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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September 2022 Newsletter

September 2022 Newsletter

Welcome to the September 2022 Newsletter for Santa Monica Primary Care. In this issue, we are going to discuss COVID-19 prevalence in Los Angeles County and try to predict its future, in the context of the new bivalent booster and an inevitable Winter surge. We will also cover medical records sharing and ‘interoperability’ between electronic systems and healthcare providers.

 

COVID-19 in LA County and the Practice during August 2022

COVID-19 cases in our practice have begun to slow slightly – a trend consistent with that seen nationally and in Los Angeles County. In August we had 12 new cases (3 were 2nd infections)  with clusters at the beginning of the month (8/1-8/3), the middle (8/16-8/16) and the end (8/29-8/31). This is a somewhat different pattern than we had seen in July (18 cases, 3 were  2nd infection), June (29 cases, 3 were 2nd infections) and May (33 infections, 3 were 2nd infections) where cases accumulated at a steady clip of about one new case a day.

Trying to figure out what is occurring in terms of case rates at the County level is a bit more difficult. Firstly, LA County continues to have a significant lag in reporting with case numbers only current to 8/24/2022. Secondly, a significant proportion of positive tests will be from home testing which the County specifically does not include in their tabulations. Despite such, COVID-19 case rates for the month of August 2022 were the highest they have been in any pandemic for the month of August. For the week ending August 24th, 2022 set the high bar at 61.2 new daily cases per 100,000 population compared with 27.4 in 2021 and 18.4 in 2020. Current case rates are about twice as high currently as they were last year.

Given the difficulty in case ascertainment, another metric that can be considered is mortality rate. The mortality rate currently is 3 times what it was at the end of August 2021 (0.04 daily deaths per 100,000 population in 2021 versus 0.12 in 2022). Current mortality rates are about three times as high currently as they were last year.

Nationally, the BA.5 variant remains the overwhelmingly dominant circulating viral strain.. BA.5 now accounts for 88.7% of the variants isolated as opposed to 81.9% in July and 54% in June. Link: https://covid.cdc.gov/covid-data-tracker/#variant-proportions 

 

BA.5 Bivalent Booster and Predicting the Future

On August 31st, 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. It is important to note that the bivalent booster will contain genetic recipes for both the original COVID strain as well as BA.4 and BA.5. The Moderna bivalent vaccine is authorized as a single booster for those aged 18 years and above, and Pfizer is approved for those 12 and older.

The question moving forward is just how effective the new booster formulation will be – both in terms of boosting neutralizing antibody levels but, more critically, in preventing infection. While there have been no human studies of the bivalent vaccine going to trial, a study of an earlier BA.1 + ancestral strain booster (2nd booster) showed improved neutralizing antibody levels as compared to the monovalent (original). Antibody levels among those with no prior COVID infection were 2372 with the bivalent booster as compared to 1473 with the monovalent booster. It is interesting to see that these levels are quite a bit lower than what we have been seeing in the practice, with most individuals having levels between 3000-6000 after a primary series + one or two boosters. Whether or not these neutralizing antibodies are of sufficient quantity and specificity to prevent infection remains to be seen.

The future is not too difficult to predict, as seen from the prevalence chart below. I think we have every reason to expect another Winter surge – most likely beginning mid December and lasting through January.

Blogs This Month

Our blog posts this month included a two part series on changes at the CDC. There is also a more lengthy essay on Monkeypox (which appears to be decreasing in frequency, at least in Los Angeles).

Structural Changes at the CDC (Parts 1 & 2):

https://drbretsky.com/29-august-2022-blog-post-major-changes-in-cdc-announced-part-1-of-2/

https://drbretsky.com/30-august-2022-blog-post-major-changes-in-cdc-announced-part-2-of-2/ 

 

Monkeypox:

https://drbretsky.com/3-august-2022-essay-everything-you-wanted-to-know-about-monkeypox-but-were-afraid-to-ask/

 

On Medical Record Sharing and Interoperability

One question I have gotten a lot this month has been about medical record sharing and, specifically, if our office receives outside consultation notes, imaging and studies. The short answer is – sometimes (even if you specifically request it from the consulting physician) but it is a process that we are working to improve.

Traditionally, consulting physicians or specialists have communicated directly with a patient’s primary care provider in the form of a consult ‘note’. Many of the more experienced specialists will not only send their clinic / chart note but also a cover letter summarizing their findings and recommendations. Sadly, with the advent of Electronic Medical Records, this tradition has largely been lost. One would think that notes would be automatically routed to the referring or primary care physician but this too does not always happen.

The term ‘interoperability’ is used as a catchall phrase by health insurers and EMR vendors to describe a “system architecture that allows for the electronic sharing of patient information between different EHR systems and healthcare providers.” The idea being that information passes between the doctors providing patient care seamlessly. Responsibility for such was intended to fall to health insurance companies, permitting data exchange should an individual change insurance. However, the current administration has decided to defer enforcement of this responsibility citing the COVID-19 pandemic (link, if you are fascinated by this: https://www.cms.gov/blog/interoperability-and-connected-health-care-system).

What we have done as a practice is begun to set up processes to physically go and look for our patients’ information. One such mechanism comes through our collaboration with Aledade (www.aledade.com) which we have discussed in previous newsletters. In addition to their quality of care metrics tracking, Aledade software includes an interface that alerts us as to any hospitalization or Emergency Department visit, prompting us to follow-up on that event.

One way that patients can further help with interoperability is to ensure that on their CareEverywhere or MyChart account that Dr. Bretsky is listed as their primary care provider. We have started a process in the Cedars / Providence / UCLA systems of adding our office contact information manually so that reports are automatically sent to us. But patients themselves can double check that we are listed as Primary Care Providers (often these listings are outdated or include other providers, such as OB/GYN).

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August Newsletter

August 2022 Newsletter

Welcome to the August 2022 Newsletter for Santa Monica Primary Care. In this issue, we are going to discuss case rates in Los Angeles County and why our Health Department decided against resuming an indoor mask mandate. We will also discuss Paxlovid rebound in the context of President Biden’s SARS-CoV-2 experience.

1. COVID-19 in the US and LA County during July 2022

COVID-19 cases in our practice have continued at a steady clip of about one new case a day – which has been consistent over the past three months.

 

Nationally, the BA.5 variant has overwhelmed the  original Omicron BA.1 and BA.2 variants as well as the BA.2.12.1 and BA.4 sublineages. BA.5 now accounts for 81.9% of the variants seen as compared to 54% of the total last month. Link: https://covid.cdc.gov/covid-data-tracker/#variant-proportions 

 

Cases in Los Angeles County after our huge Omicron surge in December and January were lowest the week ending March 22nd when they were at 5.8 new daily cases per 100,000 population (note viral containment is generally defined as under 1 new daily case per 100,000). They have risen steadily since that time and now stand at 59.3 cases/100,000. Note the slow rise as compared with the sharp peak of Omicron.

Similarly, prevalence (the proportion of active cases per 100 individuals) has steadily increased over that time period.  While down as low as 0.05% in late March, the most recent prevalence estimate is 9.6%. This has risen from 8.2% the week prior.

The Health Department based their decision to forego an indoor masking mandate as hospitalizations seem to have plateaued (link: http://dashboard.publichealth.lacounty.gov/covid19_surveillance_dashboard/).

We are not seeing a reduction in incidence case rates or prevalence at this point, either in the County or in the practice as a whole

 

 

2. Paxlovid Rebound

We have covered Paxlovid rebound in prior Newsletters and, as mentioned before, Paxlovid rebound has continued to be a thorny issue. To see it occur with President Biden was not a complete surprise. In our aggregate experience, 10 of the 35 patients (28%) we have treated with Paxlovid have experienced a clinically apparent rebound.   

 

Most national estimates discuss a Paxlovid rebound rate between 10% and 40%. While patients taking Paxlovid feel better faster and the rebound infection is typically milder than the initial symptoms, it nevertheless is something to consider before starting treatment.

 

 

3. Blogs This Month

Our blog posts this month focused once again on our ongoing COVID-19 pandemic, which has changed in contour since we first began covering it in March of 2020. We specifically discussed the absurdities of the CDC’s 5 day isolation guidance in “Do As I Say, Not As I Do”.  We also covered the population dynamics of the virus as well as what some call the inevitability of acquiring the infection.

 

On The CDC ‘5 Day Rule’:

https://drbretsky.com/28-july-2022-blog-post-do-as-i-say-not-as-i-do-and-the-cdc-5-day-rule/ 

 

On Population Prevalence and the ‘Luck’ of COVID Acquisition:

https://drbretsky.com/27-july-2022-blog-post-population-prevalence-and-the-luck-of-covid-acquisition/ 

 

On The Return of Masking, Summer 2022 Edition:

https://drbretsky.com/25-july-2022-blog-post-on-the-return-of-masking-summer-2022-edition/

 

4. August’s Epidemiology Definitions

Clinical Trial: A synonym for an epidemiologic experiment which is typically conducted with the aim of evaluating which treatment for a disease is better. 

 

Placebo: A comparison group in a clinical trial intended to have no biologic effect outside of the roffer of treatment itself. The term is from the Latin “I shall please” and placebo pills typically contain sugar or other inert ingredients.

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JULY Newsletter

July 2022 Newsletter

Welcome to the July 2022 Newsletter for Santa Monica Primary Care. In this issue, what’s old is new again (unfortunately).  We are going to revisit case rates in Los Angeles County and why Health Department counts are undoubtedly an underestimate. We will also discuss SARS-CoV-2 antibody levels and Evushield, an exciting new pre-COVID exposure preventive tool.

  1. COVID-19 in the Practice during May and June 2022

COVID-19 cases in our practice continued at a steady clip of about one new case a day. In total, we recorded 24 cases of SARS-CoV-2 infection, two of which were second infections. This was down from May when we had 33 cases. 

Nationally, the original Omicron BA.1 and BA.2 variants have given way to the BA.5 (54% of total) and BA.4 (16.5%) sublineages. A third, BA.2.12.1 accounts for about 27% of total cases observed.  As these new subvariants emerge, there exists the possibility that immunologic protection from a prior variant may not protect against a new variant. In fact, there is preliminary evidence that prior infection with BA.1 may not protect against BA.4 or BA.5. Link: https://covid.cdc.gov/covid-data-tracker/#variant-proportions 

There is not yet any evidence that either BA.4 or BA.5 lead to more severe illness as compared to other Omicron strains. In our experience, the currently circulating variants may even be a bit less severe.  We categorized 17 of our 24 cases (71%) in June as ‘mild’ as opposed to 17 of our 33 cases (51%) in May.

  1. COVID-19 in the Community

With widespread availability of home testing combined with the fact that home test results are no longer reportable to the County of Los Angeles, officially published numbers should be viewed as a significant underestimate of the true impact of infection. 

One useful active surveillance tool that might give some insight into community rates are data from Santa Monica Malibu School district which performed weekly PCR testing on students. With the school year ending, the final week of testing was May 31st – June 5th showing a slight decline in prevalence from 1.45% to 1.36% (note that no testing was done in the high school that week).

  1. Paxlovid Rebounds

Dr. Bretsky was one of the first physicians nationally to begin to discuss the impact of Paxlovid rebound on the duration, trajectory and transmission patterns of SARS-CoV-2 being quoted in a widely publicized Washington Post article at the end of April 2022 (link: https://www.washingtonpost.com/health/2022/04/27/paxlovid-second-case-covid/).

Paxlovid rebound has continued to be a thorny issue as 50% of those treated with Paxlovid during the month of June experienced a rebound case (5 rebounds among 10 patients treated). Most national estimates discuss a Paxlovid rebound rate between 10% and 40%. While patients taking Paxlovid feel better faster and the rebound infection is typically milder than the initial symptoms, it nevertheless is something to consider. As I tell patients, Paxlovid can turn a 5-7 day illness and isolation into a 3 week extravaganza.

  1. Blogs This Month

Our blog posts this month focused on the public health threat posed to women through the overturning of Roe v. Wade. We also highlighted how maternal mortality rates in the United States showed statistically significant increases during the last two years of the Trump Administration as states began rolling back pregnancy termination access. There are two major factors that significantly modify the risk of maternal mortality: 1. Access to contraception and 2. Access to safe pregnancy termination. This makes it straightforward to protect but also incredibly easy to dismantle.

On SCOTUS and the Dismantling of Women’s Health:  https://drbretsky.com/29june-2022-blog-post-on-scotus-an-the-dismantling-of-womens-health/

Overturning Roe v. Wade: https://drbretsky.com/24-june-2022-blog-post-overturning-roe-v-wade/

With the Euro sinking to a 2 decades low against the dollar, and more people electing to travel to Europe this summer, a COVID update for the continent seemed timely.

On COVID in Europe: https://drbretsky.com/22-june-2022-blog-on-covid-in-europe/

  1. July’s Epidemiology Definition

Odds Ratio: A statistic that quantifies the strength of association between two events, A and B or the “odds” of A in the presence of B. An odds ratio of one (1) means that A and B are independent. If the odds ratio is greater than one then A and B are correlated such that the presence of B raises the likelihood of A. If the odds ratio is less than one then the presence of one even reduces the odds of the other event.

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JUNE Newsletter

June 2022 Newsletter

In this issue, what’s old is new again (unfortunately). We are going to revisit case rates in Los Angeles County and why Health Department counts are undoubtedly an underestimate. We will also discuss SARS-CoV-2 antibody levels and Evushield, an exciting new pre-COVID exposure preventive tool.
Rising COVID-19 in the Practice during May
As Omicron waned in late January and early February, I regrettably predicted to patients that we would ‘have a good Spring.’ Some of my optimism was based on 2021’s experience when SARS-CoV-2 infection rates were very low (of course, mask mandates remained in place and the far less infectious Alpha variant was circulating). I also thought that given the significant number of Omicron cases in the community that subsequent case rates would remain low. That changed dramatically in our office during May during which we had 28 new COVID-19 cases, as compared to 4 in April
 
Case rates in the Country as a whole have shown a similar trajectory, although not quite as dramatic. Reaching a low of 5.8 new daily cases per 100,000 in mid-March, rates have have shown a steady climb upwards, and are now at 35.7 (note that viral containment is defined as under 1 new daily case per 100,000 population)

A very similar trend is seen when looking at Santa Monica Malibu School District weekly PCR surveillance data (among students).

Based on prevalence rates seen in schools, we are currently looking at about 1.5% of the population returning with positive tests – now granted these are PCR tests so that number may reflect those who have recovered from the disease but are still testing positive. Extrapolating to Los Angeles County as a whole, we would estimate that about 150,000 positive tests would be reported – yet only 25,000 were over the same time period.

 

COVID-19 Deaths Continue to Decline

Looking for good news?  Mortality rates in Los Angeles County due to COVID-19 are the lowest they have been since the last week of March – 2020!

Blogs This Month

The first blog of the month was a bit of departure from the usual COVID-19 headlines, but was timely nevertheless, looking at the leaked Roe v. Wade SCOTUS decision document. When taken from a public health perspective, the absurdity of limiting abortion access becomes abundantly clear. The other two are more typical reading, with the third in the series being an attempt to quantify spike protein levels in a blood sample that would provide sufficient neutralizing antibodies to prevent COVID-19.

On Roe v. Wade: https://drbretsky.com/3-may-2022-blog-post-on-roe-v-wade/

An Update of COVID-19 in Los Angeles County: https://drbretsky.com/18-may-2022-state-of-covid-in-la-county/

On Antibody Levels: https://drbretsky.com/31-may-2022-blog-post-making-sense-of-antibody-levels/

 

June’s Epidemiology Definitions

Surveillance: The ongoing systematic collection, analysis and interpretation of health data that are essential to the planning, implementation and evaluation of public health practice. This is generally divided into two categories, passive and active. There are representative examples of each in this newsletter. Passive surveillance (or reportable disease) is that collected by our local health department based on physician or laboratory reports. The COVID-19 case numbers summarized by LA County Health are based on passive surveillance as they do not seek out cases (and, in fact, specifically do not count home tests as valid cases). Active surveillance is illustrated by the SMMUSD data highlighted above. In such, active cases are sought out and reported nearly in real time.

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