Oregon Coronavirus Update: Cases continue to rise. Gov Brown's guidelines. School & vaccines.
Oregon Coronavirus Update
Lisa Reynolds, MD, pediatrician and Representative-Elect for Oregon House District 36.
Companion to Lisa’s 12/6/20 Virtual Town Hall (you can watch it on facebook)
Resources from Town Hall:
COVID Survivors for Change: www.covidsurvivorsforchange.org;
email ED Chris Kocher: firstname.lastname@example.org
If you are a COVID survivor (have personal had COVID or have lost a loved one to COVID) and need help: https://www.surveymonkey.com/r/COVIDSurvivorHolidayDrive
If you want to help a survivor or survivor’s family: https://forms.gle/LVohtJezv3NsXxEQ7
Summary: COVID cases continue to rise in Oregon, the US, the world. Testing is inadequate in Oregon. Governor Brown’s guidelines. The case for prioritizing the reopening of schools. Updates on treatments and vaccines, including Oregon’s vaccine plan.
“Everyone who knows what’s coming with COVID is wandering around in a fog of anticipatory grief.” Lindsay Beyerstein on twitter (repeat of this quote, which captures my feelings
COVID in the World
Cases: 67 million; Deaths: 1.5 m
COVID in the US
Cases: 14.7 m; Deaths: 282,000
(pace: 200,000 cases/day; 2,000 deaths/day; our 14 day case count is up 12% compared with previous 2 wks)
The US makes up 4.4% of the world’s population, but we make up about 20% (18.8%) of the world’s deaths. And we are the richest, most advanced country in the world. And our health system is proving to be the worst in the world--our public health system is broken and has failed miserably. And yes this in part due to Trump’s politicization of masks and of social distancing. (Although the US has the highest degree of wealth inequality in the world.)
COVID in Oregon
Oregon COVID Cases: 83,000 (2000/100K) - we are averaging 1800 cases/day; up 40% and the highest daily cases ever. Our rate is projected to reach 2700 case/day by Christmans. Our Rt is 1.14, which means that for every case of COVID, 1.1 people catch COVID. This is stable for about 3 weeks) and is a little better than average Goal is to <1 (then our case counts go down). [https://rt.live]
Oregon COVID Deaths: 1000 (36/100K); up 100%. We continue to be among the 10 best in the nation for cases and deaths.
Metro area Hospital Capacity: The number of people in the hospital with COVID has rapidly increased in the past month. Hospitals are cancelling elective procedures and are reconfiguring hospital wards and operating rooms, in an effort to make more beds available for the 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.)
(This section is mostly an excerpt from earlier reporting): 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)
Governor Brown’s Framework for Counties, as of Dec 3
TriCounty area (Extreme Risk):
Limiting restaurants and bars to take-out and outdoor dining only.
Closing gyms and other indoor recreational facilities, museums, and indoor entertainment like theaters.
Outdoor recreational facilities, zoos, gardens, and entertainment venues with strict numbers (<50). 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 50% 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 (worship/funerals) to 25% or 100 people when indoors and 150 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.
See chart below.
School in Oregon: Criteria for Reopening (Repeat of earlier reporting with a few updates)
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.
CONSIDER summer school aka “5th Quarter” (Oregon is looking into this).
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. Still, there is long term disability for survivors of COVID.
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.
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! Awaiting emergency FDA approval, expected any day now.
How it works: Vaccine delivers viral genetic material (mRNA) into our own cells. mRNA instructs the cell to 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.
Difficult issue: the vaccine needs to be shipped/stored frozen (-94 degrees F).
Funded: $2B from US govt as “pre-purchase” of 100 millions doses; no fed money for research and development.
Great New York Times piece on the husband-wife German team who invented this vaccine with their company BioNTech (licensing it to Pfizer).
Already being administered in England
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.) Awaiting emergency FDA approval (any day now).
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 that 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. OHSU is conducting a study using this vaccine.
Oregon has a plan to procure, distribute and administer COVID vaccine, using pop up clinics, Emergency Medical Services, and more.
Oregon is expected to receive 270,000 doses of vaccine (164K Pfizer, 104K Moderna) this month (assuming emergency FDA approval, which is expected). 2 doses needed. Must be stored at 70 degrees below zero celsius (neg 94F), Pfizer: multidose vials (5 doses/vial). Oregonian article. Production schedule is not clear - we don’t know when we will get more doses.
The initial limited doses will go to the state’s approximately 300,000 frontline health care workers and 60,000 to 70,000 senior care home residents and staff. (requires 740K doses). (39% of COVID deaths in US have been in longterm care facilities)
Next on the priority list will likely be essential workers (BIPOC overly represented in this group), people with chronic health conditions and people over 65.
The vaccines are not yet approved for kids….
Population: US Total: 328m; US over 18 years old: 209m; Oregon: 4.2m
The state said it would consider a “hub system,” in which providers who are able to store the vaccine get enough doses to then distribute to providers who are not. The Oregon Health Authority plans to map out where in the state providers are able to keep the vaccine at such low temperatures to determine where we can send vaccine.
Why 270K doses? Each state will get a certain amount of the first 6.4m doses, determined by how many adults live there. The priority list is derived from CDC recommendations.