate of seasonal flu) – and the death rate in Rhode Island for the last month is one of the lowest in the US, which is a huge change for us.  (Our death rate since the beginning of the pandemic is still quite high, so don’t believe any politician who wants to take credit for where we are now.  Those politicians bear the responsibility for our high death rate because they pandered instead of led, and decided in the process that the economy was more important than human lives.)

The evidence suggests that we have developed something like herd resistance, but not herd immunity: lots of people are still getting sick and SARS-CoV19 is still circulating in waves, but it isn’t killing as many people in Rhode Island now.  Our dense population and too many people living in poverty likely set us up for many early infections (and many early deaths.)  That, plus a pretty effective vaccination campaign, once we got off our high horses and started vaccinating people at highest risk, has created herd resistance, at least for the moment.  All to the good. 

Is the pandemic over, like Joe Biden said? 

Technically, while we are not now experiencing pandemic spread of SARS CoV-2, the virus still continues to circulate widely. Because many people have some level of immunity, the virus isn’t now likely to infect the entire human race all at once, which was where we were in the late fall of 2019. But while we may no longer be in a pandemic per se, the virus can still infect lots of people and even lots of people at once, particularly as it evolves.  It just isn’t as likely to overwhelm hospitals and kill lots of people in short order at the moment.  Still, it can sicken lots of people, and kill many more than we’d like, particularly the old and sick.

Covid-19 is still killing almost 500 Americans every day, or over 150,000 people a year in the US if this keeps up, or three to five times as many as seasonal flu. That makes COVID something like the third or fourth leading cause of death in this country. It is killing elders, those with lower resistance, and still killing the unvaccinated in other parts of the country.  Rhode Island is now one of the best vaccinated states in the nation, again, finally.  But the immunity of individuals is likely waning, but we don’t know how big a factor that is going to be over time.  I’m hoping that if waves of infection from new variants continue to sweep through, as is likely, the virus will make many people a little sick, which will function like mass vaccination campaigns, keeping everyone with a functional immune system safe. And I hope and pray that people at risk keep getting vaccinated, likely every six months, for the next year or two at least, because immunity lasts three to four months, and we just don’t know how dangerous (virulent) the next variant will be.

So young people are in pretty good shape, and older at-risk people remain at some risk, but perhaps less risk than three or four weeks ago, and nine months ago, and community spread appears to be weakening, although it isn’t gone.

CDC keeps gyrating, changing the rules and now admits that it messed up.

Okay, Dr. Fine, what should we do about masking, testing, vaccinations, isolation and quarantine, restaurants, and shopping?

Understand that there are now three kinds of risks:

First, the risk of getting sick, which remains robust, but for most of us just means three to five days out of commission, and another five to ten days masked, if you are an ethical human. 

Second, the risk of hospitalization and death, which is tiny if you are vaccinated and boosted but real if you are unvaccinated, elderly or have chronic disease, remembering that some of us (in our later seventies and early eighties) are crossing the higher risk threshold every day as we age. 

Third, the risk of Long COVID.  The latest studies show that about 20% of all those who become infected, and 25% of those over age 65, may develop long term health symptoms or conditions, some of which can be very serious – including the risk of developing diabetes or Alzheimer’s Disease.

The challenge for most of us is to avoid getting sick at all, and particularly avoid it when you have a big event or travel coming up.  For those at risk, the challenge is also to avoid hospitalization and death.

So, what to do?  First, masks still make sense if you are out and about and don’t want to get sick.  There is no downside to masking. Ever. I’d mask if a lot of people you know are sick, if you are planning to travel, or have a big event coming up in the next two weeks, or if you are an at-risk person who wants to shop, eat out, or go to the movies. But the masking imperative to protect others seems unnecessary now: mask to protect yourself from getting sick. 

Many studies have shown that masks really do work, and work very well, to reduce your risk of getting infected (any mask is better than none at all, but for good protection wear a N95, KN95, or equivalent mask). You can, but you don’t need to mask at the moment to protect others from dying – there is enough immunity in the community to do that, at least for the present, although masking can and should be seen as an unselfish act as it may help reduce transmission, just a little bit. (Note that this advice could change if we get a very virulent (dangerous) and very transmissible variant.  But there isn’t anything like that spreading widely in Rhode Island at the moment.)

Masking now is like dipping your brights when you see an oncoming car on a country road.  It’s simple courtesy.

What about testing?  I’ve never been a big fan of testing people who are sick as a public health measure, because you don’t need a test to tell you if you get sick — your body does that. So, if you get sick, you should stay home for five days after all your symptoms resolve, and then mask for 10 more days if you go out.  Not rocket science. No test needed.  You can test if you want, and it is considerate to test if you want to visit someone elderly or at risk just to be a little extra cautious, but if you follow these simple guidelines, routine testing isn’t really necessary now. 

(There is some question about how accurate the rapid tests are for our current variants. Here’s a good rule of thumb. A positive test is probably accurate. But a negative test doesn’t say you don’t have Covid. (Sorry for the double negative.)

Routine twice weekly PCR testing of populations at schools was quite helpful in controlling disease transmission before we had vaccines. But now, with most people vaccinated or having been infected, we don’t have the same need to control disease transmission – or focus needs to be on preventing hospitalization and death. That said, our failure to routinely test a portion of the population regularly means we have very little real-time data on community spread of a virus that isn’t going away.

Testing IS helpful if you are at higher risk, and you get sick.  Then if testing confirms that you have Covid, you can take Paxlovid or other medications.  (I’m pretty sure we will end up using Paxlovid for ten days, not five, when all this shakes out, but some treatment is better than no treatment if you are at high risk – and perhaps one day CDC and FDA will get their heads screwed on right about the duration of Paxlovid treatment, if we can ever get politics and profit out of health care.) 

But I don’t think testing has any other significant use at this juncture.  All that testing – before weddings and bar mitzvahs, before concerts and events, and so forth that I was recommending and we were doing a few months ago, just isn’t useful anymore.  (It wasn’t actually all that useful then.  Rapid testing attendees didn’t work well to prevent disease transmission. It might have helped prevent some spread a little.  It didn’t do any harm.  But it turned out not to be very effective at the end of the day.)

Vaccines seem like a no-brainer.  Get vaccinated if you aren’t already.  Get boosted if you are a higher risk and are three or four months out from your last boost or infection and are at average risk and its two weeks before travel or a big event.  Vaccines won’t completely protect you from getting sick, but I’m betting time will show they reduce the intensity of the illness, and there is already good data that they make illness less likely.  Not perfectly, though.  You can still get sick if you are vaccinated.  Remember that.  Again, vaccines reduce hospitalization and prevent most death, particularly in the at-risk population. Just do it.

What about isolation and quarantine?  I think you need to isolate at home for five days after the last symptom if you get sick and to mask for ten days after that.  That’s the best way to reduce community spread.  Everyone should, but we are beyond the point of enforcement of isolation by public health authorities.  There is no need for quarantine now if you are the contact of someone who tests positive. You likely have immunity and aren’t at significant risk of hospitalization or death.  It would be nice if you mask in public for five days, just to be sure, but not really necessary.  If you get sick, though, well, you know the drill:  isolate for five days, mask for ten after your last symptom.

I’m shopping again.  I’m wearing a mask most of the time. I go to synagogue once a week, masked.  The mask fogs my glasses but doesn’t hurt.  I’m eating outside in restaurants.  Again, why not be a little cautious?  There’s plenty of disease around.  So why not avoid a few days of illness?  I’m betting that the little contact with other people I do have exposes me to virus but with a low viral load, so I don’t get that many viral particles at once.  My hope is that this level of exposure helps maintain my immunity but doesn’t make me sick.

What about reinfections?  How often can you get this darned thing?  Pretty often.  It’s a virus that infects your nose, mostly, and the immune system isn’t perfect about clearing infections from the nose.  But every time you get infected, and every time you get vaccinated, your immune system gets another booster, even though that booster likely only lasts three or four months (but likely less if you are elderly or immunosuppressed).  So, you are way less likely to get very sick within three or four months of having been vaccinated or having a symptomatic infection.

Finally, we need but don’t have a good process that gets the at-risk population rapidly tested and treated, an 800 number with test-and-treat flying squads. That is our best shot for further reducing hospitalization and death, and for preventing preventable death during the next surge.  Because we are back to square one: no health care system in Rhode Island or the USA.  Right now, it is still inappropriately difficult to get tested and treated, because we haven’t organized making testing and treatment easy.  If you are elderly or non-English speaking, just try calling a primary care doctor’s office and getting quickly tested and treated, should you get sick.  Especially if you don’t have a primary care doctor already, the situation of more than a quarter of those of us with Medicare, and more who are younger.  We don’t have a health care system in Rhode Island or in the US.  Shame on us for that.  This is a do-able thing.  Shame on us all for electing people who haven’t made this happen.

When will I let down my guard and let it all hang out? Be everywhere unmasked?  Perhaps next spring.  But sooner, possibly by the first of the year if the mortality rate in Rhode Island stays low.  I want to see what happens in the next surge, which I’m expecting in November or December.

We should also be prepared for the situation to change. The virus taught us is to expect the unexpected. What is true today may not be true tomorrow.

Joe: It’s not over.  Its changing.  Tell people what we all need to do to save lives and to keep ourselves from getting sick. Build us a health care system and save 100,000 or more American lives a year.  Stop the partisan blithering.  We have a democracy to save.

Many thanks again to Nick Landekic, who generously sends me tons of data, brilliant observation, thoughtful critique , and whose knowledge of Covid-19 is encyclopedic.  Thanks as well to the many readers who respond to these emails and help keep me on-track and accurate. 

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Michael Fine, MD has served as Health Policy Advisor in Central Falls, RI and Senior Population Health and Clinical Services Officer at Blackstone Valley Health Care, Inc. He is facilitating a partnership between the City and Blackstone to create the Central Falls Neighborhood Health Station, the US first attempt to build a population based primary care and public health collaboration that serves the entire population of a place.

He has also recently served as Health Liaison to the City of Pawtucket. Dr. Fine served in the Cabinet of Governor Lincoln Chafee as Director of the Rhode Island Department of Health from February of 2011 until March of 2015, overseeing a broad range of public health programs and services, overseeing 450 public health professionals and managing a budget of $110 million a year.

Dr. Fine’s career as both a family physician and manager in the field of healthcare has been devoted to healthcare reform and the care of under-served populations. Before his confirmation as Director of Health, Dr. Fine was the Medical Program Director at the Rhode Island Department of Corrections, overseeing a healthcare unit servicing nearly 20,000 people a year, with a staff of over 85 physicians, psychiatrists, mental health workers, nurses, and other health professionals.

He was a 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, Rhode Island and rural Scituate, Rhode Island. He is the former Physician Operating Officer of Hillside Avenue Family and Community Medicine, the largest family practice in Rhode Island, and 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 convened and facilitated the Primary Care Leadership Council, a statewide organization that represented 75 percent of Rhode Island’s primary care physicians and practices. 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, a community-based, population-focused non-profit organization, which made Scituate the first community in the United States to provide primary medical and dental care to all town residents.

Dr. Fine is a past President of the Rhode Island Academy of Family Physicians and was an Open Society Institute/George Soros Fellow in Medicine as a Profession from 2000 to2002. He has served on a number of legislative committees for the Rhode Island General Assembly, has chaired the Primary Care Advisory Committee for the Rhode Island Department of Health, 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.