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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www.santamonicaprimarycare.com

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.

Click here for more Details

www.drbretsky.com

www.santamonicaprimarycare.com

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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