Lisa Reynolds, MD, pediatrician and Representative-Elect for Oregon House District 36.
11/24/20
Summary: COVID cases continue to rise in Oregon, the US, the world. Testing is inadequate in Oregon. Governor Brown’s necessary “freeze”. The case for prioritizing the reopening of schools. Updates on treatments and vaccines.
Thought for the week:
“Everyone who knows what’s coming with COVID is wandering around in a fog of anticipatory grief.” Lindsay Beyerstein on twitter
Actions: As an official future lawmaker, I have been involved in two public actions on COVID:
A group of legislators wrote a letter to Governor Brown expressing frustration and asking for action on Oregon’s COVID testing debacle (there are not enough tests in Oregon and it’s difficult to get one). (Oregonian article about the letter.)
An OpEd with my colleagues who are legislators and health care providers about the importance of following Governor Brown’s “freeze” guidelines. OpEd Oregonian
COVID in the World (today 11/24)
Cases: 59.5 million; Deaths: 1.4 m
(pace: 530,000 cases/day, up 6% from previous 14 day period)
COVID in the US (today 11/24)
Cases: 12.5 m; Deaths: 257,000
(pace: 180,000 cases/day; our 14 day case count is up 49% compared with previous 2 wks)
The US makes up 4.4% of the world’s population, but we make up about 20% of the world’s deaths. And we are the richest, most advanced country in the world. (Although the US has the highest degree of wealth inequality in the world.)
Cases continue to increase: 49% over a two week period, with an average of 180,000 new cases per day.
COVID in Oregon (from 11/23)
Oregon COVID Cases: 65,000 (1500/100K) - we are averaging 1100 cases/day; up 65% and the highest daily cases ever. Our Rt is 1.14, which means that for every case of COVID, 1.14 people catch COVID. This is down from previously and is in line with the US average right now. Goal is to <1 (then our case counts go down). [https://rt.live]
Oregon COVID Deaths: 822 (19/100K); up 54%. We continue to be among the 12 best in the nation for cases and deaths.
Metro area Hospital Capacity: Oregon’s non ICU hospital beds are at 88% capacity, and in the Portland area we are at 92% capacity. ICU beds are at 82% and 90% capacity, respectively. The number of people in the hospital with COVID has doubled in the past month. This overall occupancy rate is not out of line with what we see in a busy flu season, but if the rise in COVID continues, we will surpass our conventional hospital bed supply. Therefore, hospitals are cancelling elective procedures and making plans to reconfigure hospital wards and operating rooms, in an effort to make more beds available for the anticipated increase in COVID hospital admissions. Hospitals in the metro area are coordinating with each other. But there is concern that we may not have the trained staff to take care of the patients in the “extra” beds. (Oregonian article.)
Testing: For the week Nov 15-22, there were about 40,000 Oregonians tested (OHA website). It turns out OHA has been reporting people tested, not tests performed, so that if a person was tested 5 times during the pandemic, they are only counted the first time. OHA plans to change their reporting to reflect tests performed. The change in reporting does lower the % positive rate, but it’s still nowhere near the goal of <5%. It’s not clear what is the “best” way to report tests, but it’s clear that different states report testing differently. (We should have a standardized method…) We continue to see an uptick in % positive tests (goal <5%, currently around 15%). Testing continues to be difficult to obtain (I know, I’ve tried, pretending to be a patient using the OHA tool to find testing.) Testing is insufficient and difficult to access. The state still does not offer universal low-barrier testing to anyone who wants it, and, in fact, some Oregonians with symptoms say they are still waiting in line for hours to get tested at hospital drive-thru locations. (Oregonian, 11/20/20, second article below)
For a deeper dive: See the Oregonian piece about lawmakers’ letter to OHA about testing, the Oregonian piece on how OHA tracks and reports testing (and their plans to change how they report, and the piece on the difficulties of getting a COVID test in Oregon. NYT op-ed piece on the need for a federal standard on how COVID tests/results are reported and this piece on the same topic.
The chart below is for Oregon through the week ending Nov 22, and the “denominator” is people tested, not total numbers of tests performed:
Governor Brown hits “freeze” on the state for two weeks (11/18/20-12/2/20), with a freeze in Multnomah County for four weeks (11/18/20 until 12/16/20) in an effort to slow the spread of COVID.
Freeze regulations include:
Limiting restaurants and bars to take-out service only.
Closing gyms and other indoor recreational facilities, museums, and indoor entertainment like theaters.
Closing outdoor recreational facilities, zoos, gardens, and entertainment venues. City parks and playgrounds will remain open.
Requiring all businesses to mandate that employees work from home when possible, and to close offices to the public.
Limiting grocery and retail stores to 75% capacity and encouraging curbside pickup service.
Prohibiting visits at nursing homes and other long-term care facilities.
Limiting social get togethers, whether indoors or out, to no more than six people from two households.
Limiting worship services to 25 people when indoors and 50 people when outdoors.
WA, CA and OR have asked folks to refrain from non essential travel and to quarantine for 14 days upon arrival from out of state.
School in Oregon: Criteria for Reopening
Oregon: metrics for school reopening have been updated so that the bar is easier to clear. It’s clear that lower cases in the community makes reopening schools safer! It’s why it’s so important to lower the case counts-so we can reopen schools. However Oregon’s rising cases, especially in the tri-county area, makes clearing this bar difficult.
OLD Metrics: metrics to be met three weeks in a row (county):
Case Rate ≤ 10 cases/100K people in county per week for 3 weeks in a row.
Test positivity ≤5% in preceding week for 3 weeks in a row.
NEW Metrics (per county): with metrics shown for the two weeks ending 11/21/20
If >200 cases/100K over 14 days: remain remote learning
If 100-200 cases/100K over 14 days: transition
If 50-100 cases/100K over 14 days, test 5-8% pos: hybrid of in person + remote
If <50 cases/100K over 14 days, test <5% positive: on site learning
Multnomah County is at 468/100K over 14 days, with 7.5% pos rate
Washington County is at 313/100K over 14 days with 7.6% positive rate
Clackamas County is at 339/100K over 14 days with 7.4% pos rate.
School in Oregon: Risks of Virtual Learning: The case to resume In Person learning
School closures are especially difficult for working class or unemployed families who cannot afford tutors, pods, or private schools. They also may have equipment, connectivity issues. These families also rely on schools to provide nutrition for their kids.
Mental health issues - isolation, toxic stress, substance abuse, suicidal ideation
Achievement Gap - those already falling behind are most affected
Less active/less outdoor time.
Attendance is lower and harder to enforce - overall engagement and checking in is more challenging.
Is there a way to open schools to the most vulnerable (how to define?)
We must shore up our schools NOW with plexiglass, PPE, hybrid plans to allow for social distancing, ventilation systems to prepare for in person learning sooner?
Schools do not seem to be superspreader events. 56 million students in the US resumed school in the fall. What can we learn from them? What are best practices? (Atlantic piece by Emily Oster). Kids under 10 (less contagious?) spread less. Many of the cases in the schools are brought in from the community, not necessarily spread in the schools.
Article in Nature: Cell Phone tracking (98m Americans in May) suggests that disease spread happens most in restaurants, gyms, and places of worship. Also noted, the more crowded the space, the higher the chance of spread. (Note: most schools were closed during this time so we cannot trace school influence, our approach to indoor dining (for example) has changed and is likely safer now than it was in May.)
Europe and Canada prioritizes keeping schools open even as they close down large parts of their economy (restaurants, bars, stores). “Schools should be the very last thing to close”. You can shore up economic closures with financial support, but you cannot always make up for lost cognitive time or recover mental illness effects. NYT piece on Canada/schools: Growing scientific evidence that time outside of school was more dangerous to children than the risk of going back into classrooms…’You can close restaurants and bars and give financial handouts so they can reopen at a later date,’ said Dr. Michael Silverman, the chair of Infectious Diseases at Western University’s School of Medicine & Dentistry in London, Ontario…’What kind of financial handout can you give to a kid for the long-term cognitive development impacts, to make up for it?’
The $3trillion HEROES act, passed by the US House this fall (and languishing on McConnell’s desk), includes $120billion for restaurants in an effort to keep them afloat, keep people on payroll, pay their rent, etc. US Congressman Earl Blumenauer of Oregon was a chief driver behind this, called the Restaurants Act.
COVID Treatments (updated)
Overall: The fatality rate from COVID is lower now than in the spring because of all that we’ve learned including measures (like positioning the patient a certain way) to prevent respiratory decline and the subsequent need for intubation.
Remdesivir: Works by inhibiting an enzyme necessary for RNA replication, thereby preventing COVID replication/multiplication. Shortens the course of illness in hospitalized patients with pneumonia. On 11/20/20, the World Health Organization concluded that Remdesivir has not been proven to improve the outcome in COVID patients and discourages its use. More to come.
Steroids (Dexamethasone): Helps blunt inflammation in hospitalized patients.
Monoclonal antibodies (investigational): Mass produced antibodies that are mimics of the molecules the body produces against the COVID virus. These molecules work in a variety of ways, including preventing the virus from infecting cells, or tamping down the number of virus in an infected patient. MAY EVEN BE USED as a preventative: giving the antibodies to those who have been exposed.
Regeneron product - given to Trump, approved by FDA Nov 22, 2020.
Hydroxychloroquine: is not useful in treating COVID.
Herd immunity
Thru vaccine + illness/recovery or both
We need (estimated) 60-70% herd immunity to slow or eliminate community transmission.
A 90% effective vaccine (see below) needs to be administered to 70% of the population to confer immunity to 60% of the population. There will be additional (presumed) immunity for people who have been sick and recovered from COVID.
If we continue with safety measures (handwashing, masks) we can achieve adequate protection from community spread with a lower % “immune”.
COVID Vaccine News: Three vaccines show promise so far
Pfizer (Phase ⅔): Announced that early trials (44,000 patients) suggest their vaccine (invented by German firm BioNTech, see below) is 90% effective! This is preliminary data, and is above the bar of 50% effective that the FDA has set for advancing the vaccine toward the production line.
How it works: Vaccine delivers viral genetic material (mRNA) into our own cells which then produce viral proteins, ie spike proteins found in the coat of COVID. The immune system reacts to the (“foreign”) spikes with antibodies and other responses. The antibodies then get activated when a COVID virus (with its spikes) enters a body and the antibodies disarm the COVID virus, preventing infection. There has never before been a successful mRNA vaccine.
Hoping for 30-40 million vaccine doses produced by the end of 2020. Two doses of the vaccine are required to confer immunity. Difficult issue: the vaccine needs to be shipped/stored frozen.
Priority for first vaccines: Health care workers and those with highest fatality rate from COVID.
Funded: $2B from US govt as “pre-purchase” of 100 millions doses; no fed money for research and development.
This is good news for all of the different vaccines being tested, especially those that use spike protein, or the mRNA model.
Great New York Times piece on the husband-wife German team who invented this vaccine with their company BioNTech (licensing it to Pfizer).
Moderna Vaccine: uses a similar mechanism as the Pfizer vaccine and preliminary studies show a >90% response rate. Vaccine must be frozen (a logistical challenge in transport and storage of vaccine.)
Astra Zeneca/Univ of Oxford Vaccine: 90% effective in early studies. Uses a weakened (cannot replicate in the host) chimpanzee adenovirus that contains a gene for codes for (and directs production of) COVID spike protein, which triggers antibodies and other immune responses. This “live” vaccine may confer stronger/longer immunity but carries risks to immunocompromised.
Oregon has a plan to procure, distribute and administer COVID vaccine, using pop up clinics, Emergency Medical Services, and more.
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