24 April 2021 Blog Post: Lifting the pause on the Johnson & Johnson vaccine

24 April 2021 Blog Post: Lifting the pause on the Johnson & Johnson vaccine

"In what is the right decision, the ACIP (CDC's vaccine advisory committee) has recommended lifting the pause on the Johnson & Johnson vaccine by a vote of 10-4 (with one abstention due to participation in ongoing clinical trials). This is indeed the right decision. Although certainly tragic for those 15 cases of vaccine-associated thrombosis, the risk/benefit analysis unambiguously falls in favor of the J&J vaccine. All of the confirmed case were in women (although one male in the clinical trial has a thrombosis event). The highest risk strata were women between the age of 30-39 years with 1.18 cases per 100,000 vaccine doses. The background general population incidence of cerebral venous thrombisis is estimated to be 0.22-1.56 per 100,000 population. It has a 3:1 female to male ratio and affected women tend to be younger (median age 34) than men (median age 42). Some women in this highest risk group may indeed opt for Pfizer or Moderna which would certainly be a reasonable choice. However, for others it is critical we have this ""one and done"" vaccine option available and pay careful attention to any unusual symptomatology arising 7-14 days post vaccination. To date in Los Angeles County we have had over 1.23 million COVID-19 cases and 23,736 deaths within a 10 million population."
Dr. Philip Bretsky

๐—ฆ๐—ถ๐—ด๐—ป ๐—จ๐—ฝ ๐—ณ๐—ผ๐—ฟ ๐—ข๐˜‚๐—ฟ ๐—ก๐—ฒ๐˜„๐˜€๐—น๐—ฒ๐˜๐˜๐—ฒ๐—ฟ

Dig deeper into the health topics you care about most by signing up for our newsletter.

By submitting this form you indicate you have read and agree to our Privacy Policy and Terms of Use. Please contact us for more information.

22 April 2021 Blog Post: Continued Decline in COVID-19 Rates in Los Angeles County

22 April 2021 Blog Post: Continued Decline in COVID-19 Rates in Los Angeles County

COVID-19 case rates continue to decline in Los Angeles County and now stand at 3.6 new daily cases per 100,000.ย  The last time we had a case rate this low was March 24th, 2020 and our total case count stood under 3300.ย  A year, 1.23 million cases and 23,702 deaths later we are left with the strangest looking epidemic curve I have ever seen (Figure 1)

Visually, I am struck by how small in magnitude our July 2020 surge seems when compared to the massive outbreak of cases we sustained from November 2020 through January 2021. However, from the week ending 1/12/2021 we began to have a steep decline in cases.

The last month has been relatively flat in terms of case numbers.

COVID-19 Incidence Rates in Los Angeles County (expressed per 100,000 population) by week

Deaths, on the other hand, remain in a consistent sustained decline from a peak of 2.66 daily deaths per 100,000 the week ending 1/12/2021 to 0.04 currently โ€“ seen in Figure 2 below.

Plotting case rates and mortality rates shows that mortality rates are in a steeper decline than case rates.ย  This, as I have discussed before, is most consistent with a vaccination effect which strongly protects against hospitalization and death (effectively 100% protection). Further, by prioritizing those at highest risk of severe disease initially, we have more strongly influenced mortality rates as a result.ย  This is seen in Figure 3 below.

So this is all very encouraging news. With such a low population case rate and now evidence of effective immunity among our most vulnerable, we can feel more confident about pushing reopening strategies and discontinuing some of our โ€œcorona-theaterโ€ such as temperature checks and outdoor masking.

๐—ฆ๐—ถ๐—ด๐—ป ๐—จ๐—ฝ ๐—ณ๐—ผ๐—ฟ ๐—ข๐˜‚๐—ฟ ๐—ก๐—ฒ๐˜„๐˜€๐—น๐—ฒ๐˜๐˜๐—ฒ๐—ฟ

Dig deeper into the health topics you care about most by signing up for our newsletter.

By submitting this form you indicate you have read and agree to our Privacy Policy and Terms of Use. Please contact us for more information.

13 April Post: On COVID testing

13 April 2021 Social Media Post: On COVID Testing

ย 

ย 

ย 

ย 

With all the (appropriate) focus on how vaccines can help open schools, business and recreation safely – we shouldnโ€™t forget about testing.

๐—ฆ๐—ถ๐—ด๐—ป ๐—จ๐—ฝ ๐—ณ๐—ผ๐—ฟ ๐—ข๐˜‚๐—ฟ ๐—ก๐—ฒ๐˜„๐˜€๐—น๐—ฒ๐˜๐˜๐—ฒ๐—ฟ

Dig deeper into the health topics you care about most by signing up for our newsletter.

By submitting this form you indicate you have read and agree to our Privacy Policy and Terms of Use. Please contact us for more information.

13 April Blog Post: J&J Vaccine Induced Thrombosis

13 April Blog Post: J&J Vaccine Induced Thrombosis

I have had several questions about todayโ€™s pause in Johnson & Johnson COVID-19 vaccine administration after 6 cases of a specific type of stroke among the 6.8 million individuals receiving the vaccine. Termed cerebral venous sinus thrombosis (CVST) this exceedingly rare outcome has occurred only among women aged 18-48 with symptoms beginning 6-13 days after vaccination.ย  According to the New York Times, one woman has died and another is in critical condition.

In general, the population frequency of CVST may be more frequent than among those receiving the J&J vaccine.ย  It occurs in about 1 in 100,000 annually and is also more common in women (3:1 female to male ratio) and at a younger age for women (average is about 34 years) as compared to men (42 years). The predominance in women may be due to conditions that increase oneโ€™s susceptibility to clotting (can be genetic but also acquired), oral contraceptive use and pregnancy.ย  About 10% of cases appear to be associated with infection โ€“ and initial theories in the J&J observation include the possibility of vaccination soon after natural COVID-19 infection as a cause. I think pausing continued administration is probably a good idea.

For women in particular we should be on the lookout for symptoms beginning between one and two weeks after administration. This is helpful insofar as most immediate vaccine sensitivity issues occur within 24-48 hours and resolve quickly.ย 

The most common symptom (not surprisingly) is headache but, more specifically, headaches with visual disturbance.ย  The two tend to be correlated โ€“ in other words, the worse the headache the greater the degree of visual involvement. This can be difficult to distinguish from a migraine which can also have visual involvement but, if in the window period of 6-13 days post-vaccination, it may not be migraine.

Seizures and alterations in consciousness are more extreme ways that CVST can present, but that would most certainly lead to immediate medical attention.

The joint statement from the CDC and FDA says that โ€œpeople who have received the J&J vaccine who develop severe headache, abdominal pain, leg pain, or shortness of breath within three weeks after vaccination should contact their health care providerโ€.

There are a couple of wrinkles in the assessment and treatment of CVST post vaccination that are important. First, an MRI/MRV is the optimal test as a CT scan may show only non-specific abnormalities.ย  Most ERs do not typically perform MRIs. Secondly, the usual treatment with a blood thinner called Heparin appears to make vaccine-induced clotting worse so alternatives (Argatroban for example) should be used.ย  These are the sorts of situations where it is helpful to have thought about the possibility beforehand โ€“ so Iโ€™d ask patients who have any concerns call me if anything unusual occurs (again Iโ€™m not expecting this) but at least I make sure we get the right testing and right treatment (if needed).

Hope this is helpful and I will update as we learn more on this developing topic.

๐—ฆ๐—ถ๐—ด๐—ป ๐—จ๐—ฝ ๐—ณ๐—ผ๐—ฟ ๐—ข๐˜‚๐—ฟ ๐—ก๐—ฒ๐˜„๐˜€๐—น๐—ฒ๐˜๐˜๐—ฒ๐—ฟ

Dig deeper into the health topics you care about most by signing up for our newsletter.

By submitting this form you indicate you have read and agree to our Privacy Policy and Terms of Use. Please contact us for more information.

11 April 2021 Blog Post: โ€œDecouplingโ€ COVID-19 Mortality from Cases

11 April 2021 Blog Post: โ€œDecouplingโ€ COVID-19 Mortality from Cases

While there are known differences in overall efficacy of the three major COVID-19 vaccine available on the US market, Pfizer, Moderna, and Johnson & Johnson, on one metric they all perform flawlessly โ€“ they all prevent COVID-19 mortality at 100% efficacy.

As we watch Michigan struggle with rising case loads (currently 9 of the top 10 affected metropolitan areas are in Michigan, source:ย ย https://www.nytimes.com/interactive/2020/04/23/upshot/five-ways-to-monitor-coronavirus-outbreak-us.html), it logically leads to concerns about the same potential uptick in cases occurring here in Los Angeles. One interesting difference between Michigan and our region is that, until now, Michigan did not suffer a mid-summer surge in the same way that we did here. This, I suspect, leaves a sizable susceptible population. The vaccine rollout in Michigan is equivalent to that here in California with 76% of accolocated vaccine having been distributed in both state (California ranking 30th and Michigan 31st).

Here in Los Angeles County new COVID-19 cases have continued to decline, now for the 12th week in a row and stand at 3.8 new daily cases per 100,000.ย  There is some plateauing to this decline, however, with its initial steep decline slowing in late February.

However, death rates have continued to plummet and are now at 0.08 new daily deaths per 100,000 population down from a high of 2.66 in mid January. The shape of this curve has turned even more sharply downwards over the last month (Figure 1 below).

ย 

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Ut elit tellus, luctus nec ullamcorper mattis, pulvinar da

The decoupling of case and mortality rates most certainly represents a vaccine effect for two reasons. Firstly, with 100% efficacy against death, a vaccine effect in the population will first show among the outcome against which it provides greatest protection (similarly, hospitalizations should also show such a pattern). Secondly, we have targeted initial vaccination efforts among those at highest risk โ€“ particularly the elderly who have shown the highest COVID-19 mortality rates. It is for this reason that we see an amplified effect of vaccination.

At this point it seems that we continue to head the right direction as a County and can look towards additional reopening measures.

๐—ฆ๐—ถ๐—ด๐—ป ๐—จ๐—ฝ ๐—ณ๐—ผ๐—ฟ ๐—ข๐˜‚๐—ฟ ๐—ก๐—ฒ๐˜„๐˜€๐—น๐—ฒ๐˜๐˜๐—ฒ๐—ฟ

Dig deeper into the health topics you care about most by signing up for our newsletter.

By submitting this form you indicate you have read and agree to our Privacy Policy and Terms of Use. Please contact us for more information.

8 April 2021 Blog Post: COVID-19 Mortality Rates in Los Angeles County

8 April 2021 Blog Post: COVID-19 Mortality Rates in Los Angeles County

We have come full circle in one yearโ€™s time โ€“ COVID-19 mortality rates for the last week of March 2021 are identical to those of the last week of March 2020, 0.1 daily deaths per 100,000 population (Figure 1).ย  It took a lot of work to arrive back where we started.

In general, mortality rates have tracked with case rates throughout the entire pandemic (Figure 2 below) โ€“ with a slight 2-3 week delay.ย  In other words, as cases begin to rise, soon thereafter deaths begin to riseย  Lending visual credence to the โ€œmore cases, more hospitalizations, more deathsโ€ adage we have experienced since the earliest outbreaks in Italy, for example.

A couple of trends are notable looking at these two juxtaposed graphs (plotted on a log scale so they can be compared directly โ€“ note that this will smooth out some of the peaks most particularly in mid-summer).ย  But what we can see is that deaths rise swiftly in the early days of the pandemic, quickly reaching a peak of 0.4 daily deaths per 100,000 that holds as a maximum until after Thanksgiving 2020. So why did they rise so quickly and then flatten?ย  Well, initially we had no idea what we were doing โ€“ no idea that individuals did better if we delayed placing them on ventilators or if we started steroids earlier. By that point there were no monoclonal antibodies and, from a public health standpoint, we were only learning that older individuals were at greatest risk. All of those factors combined to create a harsh initial reality and high mortality rate.

By December, however, we had completely overwhelmed our healthcare system with cases which had been rising since September but then jumped with Thanksgiving travel (note Los Angeles County put in travel restrictions after Thanksgiving but should have done so beforehand). So our early September ratio of 7.8 new daily cases per 100,000 to 0.2 daily deaths became 140 / 2.7 at our January peak. In fact, our mortality rate ratio (cases : deaths) went from 39 to 52 again likely indicative of an overwhelmed system.

But look at the two curves after January โ€“ we can now see a bit of a plateau in case rates over the last month, but death rates have still dropped sharply nearly approaching zero. While a less punished healthcare system and better treatments are no doubt part of this trend, consider too the potential effect of vaccinations which began in earnest in January among our most vulnerable. With 100% effectiveness against hospitalization and deaths, we may indeed be seeing the efficacy of these vaccines (primarily Pfizer and Moderna) in action.

See โ€“ not all doom and gloom from this writer.

Acknowledgements: thanks to @tdubey from Twitter for pointing out the contribution of vaccination (even just first doses) on the mortality rate curve

๐—ฆ๐—ถ๐—ด๐—ป ๐—จ๐—ฝ ๐—ณ๐—ผ๐—ฟ ๐—ข๐˜‚๐—ฟ ๐—ก๐—ฒ๐˜„๐˜€๐—น๐—ฒ๐˜๐˜๐—ฒ๐—ฟ

Dig deeper into the health topics you care about most by signing up for our newsletter.

By submitting this form you indicate you have read and agree to our Privacy Policy and Terms of Use. Please contact us for more information.

7 April 2021 Blog: Towards More Aggressive Reopening in Los Angeles County

7 April 2021 Blog: Towards More Aggressive Reopening in Los Angeles County

In near simultaneous statements, Governor Newsom announced plans for a wide reopening of the state (link:ย https://abc7news.com/newsom-update-green-tier-california-system-orange-rules/10491250/),ย  while Los Angeles County officials revealed that COVID-19 case declines have โ€˜stalledโ€™, risking such plans (link:ย ย https://patch.com/california/los-angeles/las-coronavirus-case-rate-levels-thwarting-more-reopenings).

Can both be true?ย  In fact, yes. But in what seems to be typical Governor Newsom impulsiveness, he has now done away with the tier system, decidedย  the state will now move as a monolith instead of county-by-county, and has pinned reopening on โ€œadequate vaccine supplyโ€ (undefined) and hospitalization rates.

My biggest gripe(s) are his scrapping of the tier system and the use of hospitalization rates โ€“ and Iโ€™m not thrilled by moving away from county-by-county granularity but I can live with that. The California tier system which I have critiqued for being arbitrary in its choice of numeric cutoffs, does at least attempt to model a well constructed tier system advanced by Harvardโ€™s Global Health Initiative (link:ย ย https://globalepidemics.org/wp-content/uploads/2020/06/key_metrics_and_indicators_v4.pdf). Using hospitalization rates to gauge reopening makes little sense as it is a lagging indicator. In other words, it takes time for individuals to become sick enough to require hospitalization so any policy based off of hospitalization rates will necessarily be a delayed reaction.

It is better to use incidence (rate of new cases) and prevalence (rate of active cases) in the population to guide policy. More cases lead to more hospitalizations which lead to more ICU beds being filled and ultimately leading to higher mortality rates. We have heard this tune before.

To this end, I have continued to calculate and track the incidence and prevalence rates of COVID-19 here in Los Angeles.ย  I have truncated the figures to begin the first week of January 2021 rather than spanning the entire pandemic.ย  Figure 1 presents the incidence (i.e. new case) rates which have declined sharply from 143.7 new daily cases per 100,000 population the first week in January to 4 currently โ€“ a 97% drop.

Similarly prevalence rates (the number of active infections at a given time) have also decreased since the first week of January (Figure 2) from 24% to 0.1%

Prevalence rate numbers have gotten so low that it is now better to express them in values per 100,000 population.ย  For the week ending January 12th 2021, there were 24,412 active COVID-19 cases per 100,000 population.ย  For the week ending 3/30/2021, there were only 64 active COVID-19 cases per 100,000 population. As an analogy, a completely packed Dodgers Stadium in January would have had 14,647 fans with COVID-19 โ€“ but today only 38 fans in the same stadium would have the infection.

Dr. Ferrar is correct to be cautious about the leveling off in case declines but, once again, misses the mark on what needs to be done about it. In fairness, so does Californiaโ€™s Health and Human Services Secretary Dr. Mark Ghaly who states it is a โ€œrace to get people vaccinated.โ€ What both should be doing instead is redoubling contact tracing efforts which are abysmal for Los Angeles County (link:ย ย http://publichealth.lacounty.gov/media/coronavirus/data/contact-tracing.htm).ย  Cumulatively, the County has only completed tracing for 44.8% of cases and in the last 7 days (despite a massive decrease in case load), have only attained a 51.0% completion rate. For effective contact tracing, the County needs to attain a 95% completion rate.

At the very outset of the pandemic, Trevor Bedford (a computational biologist at the Fred Hutchinson Cancer Center in Seattle) noted that COVID spread is analogous to smoldering fires that can then flare up and spread widely. It is not always clear why some fires stay contained and others spread widely, but each needs to be treated with care. This visualization remains true today. By simply watching case or hospitalization or ICU rates, we are solely reliant on vaccination efforts which have been way too slow already and are leaving swaths of people left behind. But we can do more! Basic test, trace and isolate measures which both the State and County seem to have abandoned in favor of complex scheduling software for vaccine appointments are precisely what can eliminate those smoldering infection pockets.

The question is whether or not our health officials want to commit to such a labor intensive process. Doing so would allow the State and County to be more aggressive about reopening filling restaurants and stadiums to capacity, returning to a sense of normalcy. But that is not the stance that has been taken to date, and I have little optimism that their approach will change. Instead, we are left with a passive, inflexible government โ€“ in charge of vaccine distribution and unwilling to douse the few (but dangerous) remaining flames of infection.

๐—ฆ๐—ถ๐—ด๐—ป ๐—จ๐—ฝ ๐—ณ๐—ผ๐—ฟ ๐—ข๐˜‚๐—ฟ ๐—ก๐—ฒ๐˜„๐˜€๐—น๐—ฒ๐˜๐˜๐—ฒ๐—ฟ

Dig deeper into the health topics you care about most by signing up for our newsletter.

By submitting this form you indicate you have read and agree to our Privacy Policy and Terms of Use. Please contact us for more information.