April 2023 Newsletter

Welcome to the April and a Half 2023 Newsletter for

Santa Monica Primary Care.

While published later in the month than usual, the information is not any less timely! In this issue we will cover LA County’s COVID-19 Emergency which ended March 31st, 2023. We also cover our clinic’s Spring experience with COVID-19and provide guidance on “new” booster recommendations.

End of LA County’s COVID-19 Emergency

With very little fanfare, Los Angeles County’s COVID-19 Emergency ended on March 31st – withthe major impact being the closure of County-run testing facilities. But beyond that, not muchchanges. An indoor masking mandate was lifted 13 months ago and face coveringrecommendations for the general public ended two months ago. In healthcare settings, maskscontinue to be required for healthcare workers providing direct patient care or working in patientcare cares. This, however, is a Los Angeles County only requirement as at other healthcaresettings in California, no masks are required whatsoever. It was certainly reasonable for the County to close testing sites as weekly testing rates are thelowest they have been (at 148 tests per 100,000 population) since May of 2020 (Figure below).At their maximum, 2745 tests per 100,000 were performed the week ending 1/11/2022.

Smoothed SARS-CoV2 Daily Testing rate (per 100,000 population): Los Angeles Country

Free testing remains available at LA County Public Health clinics.

Current COVID Incidence and Prevalence

The Los Angeles Times offered this outstanding turn of phrase when reflecting on the lifting of the COVID Emergency:

“But just as March 2020 is now indelibly etched in our collective consciousness— a watershed moment when daily life screeched to a — March 2023 may be remembered as when COVID-19 officially went from top of mind to back of mind.”

From my perspective, I was concerned that we would experience another January surge as wehad in 2021 and 2022 but that never materialized (Figure below)

Smoothed Daily Incidence Case Rate (per 100,000 population) of SARS-CoV2: Los Angeles Country, California for 2020 (Blue)

We are now in our current and expected Spring lull in cases, seen in all years of the pandemic -although 2020 should be interpreted cautiously given that we were under shelter-in-place orders.

Current prevalence rates (active cases per 100 population) are the lowest they have been at less than 0.1% – so fewer than 1 case per 1000 individuals – since October of 2022 (Figure below).

Estimated Prevalence Rate (per 100 individuals) of SARS-CoV2: Los Angeles Country, California

Death Rates - At A Historic Low

One common mantra that has been repeated throughout the pandemic is that of “more cases,more hospitalizations, more deaths.” This is a pattern currently holding in the inverse with deathrates also now at historic lows as case rates are at seasonal lows as well. However, in 2023 withearly detection from accurate home testing and widespread availability of Paxlovid, mortalityrates now stand at 0.02 deaths per day per 100,000 population (equivalent to 2 deaths per dayin LA County, with 10 million people). The last time mortality was this low?

The week of March 17th, 2020.

The figure below is a log transformed graph which shows more clearly just how much mortalityrates have dropped/

Smoothed Daily Mortality Rate (per 100,000 population) of SARS-CoV2: Los Angeles Country, California

Santa Monica Primary Care and COVID-19: Paralleling the County’s Experience

Similar to the County’s experience, we too have seen a massive decline in cases sinceNovember 2021 when we had 29 new cases (and 5 repeat infections). Thus far in April we havehad only 3 cases (2 of which were repeat infections)

Total COVID-19 Cases and Repeat Infections by month in 2022/2023: Santa Monica Primary Care

FDA Recommendations for a Repeat (Second) Bivalent Booster

This past week, the FDA amended the terms of its Emergency Use Authorization (EUA) for theModerna and Pfizer bivalent boosters, permitting individuals 65 and older and those withunderlying immunocompromise to have an additional dose (providing that it has been 4 monthsfrom the last).

In conversations with patients about this new recommendation, I’ve found myself clarifying a fewaspects of the FDA’s communication:

  • This is not a “new” booster, it is a new recommendation. The booster is identical to that originally authorized at the end of August of 2022.
  • The Bivalent booster contains mRNA components from the original strain ofSARS-CoV-2 as well as from the BA.4/BA.5 omicron variants. The BA.4 and BA.5variants have not circulated since the Fall of 2022.
  • This recommendation brings the US more in line with the UK and Canada. In the UK, they have referred to the second bivalent booster as a ‘top off’ for vulnerable populations.
  • Fall 2022 bivalent booster uptake was far higher in the UK than the US. In the UK, 65%of those 50 and over received the bivalent booster, and >80% of those over 70 received the booster. In the US, only 42% of the population over 65 had a booster dose. So some of the rationale for recommending a second bivalent booster may, in fact, be to encourage people simply to get their first.
  • The general expectation is that there will be a new booster available in the Fall of 2023which would be updated for circulating variant(s) at that time and also coincide in timing with an annual flu shot.
  • For now there is little compelling reason if one is young and healthy to have another bivalent booster. Individuals that are older (65 and above) with comorbidities or any immunocom promise could think about one at this point, with the context that cases and deaths are currently at historic lows. 

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