A Message on COVID-19 from WorkSTEPS Chief Medical Officer Dr. Ben Hoffman
Help Is on the Way – Don’t Let Up!
We are in a weird place with COVID-19 right now. Here are the basic facts:
- Vaccinations have begun. The process is better organized in some states than others, but in all states, the process has begun. There is reason for hope!
- Meanwhile, infections rates, hospitalizations, ICU occupancy rates and deaths have all been setting records.
- Despite the dire news, based on my own observation and discussion with colleagues, it seems like organizations and individuals have grown weary of prevention.
It’s like an ocean-liner has capsized, and survivors – despite hearing the desperate cries of fellow passengers taking their last breath and swimming among bodies of the dead – have stopped trying to tread water because they’ve spotted the lights of a rescue boat.
Help is on the way, but we’re still very much at risk of getting sick and dying. We can’t let up!
Bad News About Pre-symptomatic and Asymptomatic Transmission
The uniquely dangerous nature of the risk we face was made even more clear this week in a study published in JAMA Network which found that approximately 59% of all COVID-19 transmission is caused by people without symptoms. Thirty-five percent of transmission is from people sick with COVID-19 who transmit disease before they experience symptoms (pre-symptomatic), and another 24% is from people who will never experience symptoms (asymptomatic).
Here’s another way to look at this new information: Even if your employees are 100% accurate in their self-assessment and are completely truthful in their reporting of COVID-19 symptoms, and even if you have in place flawless quarantine, testing, isolation and quarantine protocols triggered by the first sign of symptoms, you’ll disrupt at most just 40% of disease transmission.
Implications for Employers
The main message is this: Employers cannot let up on implementation and enforcement of their comprehensive prevention strategies. We’ve written about comprehensive strategies here and here. Also helpful for thinking about and evaluating your company’s strategy, the Swiss Cheese Model of Pandemic Defense pictured below.
Two comments:
1. It’s About Execution: If you’re a regular reader of this, there is little mystery about what your company should be doing to prevent the spread of COVID-19. If you’re company is struggling, it’s likely with execution of your strategy. Fatigue has set in at every level. Employees are sick of following the rules, and supervisors are beyond tired of enforcing them. And now that vaccinations have started – now that the rescue craft has been spotted – people are even less motivated to do what they need to do to prevent the spread of COVID-19.
The truth of the matter is that we cannot let up on prevention. Until herd immunity has been achieved through vaccination, the risk of infection and outbreak persists. We must keep working to tread water while the rescue craft makes its way to us.
2. Time to (Re)Consider Testing for Surveillance: Antigen testing has become accurate enough, fast enough, and cheap enough to be considered by many companies as another layer of protection. A well-designed testing strategy can cost-effectively screen and identify sick-but-symptom-free employees capable of spreading disease.
If you’d like to understand what an efficient and effective testing program would involve for your company, give us a call (512-617-4100) or send us a message here.
As I wrote recently, we’re in the home stretch, but it’s going to be a long one. This is exactly the time we are – individually, professionally, and corporately – most tempted to let up. It’s also exactly the time when we can least afford to do so. We have people and programs to help. Let us know if we can help you.
Ben Hoffman, MD, MPH
Chief Medical Officer, WorkSTEPS
For more from Dr. Hoffman, connect with him on LinkedIn.
Medical:
Global: The U.K. is the epicenter of Europe’s COVID-19 outbreak once more. More than 3 million people in the U.K. have tested positive for the coronavirus and 81,000 fatalities — 30,000 in the last 30 days. Hospitals are overcapacity and stay-at-home restrictions have been re-started. Britain’s Health Secretary stated, to relieve pressure on hospitals, the NHS is considering plans to discharge patients into hotels as hospitals are overwhelmed with COVID patients.
National: On Monday, Moderna announced at a health care conference that Immunity from their COVID-19 vaccine should last at least a year. The company’s vaccine, mRNA-1273, uses synthetic mRNA to mimic the surface of the coronavirus and teach the immune system to recognize and neutralize it. In late December, Moderna stated they planned on running tests to confirm the vaccine’s activity against any strain. Moderna expects to deliver between 600 million doses and 1 billion does of its vaccine in 2021 based on advance purchase agreements signed with governments.
Things are likely to get worse before they get better: The virus is spreading so rapidly that hospitals are struggling to keep up. About 130,000 Americans are hospitalized with COVID symptoms, more than double the number two months ago. The strain on hospitals raises the possibility that many patients will not receive the best available treatments.
Los Angeles has recently had to ration oxygen. And Esteban Trejo, an executive at a company in El Paso, Texas, that provides oxygen to temporary hospitals, told Kaiser Health News, “It’s been nuts, absolutely nuts.”
The recent data on cases and deaths is noisy, because diagnoses artificially slowed during the holidays, says Mitch Smith, a Times reporter who follows the numbers. Still, deaths have already hit a record this week — more than 3,000 a day, on average — and the recent explosion of cases suggests they may be heading to above 3,500 and perhaps to 4,000.
High-titer Convalescent Plasma: A study published in The New England Journal of Medicine, conducted on behalf of the Fundación INFANT–COVID-19 Group, evaluated convalescent plasma with a high IgG titer as a COVID-19 treatment. The randomized, double-blind, placebo-controlled trial included 160 patients in Argentina aged 75 years or older or aged 65-74 years with at least 1 pre-existing condition associated with elevated risk of severe COVID-19 disease and death. The convalescent plasma used in the treatment group included “antibody concentrations in the upper 28th percentile,” and the study participants were divided equally between the treatment and placebo groups (80 in each). The treatment group exhibited a 48% relative reduction in risk of severe respiratory disease compared to the placebo group—13 patients (16%) in the treatment group compared to 25 patients (31%) in the placebo group. Additionally, fewer patients in the treatment group died than in the placebo group, 2 (2%) compared to 4 (5%), but this result was not statistically significant. No adverse events were reported in either group.
Long-term health effects: Evidence continues to emerge on the many and varied long-term health effects of COVID-19. Research has already established correlation between COVID-19 disease and certain cardiac, respiratory, and neurological conditions, but it is still unclear for how long these “long COVID” symptoms may persist. A study published in The Lancet followed 1,733 recovered COVID-19 patients from Wuhan, China, who were initially recovered between January and May. Among these patients, 76% reported at least one symptom 6 months after their recovery, including muscle weakness or fatigue (63%), difficulty sleeping (26%), and hair loss (22%). Additionally, 23% of the participants reported anxiety or depression, and 27% reported persistent pain or discomfort.
CDC: No Sign of Homegrown U.S. Coronavirus Variant, but Scientists Need to Look Harder (Washington Post): Infectious-disease experts say there is no evidence the massive winter surge that is killing thousands of people a day in the United States is linked to the U.K. variant or to a homegrown strain. But they acknowledge their battlefield awareness is limited.
Coronavirus Shutdowns have Quashed Nearly All Other Common Viruses. But Scientists Say a Rebound is Coming: Veteran virus trackers say they are chronicling something never before seen — the suppression of virtually every common respiratory and gastrointestinal virus besides the novel coronavirus. They theorize that is largely due to global shutdowns, mask-wearing and a host of other health protocols aimed at stemming the spread of the coronavirus.
Study shows COVID-19 severity could depend on route of infection: An NIH study showed Infection through inhaling airborne virus could lead to more severe disease than infection from fomites (contact w/ contaminated objects.) Fomite exposure led to milder disease. Also, compared to intranasal exposure, aerosol exposed hamsters had higher viral load in trachea and lung which suggests aerosol exposure more efficiently deposits viral droplet nuclei in the lower respiratory system. In humans, larger aerosols deposit in upper throat, nose, & tracheobronchial region of the lung. Medium-sized aerosols mostly deposit in small airways further down. The really small aerosols <1 μm can penetrate all the way to the alveoli – the basic units for gas exchange.
Mitigation/Suppression:
Vaccinating Recovered Individuals: Since the onset of the pandemic, health experts and officials have studied the role of immunity conferred by natural infection. While reports of are relatively rare, the potential for reinfection does exist. In light of this risk, the US CDC emphasizes that individuals who were previously infected and recovered should still get vaccinated due to the “severe health risks” and uncertainty regarding the duration of natural immunity. Additionally, the degree of natural immunity “varies from person to person.” The duration of the immunity conferred by vaccination remains uncertain as well, but research is still ongoing via clinical trials. Depending on the duration of immunity following vaccination, it may be necessary for individuals to receive regular boosters to provide longer-term protection.
Mass Vaccination Events Planned: As vaccination efforts scale up nationwide, including expanded eligibility, state and local public health and healthcare officials are proceeding with plans to establish mass vaccination capacity. Some of these efforts are leveraging space available at large venues—such as stadiums, convention centers, and fairgrounds—which can provide space for many vaccinators that can process large crowds quickly. For example, Los Angeles, California, is converting Dodger Stadium from a mass testing site to administer vaccinations. California is reportedly also establishing mass vaccination sites at Disneyland Resort (Anaheim), Petco Park (San Diego), and CalExpo fairgrounds (Sacramento). In San Antonio, Texas, health officials began administering vaccinations at the Alamodome, where they expect to be able to vaccinate 30,000 people per week. With its regular season over, and most teams no longer playing, the NFL (football) is encouraging teams to make their stadiums available to serve as vaccination sites. While these large sites provide the space needed to administer vaccinations rapidly, many barriers still remain, including the logistics of transporting and storing vaccines and the need for additional personnel who are trained and qualified to administer vaccinations.
CDC interim guidance on variants: A new variant strain of SARS-CoV-2 that contains a series of mutations has been described in the UK and is called B.1.1.7. This variant strain has been predicted to potentially be more rapidly transmissible. CDC has announced plans to double testing of genetic samples to watch for any new variants from 3000 weekly samples to 6500 weekly samples. The CDC plan, when fully implemented in January 2021, calls for each state to send CDC at least 10 samples biweekly for sequencing and further characterization.
WHO Shared update, and guidance regarding SARS-COV-2 variants: In December, the WHO released a report, including a risk assessment and guidance, on a series of recently observed SARS-CoV-2 variants during the COVID-19 pandemic. Variants noted in 2020 include: D614G Substitution variant – the Primary Virus, Danish “Cluster 5” Variant, British B.1.1.7 variant, and the South Africa 5O1Y.V2 variant. They advised nations to continue undergoing epidemiological and virologic assessments on these variants. They highlighted actions initiated to respond to the new concern of increased transmissibility. Actions include: intensified genetic sampling in affected regions to interpret variant circulation and spread; recommended national scientific teams observe the mutations’ effects on reinfection, vaccination, diagnostic testing, infection severity, and transmissibility. Other actions recommended can be found here.
Genomic Evidence of In-Flight Transmission of SARS-CoV-2 Despite Predeparture Testing: A study published in the US CDC’s Emerging Infectious Diseases journal describes in-flight transmission of SARS-CoV-2 among passengers on a flight from Dubai, UAE, to Auckland, New Zealand—with a stop in Kuala Lumpur, Malaysia. Upon arrival in New Zealand, all passengers were subjected to mandatory 14-day quarantine, with testing conducted at approximately Day 3 and Day 12. Testing identified 7 SARS-CoV-2 infections among the passengers, including 5 that tested negative prior to their departure. Genomic analysis of specimens collected from each passenger found that the viral genome in 6 of the 7 passengers was identical, with 1 mutation present in the seventh passenger. Combined with the timeline of symptoms and positive tests, this suggests that the infection was transmitted among the passengers, rather than from multiple sources prior to travel. Travel screening can mitigate the risk of importing cases or transmission during travel, but it cannot prevent them.
CDC Updated guidance on protecting your home from COVID-19: If someone you live with is 65 or older or has a serious underlying condition, they are more likely to get very sick from COVID-19. Everyone in the house should take extra care to avoid spreading COVID-19.
Moderna Vaccine Phase 3 results: On December 30th, Moderna released their Phase 3 clinical data report showing 94% efficacy. The Trial was conducted at 99 US centers. Persons at high risk of infection/serious illness received mRNA vaccine (100 μg) or placebo 28 days apart. The goal was to assess prevention of COVID-19 at least 14 days after 2nd injection. The trial enrolled over 30,000 volunteers to receive the vaccine or placebo. Symptomatic illness occurred in 185 people in placebo group but only in 11 in the vaccine group. Efficacy was 94%. Severe COVID-19 occurred in 30 participants, with one fatality; all off of whom were in the placebo group. Overall, local reactions to vaccine (e.g. pain at injection site) were mild. Stronger side effects (fatigue, myalgia, arthralgia, headache) were common after 2nd dose but largely transient/resolved by day 2. More on the research summary here.
Corporate:
FDA Statement about COVID-19 vaccines dosing: The FDA said it is premature to change COVID-19 vaccination protocols. The two different mRNA vaccines currently available have shown remarkable effectiveness of about 95% in preventing COVID-19 disease in adults. The FDA stated they are following discussions about reducing the number of doses, extending the length of time between doses, changing the dose (half-dose), or mixing and matching vaccines in order to immunize more people against COVID-19. These are all reasonable questions, but they need to be evaluated in clinical trials. Per the FDA. at this time, suggesting changes to current FDA-authorized dosing or schedules of the Pfizer and Moderna vaccines is premature and not rooted in evidence-based science. Without appropriate data, changes could potentially place public health at risk, and undermine the historic vaccination efforts.
CDC requiring international passengers to have a negative test: Before boarding their flights, all international passengers headed to the United States will first need to show proof of a negative coronavirus test, according to a new federal policy going into effect on Jan. 26.
“Testing does not eliminate all risk,” Dr. Robert R. Redfield, the director of the Centers for Disease Control and Prevention, said in a statement describing the new policy.
“But when combined with a period of staying at home and everyday precautions like wearing masks and social distancing, it can make travel safer, healthier, and more responsible by reducing spread on planes, in airports, and at destinations.”
What to Expect after Getting a COVID-19 Vaccine?
COVID-19 vaccination will help protect you from getting COVID-19. You may have some side effects, which are normal signs that your body is building protection. These side effects may affect your ability to do daily activities, but they should go away in a few days.
The Work From Home WorkSTEPS Medical Team:
Ben Hoffman, MD, MPH
Chief Medical Officer
Tony Nigliazzo, MD
Medical Director
Loraine Kanyare, MSN, MPH, RN
Director of Case Management
Lynda Phillips, LVN
Nurse Case Manager
Codey Church, LVN
Nurse Case Manager
Kerry Womack, LVN
Nurse Case Manager
Chuck Reynolds
Strategic Communications Consultant
This Guidance (“Guidance”) is provided for informational and educational purposes only. It is not intended as Legal Advice or Medical Advice. Adherence to any recommendations included in this Guidance will not ensure successful diagnosis or treatment in every situation. Furthermore, the recommendations contained in this Guidance should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific therapy must be made by the physician and the patient in light of all the circumstances presented by the individual patient, and the known variability and biological behavior of the medical condition. Similarly, this Guidance is based on current advice, comments, and guidance from the EEOC, CDC and the CMS made publicly available. The ultimate judgement regarding the propriety of any specific employment action must be made by the company and attorney in light of all of the circumstances presented by the company, state and federal rules existing at the time and the then current state of the National Pandemic. This Guidance and its conclusions and recommendations reflect the best available information at the time the Guidance was prepared. The results of future studies or changes in rules, regulations or laws may require revisions to the recommendations in this Guidance to reflect new data. WorkSTEPS does not warrant the accuracy or completeness of the Guidance and assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this Guidance or for any errors or omissions.
