CRITICA

The following is excerpted from the PINC Topicbox on August 6, 2021. The issue had been raised as to how PINC community members were responding to the emergence of the delta variant of Covid-19 in terms of conducting in-person sessions. Jeff Sandler’s contribution is included below along with a question posed to him by Michael Korson asking for documentation supporting Jeff’s initial posting. At that time, persons had been returning to in-person treatment as there had been a significant waning of infections following the third wave of Covid-19 along with an enhanced sense of security afforded by the advent of highly efficacious vaccinations. Jeff Sandler The delta variant is surging across the country and in the Bay Area. Being vaccinated does not prevent individuals from becoming infected and infectious. Becoming infected even if vaccinated can result in severe illness and lingering symptoms (perhaps long Covid or ailments that the medical profession has yet to recognize that emerge and persist beyond any acute infection and illness or even when the acute infection has been completely asymptomatic). The delta variant is extremely contagious which means it gets transmitted much more readily with much less exposure required resulting in many more persons becoming infected. We don’t know just how widespread the delta variant is among vaccinated persons since so many more of them who become infected will be asymptomatic or only mildly symptomatic, but these persons are spreading the virus covertly to others, vaccinated and unvaccinated. Many unvaccinated persons who become ill with the delta variant are appearing more ill compared to illness severity in those infected by other variants. Hospitalizations and deaths are occurring among younger persons and healthier persons in much greater numbers with the delta variant, which is another indication that this variant is more pathogenic. I suspect many of us have a somewhat erroneous belief that taking the same precautions as we have from the beginning of the pandemic will provide the same level of protection; while being vaccinated is a major game changer in substantially lowering the risk of becoming infected overall, the delta variant by being so contagious diminishes the degree of prophylaxis offered by the vaccination. Everyone must determine for themselves how essential meeting in-person is, but the above provides a sense of the risk involved and what is at stake. Michael Korson Thank you Jeff. One question: Can you point to the data that suggests breakthrough cases are now leading to “severe illness”? My understanding, as it is now, is that breakthrogh cases (such as that of a friend of mine) are leading to mild to moderate illness and for the most part not requiring hospitalization. Is there data to suggest that has changed now? Of course, as immunity from the vaccine wanes, it is likely that severity of illness will increase. Jeff Sandler As for Michael’s question about the basis and data for my referencing severe cases in vaccinated persons, this is largely anecdotal and impressionistic based on the following. There has been a shift in public statements and various news reports, etc. away from saying that vaccinated persons with breakthrough cases can essentially expect to be asymptomatic or mildly symptomatic to saying that being vaccinated practically (but not absolutely) guarantees prevention of being hospitalized or dying. I have heard of anecdotal reports suggesting that some persons with breakthrough cases describe the illness as the worst viral illness ever experienced. One person said they felt so ill they could not imagine surviving had they not been vaccinated. The following is excerpted from a recent article in the Guardian: “There is very little data on long Covid in breakthrough infections. What little data we do have comes largely from a New England Journal of Medicine study by researchers in Israel, who found 19% of people with breakthrough infections had “persistent” symptoms.” In my mind, an occurrence of persistent symptoms of 19%, even if these are only mild symptoms, is an indication of a severe case. We know very little about long Covid and the long-term health implications that may accompany it. This is from a Kaiser Family Foundation report: “Importantly, not all hospitalizations and deaths of those fully vaccinated and diagnosed with COVID-19 are due to COVID-19 or have a known cause at the time of reporting. The CDC reports that as of July 19, of 5,601 hospitalized breakthrough cases, 27% were asymptomatic or not related to COVID-19 and of 1,141 fatal cases, 26% were asymptomatic or not related to COVID-19. States differ in whether they provide this detail. DC, for example, reports that as of July 11, 50% of hospitalized breakthrough cases were due to COVID-19, 19% were not, and 31% were of unknown reason. However, few states made these distinctions. Where they did, we only included breakthrough hospitalizations and deaths due to COVID-19. In other cases, some of these breakthrough events may be due to causes other than COVID-19.” As a percentage of breakthrough cases leading to hospitalization and death, the number of cases reflected above is a very small fraction. Yet in terms of absolute numbers, ie thousands, it is clear that there is a very real, albeit very, very low risk of breakthrough illness leading to hospitalization and/or death. From the same report, “The share of hospitalizations among those with COVID-19 who are not fully vaccinated ranged from 95.02% in Alaska to 99.93% in New Jersey. (Note: Hospitalization may or may not have been due to COVID-19.) The share of deaths among people with COVID-19 who are not fully vaccinated ranged from to 96.91% in Montana to 99.91% in New Jersey. (Note: Deaths may or may not have been due to COVID-19.)” This implies that the rate of hospitalization or death in vaccinated persons could be as high as 5%. So as a statistical matter, being vaccinated provides a tremendous amount of protection and security. But if you or one of your patients or someone else you or they have contact with becomes infected and suffers some form or severe illness, it doesn’t matter for that person that they were the one in 10,000 to have such bad luck. I’ll repeat what I said in my prior post, everyone must determine for themselves how essential meeting in-person is, but the above provides a sense of the risk involved and what is at stake. Everyone wants to put this horrible pandemic behind us. We all need to be aware of how powerfully we can be pulled into deceiving ourselves that the situation is better, more resolved, and less threatening so that we can return to living our lives in the more meaningful ways we used to and have had to relinquish. Clearly the desire to return to working in-person with our patients is a powerful influence on our thinking and feelings in this regard. Michael is correct that breakthrough cases are leading to mild-to-moderate illness and for the most part not requiring hospitalization. I am highlighting that there are those statistically rare cases that are not following the prevailing trend and we need to be careful not to minimize that dimension of this crisis.