September 2023 Newsletter

Welcome to the September 2023 Newsletter for

Santa Monica Primary Care.

In this issue, we cover seasonal vaccines coming due this Fall  (Flu, COVID booster and RSV) with some detail on how they are formulated and deemed effective. We borrow heavily from analysis performed by the UK’s Joint Committee on Vaccination and Immunization (or “Immunisation”).

Flu Shots are “IN”: On Seasonal Influenza Vaccine

Doses of the 2023/2024 seasonal flu shot are stocked in our office and can be given any time as the best time to receive the vaccine is during the months of September and October.

The rationale for such timing is that annual local epidemics follow a fairly predictable
seasonal pattern with outbreaks in North America occurring between November and March. These begin abruptly, peaking in 3 weeks, and then end about 8 weeks later. Viral spread during winter months is presumed to be favored by improved virus survival in lower temperature environments and, indoor crowding due to cold weather. These annual epidemics can affect 10% to 30% of the world population.

Each year in January, a review of circulating influenza viruses is undertaken by the World Health Organization (WHO) and the most likely epidemic strains from two main categories – Influenza A and Influenza B – are selected. For Influenza A this year’s shot contains the ‘swine flu’ familiar H1N1 as well as H3N2 subtypes (H and N are specific surface proteins termed hemagglutinin and neuraminidase). The Influenza B lineages generally cause less severe disease and are called Yamagata and Victoria. So there are 4 components which is why you will hear the shot referred to as ‘quadrivalent’.

The decision on which strains to include in the vaccine formulation is based on global
surveillance data but, in the end, it is a prediction and not always correct. As such, the
effectiveness of the seasonal flu shot can vary from year to year. Even if the vaccine doesn’t completely prevent the flu, it can still reduce the severity and complications of the illness should you become infected.

Vaccination is associated with a reduced incidence of influenza from 2.3% among adults who were unvaccinated as compared to 0.9% among vaccinated. This effect is even stronger among those 65 years and older, wherein vaccination reduced the incidence from 6% to 2.4%.

Side effects to the flu vaccine are generally mild, most common being local injection site reaction (soreness), headache, muscle aches or low grade fever – all resolving within a day or so. About 15% of flu vaccine recipients experience a side effect.

COVID-19 Boosters Will Be “IN”: On the 2023 Booster

For the first time ever, our office will be stocking a COVID vaccine, in this case the 2023
booster. We have been able to bypass the LA County Health Department who had been unwilling to supply us with vaccines and instead are receiving them directly frow the manufacturers. Unlike the influenza vaccine which has population-wide applicability, I am favoring a narrow scope of vaccine efforts for COVID-19. Some of this recommendation is based on bivalent booster experience of 2022 wherein only 17% of the total US population ever received a booster dose. That percentage was a bit better for those over the age of 65 years at 43.3%.

Similar to influenza, COVID historically (until 2023 that is) has had a strong Winter surge beginning right after Thanksgiving (not a big surprise why an airborne virus would spike after such). The Fall 2023 COVID booster, which should gained FDA approval this week, targets the XBB.1.5 a coronavirus subvariant that emerged in late 2022. While XBB.1.5 only makes up 3.1% of the currently circulating variants in the US, basic science data has indicated that its offshoots (EG.5, FL.1.5.1, KBB.1.16.1 and KBB.1.16) share a close relationship with KBB.1.5. As such, it is expected that the updated booster will provide protection against these related variants

The UK’s Joint Commission on Vaccination and Immunization (JCVI) has offered some of the most coherent advice on boosters, recommending them for those at high risk of serious disease and therefore most likely to benefit from vaccination. These include:

  • Residents in a care home for older adults.
  • All adults aged 65 years and over.
  • Persons aged 6 months to 64 years in a clinical risk group.
  • Frontline health and social care workers.
  • Persons aged 12 to 64 years who are household contacts of people with immunosuppression.
  • Persons aged 16 to 64 years who are carers and staff working in care homes for older adults

Similarly, we will advise patients over 65 and those in higher risk groups to strongly consider having the booster by the end of October in time for an expected late November to January surge in cases (this differs from the UK recommendation to have the booster by the end of December). The crux of the JCVI’s advice is based on a coherent analysis of the number needed to vaccinate to prevent a hospitalization or death due to COVID-19. Based on the 2022 booster experience, it would require giving a booster to 240 high risk >90 year olds to prevent one COVID death but over 2 million booster doses to prevent one death amongst healthy 15-19 year olds.

Vaccine efficacy of the 2022 booster dropped rapidly from 53% 2-4 weeks after vaccination to 28% at greater than 15 weeks. Protection against hospitalization after an mRNA booster increases in the two weeks after vaccination and then declines towards a stable plateau of around 50-60% by six months.

While you can have both the flu vaccine and COVID booster at the same time, it may be more prudent to separate the two. That way in the case of an unlikely, but possible, vaccine reaction -the cause will be apparent. A recent study from Sheba Medical Center in Israel showed that systemic reactions among those who received a flu+COVID co-administration was 27.6% as compared to 27.4% for COVID only and 12.7% in flu only. However, COVID spike protein antibody levels were 19% higher amongst those who received the COVID booster separately as compared to those who received COVID and flu vaccines together (link:https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2809119

RSV Vaccine is OUT there: On the New RSV Vaccine

This Fall will be the first time that an RSV (Respiratory Syncytial Virus) vaccine becomes available but is not a vaccine we will stock in the office. It will be available, however, at local pharmacies. Approved in May 2023, two RSV vaccines are available in the prevention of respiratory tract disease – Arevxy (82% effective) and Abrysvo (67% effective)

RSV is a common respiratory illness that infects up to 90% of children in their first two years of life and frequently reinfects both older children and adults. In most cases, RSV infection is mild and may even go unnoticed – with infants under the age of one year and the elderly at greatest risk. For infants, RSV can cause such severe inflammation of the small airways in the lungs that significant breathing difficulties can occur. There is no pharmacotherapy other than supportive care with fluid and respiratory support. RSV is a leading cause of infant mortality globally and, in
some developing countries, is second only to malaria as a cause of death among infants.

The burden of RSV disease in adults is less well understood but undoubtedly
underestimated given that it is most typically (and correctly) associated with respiratory illness in infancy. The same JCVI grappled with a population-wide rollout of RSV vaccine in the UK where the annual number of deaths was estimated to be somewhere between 741 and 6472. The US has about 5 times the population of the UK so that would translate to between 3700 and 32000 deaths here. They also considered the burden of RSV on the health system in general and concluded that a programme for those 75 years and older would be the most ‘efficient’ but one directed at 65 years and older would provide the most benefit. Note: they only considered the Arevxy, noting that these data provided the most ‘comprehensive read out’ and is also more effective. The committee was hopeful that Arevxy would provide multi-year protection, as RSV does not have the same mutation frequency as COVID-19 and influenza. At $336 a dose, one would certainly hope for longer lasting protection.

Side effects seem to be generally mild but common. 34% of recipients reported fatigue, 29% muscle aches and 27% a headache. These typically resolved in 24 to 48 hours.The current RSV vaccine is recommended only as a single dose for individuals 60 years and older in the United States. I would revise that upwards to 65 years of age. Those most likely to benefit would be those with pulmonary disease (such as COPD or asthma), cardiovascular disease, moderate to severe immune compromise, and diabetes. The CDC does not recommend against co-administration with seasonal flu shot or other vaccines although antibody titers for both influenza and RSV were lower when given together. So my recommendation would be to separate RSV vaccination out from other shots by two weeks.

 

Vaccine Recap

Seasonal Flu: An unqualified, yes
COVID Booster: Everybody 65 and older, patients with an immunosuppressed household member, those under age 64 with a risk factor for severe disease
RSV Vaccine: Everybody over the age of 65, those 60-64 with asthma, COPD, diabetes or immune compromise

.

What’s Happening with COVID?

In August, the Los Angeles County Health Department reported a “concerning increase” in reported COVID-19 cases and indeed cases in our clinic showed a notable uptick as compared to much of the Spring of 2023. We had a total of 13 cases, of which 10 were first time infections (Figure 1 below).

Total COVID-19 Cases(Blue) and Repeat Infections (Red) by Month in 2022/2023: Santa Monica Primary Care

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

While this did represent a significant increase, it is important to contextualize the magnitude of such against the historic low rates of this Spring. Historically, a mid to late summer surge has been seen in every year since the pandemic began, but rates this summer (Green Line in Figure 3 below) were the lowest we have ever seen, including the Summer of 2020 (Blue Line). We were all under shelter-in-place orders during the Summer of 2020 as well.

Smoothed Daily incident Case Rate (per 100,000 population) of SARS-CoV2: Los Angeles Country, California for 2020(Blue), 2021(Red), 2022(Yellow), and 2023 (Green)

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10 August 2023 Blog Post: Surge, What Surge?

Surge, What Surge?

The growing consensus I have heard from patients is that we are having a COVID-19 surge in Los Angeles and, given such, they are wondering what additional precautions need to be taken. I was somewhat surprised to hear that we were experiencing an increase in cases in the County, as this has not been seen in our practice case numbers. Whereas November 2022 we say 29 cases, case rates here at Santa Monica Primary Care have been a slow drumbeat since March. 6 cases in March, 7 in April, 4 in May, 5 in June, 6 in June and only 2 thus far in the first 10 days of August.

But turning to headlines, I can see why a surge is of concern.  Yesterday the Los Angeles Times headline blared “COVID-19 is heating up all around’ this summer. Should we be wearing masks again?” (link: https://www.latimes.com/california/story/2023-08-09/covid-19-is-heating-up-this-summer-should-we-wear-masks-again).  According to Dr. Peter Chin-Hong, a UC San Francisco infectious diseases expert, said transmission is increasing and “we haven’t seen the crest yet” of the wave.

Now I understand that my small slice of the medical universe is not necessarily generalizable, but generally with a communicative patient population I’m aware when case burdens increase – whether it be flu, RSV, or COVID.  

Reading further into the Los Angeles Time’s coverage, state Epidemiologist Dr. Erica Pan noted that California’s test positivity rates have gone up in the last two to three weeks, “and I’m sure many of you are anecdotally both hearing about friends and family and colleagues … about some more circulating COVID,” Pan said. “Thankfully, our hospitalizations are looking very reassuring so far.”

Those who have followed my blog posts in the past will remember that test positivity rates are an inaccurate and problematic metric as it depends on the denominator of who is being tested. Few go to public health labs or obtain reportable PCR tests any more; rather most COVID cases are identified through home testing which are not reportable to public health agencies.

When diving into Los Angeles County Data, Dr. Pan is indeed correct that test positivity rates have increased, but not just over the past 2 to 3 weeks but rather over the past 2 to 3 months. Test positivity rates were as low as 2.9% in early May and have climbed to 7.9% in the last week in July (Figure 1 below).

Left unmentioned by the Los Angeles Times and Dr. Pan is the sharp decrease in testing itself (the denominator of test positivity). Only 45 Daily tests per 100,000 population are currently being reported to the County (Figure 2 below). For reference, at the height of the January 2022 surge there were 2,744 reportable tests being performed daily per 100,000 population. As numbers become smaller, the accuracy of a reported metric becomes less accurate.

To account for this statistical noise, we turn to prevalence rate which is the estimated number of active (not necessarily infectious) cases per 100 individuals. Currently, the County’s prevalence rate stands at 0.22 or, expressed differently, 22 cases per 10000 individuals. While this is an uptick compared to the rate seen in early May (9 cases per 10000 individuals), it is far lower than the late February rate of 60 cases per 10000 individuals (Figure 3 below).

It is important to note that mid to late summer surges have been a feature of COVID-19 in years past, most notably in 2022 when prevalence rates indeed surged to an estimated 9.7% of the population having the infection.  Placing this summer in perspective – the green line in Figure 4 below suggests that we are having an unexpected lull in cases, certainly when compared to prior years.

This is not to suggest that cases will not increase moving forward. In 2021 (red line), cases increased significantly through late July and peaked mid-August. However, at this point in time, there does not seem to be evidence of increased community transmission nor a particularly significant population burden of disease, particularly when compared to prior years.

Aug 2023 Newsletter

Welcome to the August 2023 Newsletter for

Santa Monica Primary Care.

In this issue, “Vaccine-palooza” we are going to cover all the vaccines that have been recommended this Fall and the rationale for each. This season we will have a new RSV vaccine as well as reformulated seasonal Influenza and a COVID booster. With so many, planning is necessary!

Seasonal Influenza Vaccine

Doses of the 2023/2024 seasonal flu shot have already begun to ship and typically vaccination efforts begin in late August or early September each year. Influenza has a seasonal pattern with outbreaks occurring in the winter months primarily (in tropical regions, it may be more year round). But this is why vaccination efforts begin in the Fall, in preparation for such. This season’s vaccine will have either three components (trivalent) or four (quadrivalent) with the latter being recommended for those over the age of 65 or with chronic conditions.

The decision on which strains to include in the vaccine formulation is based on global
surveillance data but, in the end, is a prediction and not always correct. As such, the
effectiveness of the seasonal flu shot can vary from year to year. It is important to note that even if the vaccine doesn’t completely prevent the flu, it can still reduce the severity and complications of the illness should one become infected.

One of my favorite online resources for influenza is Columbia University’s Flu Forecasting System (link: https://cpid.iri.columbia.edu/) which provides geographic spread predictions by US city. Influenza travels east to west so we will see case spikes along the eastern seaboard before we have a surge of cases in Los Angeles. But, for those who travel for business or leisure, this web resource is helpful to see if you are heading into an area with either a high current case load or a predicted increase. Historically, the peak of influenza cases in Los Angeles has occurred in the last week of December and first week of January, coinciding with holiday travel. My general recommendation is that patients have the flu vaccine by Halloween, although those
who have travel to the east coast or Europe may want to have it sooner.

COVID-19 Booster

Last year at this time, the FDA authorized the use of Moderna and Pfizer Bivalent Vaccines for a single additional booster dose at the end of August 2022. This updated booster was to be given at least 2 months after completion of a primary series or the most recent booster dose of a monovalent (original) COVID-19 vaccine.

Population uptake of the bivalent booster was abysmal – only 17% of the total US population received a booster dose. That percentage is a bit better for those over the age of 65 years at
43.3%.

Similar to influenza, COVID historically (until 2023 that is) has had a Winter surge although there has been historically a mid-summer increase in cases as well (Figure below).

Smoothed Daily Incidence Case Rate (Per 100,000 population) of SARS-CoV2: Los Angeles Country, California for 2020 (Blue), 2021 (Red), 2022(Yellow), and 2023(Green)

Both the CDC and vaccine manufacturers have indicated that COVID booster shots will move closer to an influenza like pattern with the goal to ‘keep up’ with COVID variants. But this isn’t really a true or fair parallel because the seasonal influenza shot is planned and predicted whereas the COVID booster is reactionary. For instance, the Fall 2023 COVID booster, which should gain FDA approval this month, targets XBB.1.5 a coronavirus subvariant that emerged in late 2022. Unfortunately, XBB.1.5 is no longer the primary circulating variant in the US. In fact, it isn’t the second most common, nor the third. It’s the fourth at 12.3%  (link:https://covid.cdc.gov/covid-data-tracker/#variant-summary). 

While the expectation is that the updated booster will provide protection against subsequent variants, I think this is going to be a difficult gap to bridge for the US public and uptake will again be low. The CDC would be better served by making a strong case for those over the age of 65 or those with chronic medical conditions to have the shot rather than an across the boards recommendation for everybody to have it.

Most likely, I will advise patients over 65 and those in higher risk groups to strongly consider having the booster by the end of October in time for an expected late November to January surge in cases (although this never fully materialized in 2022 -2023). I have not seen compelling data to support its use in those that are younger and without risk factors for developing severe disease.

While you can have both the flu vaccine and COVID booster at the same time, it may be more
prudent to separate the two. That way in the case of an unlikely, but possible, vaccine reaction -the cause will be apparent.

RSV Vaccine

This Fall will be the first time that an RSV (Respiratory Syncytial Virus) vaccine becomes available. Approved earlier this year, this vaccine has been recommended for adults 60 years and older based on clinical trial data showing that one dose of the vaccine was ‘moderately effective’ in preventing respiratory tract disease from RSV.

Epidemiologically, RSV affects children more severely than adults and also displays a seasonal pattern with outbreaks more common during the winter months. Infection in healthy adults typically results in mild cold-like symptoms but can lead to more severe respiratory infections inhigher risk groups (infants, young children, older adults and those with a weakened immune system).

Developing a vaccine has been complicated due to the complexity of the virus, the fact that prior infection does not protect against re-infection (even amongst those with high specific antibody titers), and the potential for vaccine-enhanced disease in certain populations. Vaccine-enhanced disease occurs when vaccinated individuals experience more severe symptoms upon subsequent exposure to the virus.

The current RSV vaccine is recommended only as a single dose for individuals 60 years and older. Those most likely to benefit would be those with pulmonary disease (such as COPD or asthma), cardiovascular disease, moderate to severe immune compromise, and diabetes. The CDC does not recommend against co-administration with seasonal flu shot or other vaccines although antibody titers for both influenza and RSV were lower when given together. So my recommendation would be to separate RSV vaccination out from other shots by two weeks

Vaccine-palooza Recap

The Fall of 2023 is shaping up to be a busy vaccination season with seasonal flu, the COVID booster and the new RSV vaccination. While the flu shot itself is generally well tolerated without significant side effects, my general recommendation would be to separate out the vaccine shots by about 2 weeks – particularly the RSV which is a completely new vaccine and has not been studied widely. The finding that antibody titers of both flu and RSV are lower when given together is yet another reason to separate them out.

Also – if you can’t remember what you’ve had when – we have good news for you! Our office recently has integrated the California Immunization Registry (CAIR, now version 2.0) directly into our Electronic Medical Record. Not only do we send vaccination data to the registry for those receiving shots in the office, we are able to query the state registry for vaccines our patients may have had previously at an outside location.

What’s Happening with COVID?

Recently, the Los Angeles County Health Department reported a “concerning increase” in reported COVID-19 cases, detailing a 32% rise in cases week over week. This is a very curious assertion given that the data published by the County do not show this rise. Week over week data are below:

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

Cases have been in a very narrow band of 2.2 to 2.6 new daily cases per 100,000 population since mid May. The largest week over week rise has been 16% when going from 2.2 to 2.4. Most recently we have seen a slow rise in the last three weeks of 2.2 to 2.4 to 2.6 but nowhere is there a 32% increase.

Cases have also been steady within our own practice with only 4 to 7 cases monthly since March of this year. So case rates remain at historic lows.

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

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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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March 2023 Newsletter

Welcome to the March 2023 Newsletter for

Santa Monica Primary Care.

In this issue we will break down the anticipated end of LA County’s COVID-19Emergency expected March 31st, 2023.We also cover our clinic’s experience with COVID-19 and how that has paralleled that of the County as a whole.

Click here for more Details

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End of LA County’s COVID-19 Emergency

On the last day of February, the Los Angeles County Board of Supervisors declared unanimously that the last day of March would mark the end of the COVID-19emergency. It seems emblematic of the County’s pandemic response that a political body of 5 individuals representing 10 million County residents would declare it ‘over.’ To date, the County has recorded 3.5 million cases and 33,859 deaths – both no doubt significant underestimates of the virus’ true impact

But looking at the pandemic as a whole (155 weeks of data), the Supervisors do have a point in declaring the emergency phase over. The presumed January peaking of cases seen starkly in the Figure below that occurred in 2021 and 2022never materialized in 2023.

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

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

So when looking at incidence and prevalence rates historically and combining such with a lack of an (expected) January surge, it does appear that we are moving away from an emergency state.

Current COVID “Situation

The Los Angeles Times article highlighting the end of the COVID Emergency (link:https://www.latimes.com/california/story/2023-02-28/la-county-to-end-covid-state-of-emergency-in-march) states the following rationale for moving to a less vigilantposture:

“But given the current situation — with vaccines and therapeutics plentiful and hospitalization and death rates having tumbled without the sort of aggressive interventions seen earlier in the COVID-19 era, such as mask mandates and stay-at-home orders — officials said the emergency declaration was no longer necessary.”

To be sure, there is no lack of vaccine availability, both the primary series and the bivalent booster remain available from a variety of sources. Stocks are available because only 17.5% of eligible County residents have received the bivalent booster, although this is slightly better than 16.1% nationally.

“Plentiful” therapeutics, however, this really isn’t the case. Monoclonal antibodies have had their use authorization revoked as they have not demonstrated efficacy against Omicron and subsequent variants. This includes: Bamlanivimab,Estesevimab, Bebtelovimab, Casirivimab, Imdevimab, and Sotrovimab. Even Evusheld, which is a long acting monoclonal antibody used for COVID-19prevention among those who may not have mounted an adequate immune response, has been removed from the market

What is available is Paxlovid which has its clearest benefit among unvaccinated adults who have risk factors for progression to severe disease. Accumulating observational data suggest that high-risk vaccinated individuals also benefit and alarge VA study has shown a 30% risk reduction in long COVID from Paxlovid. Therehas been no difficulty in prescribing or obtaining Paxlovid through local pharmacies.

However, Paxlovid interacts with a variety of medications, most particularly medications for cholesterol, hypertension and migraines as well as blood thinners. For some patients, these medications can be held during the 5 day treatmentwindow but, for others, Paxlovid cannot be given. The only other recommendedCOVID-19 therapeutic in Remdisivir but this is administered intravenously for three consecutive days which each administration taking up to two hours. So, functionally, only one therapeutic is plentiful.

Death Rates - Have They Tumbled?

Hospitalization data are not published in a raw format by Los Angeles County, so we cannot independently evaluate the Board of Supervisors statement about hospitalizations having tumbled. But mortality rates are trending lower after a small rise in November and December 2022. They currently stand at 0.06 daily deaths per100,000 individuals. They peaked at 2.8 daily deaths per 100,000 in mid-January2021 and rose as high as 0.87 in February 2022. The lowest rates (0.03) have been seen in a couple of instances: June 2021 and May 2022.

A factor of 100 makes the County-wide mathematics easy when considering the totals. Currently, 6 County residents (0.06*100) die from COVID daily. At the peak that number was 280 and at the lowest, that total was 3. Extrapolating this out further, COVID at its lowest observed rate (10.95 deaths annually per 100,000population) would place it as the 11th leading cause of death in the County above motor vehicle accidents (8.6) and below colorectal cancer (14.2). Since we wear seatbelts and have colonoscopies, it would seem prudent from a public health perspective that we do something about COVID moving forward.

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

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

Similar to the County’s experience, we too have seen a steady decline in casessince November 2021 when we had 29 new cases ( and 5 repeat infections). InFebruary 2023 we had only 9 cases, all of which were first infections. Totals fromJanuary 2022 until the end of February 2023 by month are outlined in the Figurebelow

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

Paxlovid Prescribing Patterns and Rebound

Given the significant benefits of Paxlovid in reducing severe disease and hospitalization as well as in reducing the risk of long COVID, I have been a proponent of early use of this medication. Of the 260 COVID cases we have had in the practice since Paxlovid came on the market, 96 (36.9%) received Paxlovid. This is significantly higher than the national rate where only about 20% of those eligible for Paxlovid have received the treatment.

The biggest downside of Paxlovid continues to be rebound which can occur about10 to 14 days after beginning treatment. It is typically characterized by a day or two of very mild symptoms but a positive rapid antigen test. I have advised patients to assume they are infectious and able to transmit the virus during these rebounds, although I have not seen any instances of such.

While Pfizer (who manufactures Paxlovid) reported a 2.3% rebound rate in their studies, a more recent Oxford study suggested that this rate was significantly higher at 14.2% (link: https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciad102/7049992?login=false)

Our observed rate in clinic is higher still at 24% (23 rebound cases among 96treated).

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February 2023 Newsletter

Welcome to the February 2023 Newsletter for

Santa Monica Primary Care.

COVID At A Crossroads
In this issue we will focus exclusively on COVID-19 as 2023 has seen a fundamental(although not necessarily correct) shift in how we are approaching SARS-CoV-2 andthe clinical consequences of infection.
As always, we will start with fundamentals and along the way answer the commonquestions we are hearing in the clinic.

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Is It Still A Pandemic?

This is an interesting question and critical question – one which was posed to me just last week by a patient. Rephrasing the question in epidemiologic terms gives the following, “is COVID-19 an epidemic still or is it endemic.” So are there new case sex ceeding what we expect (epidemic) or is it now a constant presence (endemic)? Case rates in Los Angeles County have declined substantially since our 2022 mid-summer peak. In fact, even the case surge we experienced in November was only half the magnitude (34.8 new daily cases per 100,000 population) of that seen at the summer maximum (64.7).

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

This significant decline is more readily apparent when we look at prevalence(number of active cases per 100 County residents). In mid to late July 9.7% of the population had an active COVID infection, and now it is 0.4%.

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

So to answer the epidemic versus endemic question, it looks like we are approaching endemicity with a base expected incidence rate of 8-10 new daily cases per 100,000 population and a prevalence rate of 0.3-0.4%. For large portions of the year we experience this low, steady rate of community transmission but at other times we are having significant surges in activity. The question being – can we predict when those surges might occur? More below..

Is It Seasonal?

If you had asked me this question the last week of December 2022 I would have said‘ absolutely’ but this past January did not follow the trend we had seen in prior years. The figure below shows weekly incident case rate data for every year of the pandemic (2020 Blue, 2021 Red, 2022 Yellow, and 2023 Green). In both 2021 and2022 we had a distinct (and massive to the point that the axis is changed in the figure to accommodate the Omicron outbreak visually) increase in cases beginning in mid November and extending until mid February. That is, until 2023. We had an increase in cases beginning mid-November (yellow line, far right) but then cases plateaued in December and collapsed in January (green line, far right).

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

Evusheld - Where Have You Gone?

As of January 26th, 2023 Evusheld is no longer authorized by the FDA and will be unavailable to patients. This is a significant and alarming development for immunocompromised individuals as well as those who did not tolerate vaccinations /boosters and relied on Evusheld’s protection. The FDA estimated that “fever than10% of circulating variants in the US causing infection are susceptible to the product.”

This decision was based not on epidemiologic data but instead on laboratory experiments (nevertheless valid) which showed as early as May of 2022 that theBA.4 and BA.5 Omicron subvariants had “escaped or reduced the activity of monoclonal antibodies developed for clinical use” but that Evusheld and Sotrovimab still showed activity (Tuekprakhon et al. link:https://www.biorxiv.org/content/10.1101/2022.05.21.492554v1.full.pdf). In July, Boschi et al. reported that Evusheld’s neutralization was 233 times less active on Omicron than the Delta variant, suggesting of “limited efficacy” (link:https://academic.oup.com/cid/article/75/1/e534/6529556).

Fortunately, there is accruing evidence that polyclonal antibody preparations – suchas plasma from vaccinated and previously infected individuals (terms: convalescent plasma) – would restore protection amongst immunocompromised patients. For amore detailed discussion, readers can refer to this excellent STAT News article – link:https://www.statnews.com/2023/02/06/covid-convalescent-plasma-antibody-therapy/

Blog This Month

Our blog posts this and previous months can be found archived on our website at www.drbretsky.com/blog. Our blog post this month covered booster vaccinations
https://drbretsky.com/12-january-2023-blog-post-on-covid-boosters/

Variants, Variants and more Variants

Both BA.4 and BA.5 (included in the currently available bivalent booster) have now essentially vanished according to CDC data. For Region 9 (which includes Arizona, California, Hawaii and Pacific Territories), BA.4 and BA.5 make up only 0.2% of the currently circulating variants, as compared to 3.9% in January and 90.1% in early August 2022.

KBB.1.5 which was 7.0% of the total variant population in early January 2022 is now the most common at 45.8% with BQ.1.1 and BQ.1 at 31.0% and 13.6% respectively. Initial concerns for an increased transmissibility of this variant were based on observations in China which, until recently, had held to a zero COVID policy and has a largely immunologically naive population. As noted above, cases in our region have decreased in January 2023 during the time period when KBB.1.5 increased infrequency. The general consensus had been that KBB.1.5 does not cause any more severe disease than Omicron or its subvariants.

Link: https://covid.cdc.gov/covid-data-tracker/#variant-proportions).

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January 2023 Newsletter

January 2023 Newsletter

Welcome to the January 2023 Newsletter for Santa Monica Primary Care – our first newsletter of the New Year!

In this issue, we are going to cover the current state COVID cases and will share our practice experience with COVID plus trends in LA County at large. 

We will also highlight a couple of initiatives that we have planned for 2023.

COVID-19 at Santa Monica Primary Care and in LA County

Readers may find it surprising that we actually saw less COVID in December than we did in November. COVID-19 cases in our practice decreased by more than 50% month over month (Graph below). After managing 27 cases in November (one of which required hospital level care), December brought 13 cases.  Of these 3 (23%) were repeat infections.

As I collated Los Angeles County numbers I noticed that we are on row 1035 of the spreadsheet. Little did I imagine in March of 2020 when I began collating the case counts that we would find ourselves in Year 3 of the pandemic.

Cases in Los Angeles County show essentially the same trend, although press reports relying heavily on guidance from County officials would lead one to believe otherwise (link: https://abc7.com/coronavirus-los-angeles-la-covid-cases-new-years-eve/12629266/).  Cases in the County also dropped nearly 50% from 34.5 to 19.8 new daily cases per 100,000 population between from the start until the end of December. 

What County officials are not talking about, however, are persistently elevated COVID mortality rates, despite a decline in cases (Figure below).

In 2020, the average mortality rate was 0.37 deaths per 100,000 population per day.  In 2021 this rose to 0.41 daily deaths per 100,000 population (largely driven by rates >2 in January and early February before vaccines were widely available).

So where would you expect mortality rates to be in 2022 given widespread vaccination, boosters and effective treatments such as Paxlovid.  Much lower, right?  Would 90% be a reasonable assumption – I would think so given that clinical trials have shown up to a 94% reduction in mortality risk with 3 mRNA vaccine doses during Omicron (link: https://www.cdc.gov/mmwr/volumes/71/wr/mm7112e1.htm?s_cid=mm7112e1_w)

Instead we are really only seeing about a 50% reduction in mortality, as at the end of 2022 the mean number of daily deaths stood at 0.18 daily deaths per 100,000 population. Yet I’ve seen little substantive discussion from the County attempting to understand who is dying of COVID and why that is occuring, but instead a dogged / singular focus on reducing cases (which is sound public health policy as reducing cases reduces mortality but there seems to be some subtlety that they are missing). 

One question which I would like to put to Dr. Ferrar is as follows:  Why in July of 2022 was the mortality rate 0.16 with a case rate of 61.8 but in December there was a mortality rate of 0.12 with a case rate of 19.8?

Paxlovid Prescription Trends and “Rebound”

Given the strong clinical data on the significant reduction in long COVID among those treated with Paxlovid (covered in December’s newsletter), utilization rates of this medication have gone up in our practice . Of the 13 individuals who tested positive for COVID-19 in December, 7 elected to begin Paxlovid (53%). Similarly, in November 17 of 27 (63%) took Paxlovid. In October only 3 of 13 cases (23%) chose to begin the antiviral.

The biggest downside of Paxlovid is the “rebound” phenomenon with a return of symptoms and again testing positive, usually about two weeks after the initial positive test. Overall about 25% of the patients for whom we have prescribed Paxlovid experience clinical and testing rebound of the disease but in December only 1 of 7 treated rebounded.

The biggest upsides of Paxlovid include a rapid clinical response where those treated are feeling better, faster – usually in 1-2 days after starting the medication. There is also strong clinical evidence of an up to 30% reduction in the risk of long COVID symptoms as well.

Two New Initiatives in 2023

Each year I try to do “one new thing” in the practice, although it always seems to be more than one. So in the spirit of realism, I will highlight the two new things we will introduce in 2023.

Get DNAbled Program

In 2022 we took our first foray into formal genetic risk analysis with the Galleri cancer screen, based on DNA methylation patterns. While this remains a viable next step (but not a replacement for) routine cancer screening (e.g. mammography, prostate examinations / PSA, and colonoscopy) this year we will also offer a comprehensive pathway for full genome scanning via a partnership with DNAbled – https://getdnabled.com/our-program.html .

For additional detail,see also: https://drbretsky.com/genomic-analysis/

Aledade

In 2023 our Medicare Shared Savings Program will begin formally as part of our ongoing collaboration with Aledade to improve both quality of care and value of care. The lynchpin for this effort will be the annual wellness examination – software developed by Aledade integrates to our Electronic Medical Record platform and identifies patients that are due for such as well as any gaps in their care. Specific emphasis will be on hypertension, diabetes and women’s health initially. Further, with their support, we will seek to manage transitions of care – such as from the hospital to skilled nursing facility and back home. Or, even better, find opportunities to keep patients out of the hospital entirely.

 

We have spent much of 2022 in a slow ramp up position for this effort which will be considerable as Medicare-age patients are a much higher proportion of our practice at Santa Monica Primary Care than most general scope practices – reflecting the age structure of the geographic area.  We have a parallel program already with Anthem Blue Cross that has been running in 2022 and will continue into 2023.  For more information on the transformative work that Aledade is doing with practices across the country, check them out at https://www.aledade.com/our-solutions

Blogs This Month

Our blog posts this and previous months can be found archived on our website at www.drbretsky.com/blog. Our blog post this month covered a couple of COVID topics.

In the first, “Observed Over Expected” we attempted to quantify the true population rates of COVID infection given that the overwhelming majority of cases are now diagnosed by home antigen testing – something that is no longer reportable to the Country Health Department.  The link for this blog is: https://drbretsky.com/13-december-2022-blog-post-observed-over-expected/ 

In our second effort, we covered yet again another Board of Supervisors foray into COVID policy, something I always find interesting because the Health Department falls under the governing scope of the LA Board of Supervisors. Nevertheless, Supervisor Hahn chose to give her thoughts to Fox 11 News.  That link: https://drbretsky.com/15-december-2022-on-protecting-yourself/ 

Variants, Variants and more Variants

Both BA.4 and BA.5 (included in the currently available bivalent booster which has been administered to a whopping 15% of the eligible population over the age of 5) are occupying a smaller and smaller proportion of currently circulating and forecasted variants.  

For Region 9 (which includes Arizona, California, Hawaii and Pacific Territories), BA.5 makes up only 3.9% of currently circulating variants as compared to 90.1% in early August. BQ.1 and BQ.1.1 are estimated to comprise 31.1% (holding steady, was 31.5% in early December) and 40.6 (rising from 31.1% in early December) respectively of the total population of variants (link: https://covid.cdc.gov/covid-data-tracker/#variant-proportions). KBB and KBB.1.5 comprise 7.6% and 7.0% of the total.

A late November CDC study suggests that the bivalent booster provided additional (but not great) protection against symptomatic SARS-CoV2 infection, even in time periods where BA.4/BA.5 sublineages (including BQ1 and BQ1.1) predominated. In this study including over 350,000 (of whom a shocking 25% were unvaccinated) the bivalent vaccine efficacy topped out at 56% (for reference, seasonal influenza vaccine is about 50% effective) amongst those 18-49 who were more than 8 months out from their prior booster. For the highest risk group (those 65+), the bivalent booster was only 43% effective when given 8 months or more after the prior booster. If given within 2-3 months, it was 28% effective. Link: https://www.cdc.gov/mmwr/volumes/71/wr/mm7148e1.htm?s (Note that Table 3 is the most useful representation of their data).

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December 2022 Newsletter

December 2022 Newsletter

Welcome to the December 2022 Newsletter for Santa Monica Primary Care – our final newsletter of the year!

In this issue, we are going to cover the (expected) seasonal rise in COVID cases and will share our current practice experience with COVID plus trends in LA County at large. 

 

We could call this issue the Paxlovid Issue, as there is a lot of detail about its usefulness both in acute illness but also in the prevention of Long COVID.

COVID-19 in the Practice and in LA County 

COVID-19 cases in our practice have increased significantly this month, more than doubling in the past month (Graph below). After the relative lull of September (8 cases), these numbers increased to 13 in October and 27 in November. Repeat cases in September were 18% of the total.  Year-to-date, 25 of our 193 cases (13%) have been repeat infections.

Cases in Los Angeles County show essentially the same trend, although the actual numbers are massive underestimates of the true incidence as positive home tests are not reportable to the County  (Figure below). Cases in the County have more than doubled from 10.5 to 25.9 new daily cases per 100,000 population between October and November. 

Based on these numbers, we would expect 4 cases in our practice at Santa Monica Primary Care when, in reality, we saw 27 suggesting a 6 fold underestimate at the County level.

The current prevalence rate (active cases per 100 individuals) stands at 2.2%, the highest it has been since the end of August.

Paxlovid Prescription Trends and “Rebound”

One of the biggest changes seen in the past month is the greater interest in Paxlovid. Some of this may be due to the large VA study showing a 30% reduction in Long COVID among those treated with Paxlovid (covered in our blog, see #3 below). Of the 27 individuals who tested positive for COVID-19 in November, 17 (63%) elected to begin Paxlovid. In October only 3 of 13 cases (23%) chose to begin the antiviral.

The Atlantic covered the paradoxical prescribing practices surrounding Paxlovid in a piece cleverly entitled “Inside the Mind of an Anti-Paxxer” (link: https://www.theatlantic.com/health/archive/2022/11/paxlovid-covid-drug-hesitancy/672210/).  Nationally, fewer than 1/3rd of Americans over the age of 80 ended up with the medication after a COVID diagnosis, a group who would benefit most from the treatment. The biggest downside to Paxlovid remains rebound, which typically presents about two weeks after the initiation of treatment. While rebound is typically a more mild clinical condition lasting a few days but can still interfere with work and life activities. A positive rapid antigen test coinciding with symptoms will have an individual back in isolation which itself is difficult.

While my experience is that patients feel better faster within 24-48 hours often (this is in contrast to the article which suggests that Paxlovid treated patients are ‘kind of sick’ for two weeks), rebound is a frequently occurring phenomenon. Of the 79 patients for whom we prescribed Paxlovid since the beginning of 2022, 21 of them (26.6%) have experienced a rebound phenomenon (confirmed by positive antigen testing at the time of returning symptoms).

Blogs This Month

Our blog posts this and previous months can be found archived on our website at www.drbretsky.com/blog. Our blog post this month covered in significant detail the compelling VA study showing an overall 26% reduction in Long COVID symptoms among those prescribed Paxlovid.

On Paxlovid and Long COVID:  https://drbretsky.com/21-november-2022-blog-post-paxlovid-and-long-covid/ 

One interesting take away from the article is that the authors go into a bit more detail in an attempt to better describe the utility of Paxlovid by testing its association with Long COVID according to the number of baseline risk factors (‘comorbidities’). Among those with 1-2 risk factors, Paxlovid reduced the risk of long COVID by 33%. The same magnitude of effect was seen among patients with 3-4 risk factors but dropped slightly for those with 5 or more to 30%. 

One downside of the study is that 87% of the study participants were male, something that reflects the VA population as a whole, but making the results less generalizable to women.

The Alphabet Soup of Variants

BA.5 (included in the currently available bivalent booster) is occupying a smaller and smaller proportion of currently circulating and forecasted variants.  BA.5 makes up only 13.3% of the variants seen in the West Coast, Pacific and Hawaii region currently as compared to 90.1% in early August. BQ.1, and BQ.1.1 which were among variants of concern are estimated to comprise 31.5% and 31.1% respectively of the total population of variants (link: https://covid.cdc.gov/covid-data-tracker/#variant-proportions).

However, both of these are offshoots from Omicron (as is BA.5) so we remain hopeful that the bivalent booster will display efficacy against these variants as well, given their genetic relationship.

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November 2022 Newsletter

November 2022 Newsletter

Welcome to the November 2022 Newsletter for Santa Monica Primary Care. 

In this issue, we are going to cover the alphabet soup of COVID variants and try to predict what may happen as we enter the Holiday Season. We will share our current practice experience with COVID cases as well as trends we are seeing in LA County at large. Lastly, we cover this month’s Blog posts, including one on the utility of colonoscopies in reducing colon cancer mortality rates.

COVID-19 in the Practice and in LA County 

COVID-19 cases in our practice have shown a slight rebound as compared to the dramatic slowing of September (Figure below).  The month of October left us with 10 cases, one of which was a repeat infection and the remaining 9 all initial infections. Cases were generally mild (5 of the 10 were characterized as such) but one did lead to hospitalization.  Of the three cases treated with Paxlovid, one led to a rebound phenomenon.

Cases in Los Angeles County, on the other hand, continue to be on the decline, and are now the lowest levels since March of this year (Figure below). The most recent daily incidence rate is 7.4 new daily cases per 100,000 population down from 7.9 the week prior.

This trend runs in direct opposition to comments from the LA County Health Department which notes that ‘coronavirus cases are no longer declining at the rate seen over the summer and appear to have plateaued.’ LA County Health Department Director Dr. Ferrer commented, “We’re no longer seeing a steady decline in cases” as LA County’s case rate began showing week-over-week increases just after mid-October (link: https://www.latimes.com/california/story/2022-11-01/new-coronavirus-omicron-subvariants-bq1-bq11-ba5).   

The prevalence rate is also the lowest it has been in many months at 3 active cases per 1000 residents (Figure below).

Lastly, mortality rates have shown a steady decline since mid-summer and are now as low as they have been since April 2022.

BA.4/BA.5 Bivalent Booster Uptake Remains Slow

In August, the FDA authorized the use of Moderna and Pfizer Bivalent Vaccines for a single additional booster dose to be given at least 2 months after completion of a primary series or the most recent booster dose of a monovalent (original) COVID-19 vaccine. The Pfizer booster is authorized for individuals 12 years of age and older. The Moderna for those 18 years and older.

According to the latest CDC data (link: https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-people-additional-dose-totalpop), only 22 million – or 7.3% of those eligible – have received a bivalent booster dose.  This has increased from 7.6 million (3.5%) last month at this time.

Blogs This Month

Our blog posts this and previous months can be found archived on our website at www.drbretsky.com/blog. As a bit of a departure, we covered a recent report suggesting that colonoscopies were not as effective in reducing colon cancer mortality. While this generated a fair amount of press coverage, the study itself was actually not all that compelling and certainly was not enough to change clinical recommendations of colonoscopy as a screening tool

On Colonoscopies:  https://drbretsky.com/11-october-2022-blog-post-on-colonoscopies/

We also covered COVID-19 in 2022 as compared to 2020 and 2021 in our second blog:

https://drbretsky.com/13-october-2022-blog-post-a-crazy-covid-year/

The Alphabet Soup of Variants

BA.5, BQ.1, and BQ.1.1 are among the ever growing population of variants of concern. But, in reality, tried and true BA.4.6 and BA.5 make up 84.6% of the variants sequenced across the United States (link: https://covid.cdc.gov/covid-data-tracker/#variant-proportions) and 83.3% of the variants seen in HHS Region 9 which includes California, Arizona, Nevada and Hawaii. While the proportion of BA.4 and BA.5 is decreasing over time (Figure below), they are nevertheless the overwhelming majority of variants seen both regionally and nationally. With booster vaccines that are directly matched to these variants, we should continue to see decreasing case rates and mortality rates.

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October 2022 Newsletter

October 2022 Newsletter

Welcome to the October 2022 Newsletter for Santa Monica Primary Care. 

In this issue, we are going to try to triangulate the state of COVID-19 in Los Angeles County. We will share the current practice experience with COVID and explain how the bivalent boosters might be so exciting. We will also cover the Blogs posted by Dr. Bretsky this month.

1. COVID-19 in the Practice and in LA County

COVID-19 cases in our practice have slowed dramatically (Figure below) with only 5 cases reported the entire month (2 repeat infections, 3 first time infections).  In August we had 12 cases (3 were 2nd infections).  In July we had 18 cases (3 were  2nd infection), June saw 29 cases (3 were 2nd infections) and in May we managed 33 infections (3 were 2nd infections). I had expected a bit of an uptick in cases with the start of school but this has not occurred, at least in our small sample.

Trying to figure out what is occurring in terms of case rates at the County level is still a bit of a guessing game – most notably hampered by the fact that the overwhelming majority of cases are diagnosed via home testing and, by the County’s case definition, are not reportable. That notwithstanding, incidence case rates have declined steadily since mid July (Figure below).

In previous issues we have discussed how a calculated prevalence rate might be a more accurate representation of the true case frequency. Current prevalence rates are as low as they have been since May at 0.7 active cases per 100 individuals.

2. BA.5 Bivalent Booster Uptake

As most of you likely know, the FDA authorized the use of Moderna and Pfizer Bivalent Vaccines for a single additional booster dose at the end of August. This updated booster is to be given at least 2 months after completion of a primary series or the most recent booster dose of a monovalent (original) COVID-19 vaccine. The Pfizer booster is authorized for individuals 12 years of age and older. The Moderna for those 18 years and older.

According to the latest CDC data (link: https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-people-additional-dose-totalpop), only 7.6 million individuals – about 3.5% of those eligible for the updated COVID booster – have received one. Of additional concern is that awareness of the new boosters is “modest” according to a recent survey (link: https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-september-2022/). One in five people surveyed have heard “nothing at all” about the new booster as compared to 17% who have heard “a lot.”

Personally, I’m pretty pumped (as Parker Schnabel would say – for my fellow Gold Rush fans out there – Discovery Channel Friday nights) about the new booster and am hopeful that it generates more specific and durable immunity than the prior boosters. Why would I feel this way?

Well, firstly, the current booster is matched with the dominant circulating strains as it contains an mRNA component from the BA.4 and BA.5 Omicron variants. The graphic below shows that these account for the overwhelming majority of variants isolated in the United States: BA.5 at 85% and BA.4 at 13%.

Additionally, this is one of the first times that we have not been vaccinating or boosting into the teeth of a case rise. Given such, the relatively slow uptake of the booster dose is less concerning as we do have the luxury of time, for once. With a general rule of thumb being that it takes about two weeks for the booster effect to take hold in our immune system, the continued decline in cases makes it less likely that one will be exposed to the virus soon after the booster dose – perhaps before it takes effect. 

I generally have been advising patients to strongly consider having the booster by the end of October – which is also a guideline for the seasonal influenza vaccine. While you can have both at the same time, it may be more prudent to separate the two. That way in the case of an unlikely, but possible, vaccine reaction – the cause will be apparent.

3. Blogs This Month

Our blog posts this and previous months can be found archived on our website at www.drbretsky.com/blog. This month we had two Blogs covering booster shots. One in the context of the seasonality of COVID (a trend which has clearly emerged) and the other structured as a Q&A session on the boosters itself.

Booster Shots and COVID Seasonality: https://drbretsky.com/9-september-2022-blog-post-new-booster-shot-heralds-covid-seasonality/

Booster Q&A: https://drbretsky.com/13-september-2022-blog-post-fall-2022-covid-boosters/

Our third blog covered more well-trod ground looking at incidence and prevalence rates of COVID-19 in Los Angeles:

https://drbretsky.com/14-september-2022-blog-post-mid-september-covid-case-numbers/ 

And out final monthly blogged looked at the idea that the US ‘follows’ the UK when it comes to COVID case rates (spoiler alert: it sort of does, but not always): https://drbretsky.com/28-september-2022-blog-post-following-the-uks-lead/ 

This final blog garnered some interesting Twitter reactions, namely critiques of the Zoe Health Study which is composed of self-selected participants who record COVID like symptoms into an app along with any COVID testing results.

4. On Patient Reviews

Patients who have seen us in the office recently will know that we have been actively seeking patient feedback about our services on rating sites, including Google, Facebook and Yelp. These have become increasingly important in quality metrics that measure the patient experience. We appreciate the time and effort that you have taken to post your experience.

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