Download - Update on COVID-19 in Hawai‘i
Update on COVID-19 in Hawai‘i October 2, 2021
Lee Buenconsejo-Lum, MD, FAAFP
Associate Dean for Academic Affairs John A. Burns School of Medicine
JABSOM Liaison to HI EMA S ESF-8 and several State Vaccine Implementation Plan committees
Topics to be discussed in this session: 1. Overview of the virus that causes
COVID-19 (SARS-CoV-2) 2. Moderate to severe COVID-19 disease
and “long COVID” 3. COVID-19 vaccines and booster plans 4. Other prevention & risk reduction
measures
Key timelines in the pandemic • New virus in December 2019 • WHO declared a Global Health emergency Jan
30, 2020 • White House declares National Public Health
Emergency February 1, 2020 • WHO declares pandemic March 11, 2020 • Disruption of services in March 2020 • Hawai‘i surge in Aug-Sept 2020 • Hawai‘i starts vaccine planning Oct 2020 • First doses of vaccine December 15, 2020 • Started vaccinating kupuna in mid-January 2021 • Second surge in January 2021 • Variant strain identified in HI January 25, 2021 • Third surge started July 2021 (Delta variant 93%)
Coronavirus basics • The name comes from the crown-like
appearance • The “spikes” on the surface are the spike
proteins, which are the target of the vaccines
• This family of viruses causes many diseases in humans and animals, including the common cold
• Can cross species from bats into other animals (found in the live-animal markets) into humans and humans to other animals (rare)
Lauring AS, Malani PN. Variants of SARS-CoV-2. JAMA. Published online August 13, 2021. doi:10.1001/jama.2021.14181
Transmission of the Novel 2019 Coronavirus (SARS-CoV-2) • Person to person • Respiratory droplets & aerosols from
coughing, sneezing, talking, shouting, singing
• Contact with surfaces (low risk) • Health care workers not wearing proper
personal protective equipment (PPE) CLUSTERS • Family transmission - gatherings • Bars, carpools, break rooms, churches,
funerals, nursing home, prisons • Weekly cluster reports on the
Department of Health (DOH) website
Factors affecting distribution of aerosols indoors
• Open windows when possible • Eat on the patio/outdoors, in
small group to allow spacing • Only vaccinated people in the
home (esp. if there are immunocompromised, elderly or children under 12)
• HEPA filter plus universal masking is very effective
https://science.sciencemag.org/content/373/6558/eabd9149.full
Incubation Period and Asymptomatic Transmission • Range 2-14 days, average 5-6 days • Long pre-symptomatic period (12 days) • ⅓ to ½ of cases are asymptomatic transmission
(up to 21 days)
The time periods of infectivity are the basis for: • Contact tracing • Quarantine • Isolation
Clinical signs and symptoms • If more severe and need oxygen
hospitalization
Chest x-rays, illness day 10, hospital day 6 White areas in the lung = inflammation
Common clinical features • Loss of smell or taste (early) • In hospitalized patients
• Prolonged fever • Cough • Body aches or fatigue • Shortness of breath
Less common clinical features • Oral rash • Myocarditis (weak heart) • Blood clots and stroke • COVID toes (more common in kids) • Multisystem Inflammatory Syndrome in
Children (MIS-C) – heart, lungs, kidneys, brain, skin, eyes, GI tract
COVID-19 disease tends to be worse in elderly and those with multiple chronic conditions • Death: 60-69 years: 3.6%; 70-79 years:
8%; ≥80 years: 14.8% • Death is higher for some
• 10.5% for those with cardiovascular disease
• 7% for diabetes • 6% each for chronic respiratory
disease, hypertension, and cancer • 49% for patients who developed
respiratory failure, septic shock, or multiple organ dysfunction
• Prevention is critical!! • Treatment is mostly supportive • Recommendations are evolving • Role of monoclonal antibody in
those who test positive and are at high risk for hospitalization/death
Post-COVID conditions “Long COVID” • Difficulty breathing or shortness of breath • Tiredness or fatigue • Symptoms that get worse after physical or mental activities • Difficulty thinking or concentrating (sometimes referred to as “brain
fog”) • Cough • Chest or stomach pain • Headache • Fast-beating or pounding heart (also known as heart palpitations) • Joint or muscle pain • Pins-and-needles feeling • Diarrhea • Sleep problems • Fever • Dizziness on standing (lightheadedness) • Rash • Mood changes • Change in smell or taste • Changes in period cycles
• Multiorgan effects (severe illness or autoimmune)
• Heart, lung, kidney, skin, brain function
• Multisystem inflammatory syndrome – adults or children
• Post-Intensive Care Syndrome https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects.html
Testing is important if you have any symptoms • PCR detects presence of viral nucleic acid • Does not distinguish between living and dead virus • Presence does not necessarily imply transmissibility • Tests were designed to detect disease in symptomatic persons • Asymptomatic may test positive • Monitored self-collected swab (mid-nose) is effective as nasopharyngeal
Questions • How did we get the vaccines so quickly?
• Work on the SARS-CoV vaccine began after SARS and MERS
• $$$$, Pre-approval production • Combined phase 1/Phase 2 trials
• Are they safe? • Held to a very high (higher than usual) standard • Close monitoring and for 1-2 years
• COVID is not like the
flu! • Much worse
• Common symptoms after the vaccine are part of the normal immune response
Yeah for Vaccines!
Janssen/Johnson & Johnson • 14M doses as of 8/26/21
mRNA vaccines given in US as of 8/26/21 Pfizer-BioNTech 2 dose 92M Moderna 2 dose 65M
mRNA Vaccines • Pfizer and Moderna
• Cannot get infected from these • Similar safety profile • Efficacy: testing positive 7 days after the second dose
• 94-95%; less against Delta variant
• Effective in preventing severe COVID-19 (95%-100%) (>80% with Delta)
Questions to be answered with additional data from ongoing trials
• How long will the vaccine last (duration of protection)?
• 6-8 months (antibody) – likely longer in immunocompetent
• Will vaccination prevent asymptomatic SARS-CoV-2 infection?
• Ongoing studies • Will vaccination reduce SARS-CoV-2
transmission? • Some suggestion of this, but Delta is very
contagious (1000-1200x) • Are two vaccine doses required for protection or
can protection be achieved with a single vaccine dose?
• 2 doses for mRNA and Astra-Zeneca/Oxford • 1 dose for Janssen • Studies ongoing
• Is the vaccine safe and effective • In children 12-15 years of age – yes • In pregnant women – yes • In children 5-11 year of age – (yes) ongoing studies
• Vaccine safety follow up reported by recipients (V-Safe and VAERS)
Who should NOT get the COVID-19 vaccine? • A history of the following is considered by
CDC to be a contraindication to both the Pfizer and Moderna vaccines:
• Severe allergic reaction (e.g., anaphylaxis) after a previous dose of an mRNA COVID-19 vaccine or any of its components
• Immediate allergic reaction of any severity to a previous dose of an mRNA COVID-19 vaccine or any of its components (including polyethylene glycol [PEG])*
• Immediate allergic reaction of any severity to polysorbate (due to potential cross-reactive hypersensitivity with the vaccine ingredient PEG)*
• Persons with an immediate allergic reaction to the first dose of an mRNA COVID-19 vaccine should not receive additional doses
Anaphylaxis • Wheezing, severe trouble
breathing • Dizzy / low blood pressure • Requires epinephrine • Often hospital / ER visit
Precautions A history of any immediate allergic reaction to any other vaccine or injectable therapy is a precaution but not a contraindication to vaccination for both the Pfizer-BioNTech and Moderna COVID-19 vaccines
• intramuscular, intravenous, or subcutaneous vaccines or
• therapies not related to a component of mRNA COVID-19 vaccines
• Should be counseled about the unknown risks of developing a severe allergic reaction and balance these risks against the benefits of vaccination
• May defer vaccination until more information on risk of anaphylaxis is available
• Patients with these precautions or other non-severe allergies to food or drugs will be monitored for 30 minutes after vaccination
What about …. • Persons with a history of Guillain-Barre
syndrome • NO CASES of Guillain-Barré syndrome (GBS)
reported following vaccination among participants in Pfizer-BioNTech or Moderna COVID-19 vaccines clinical trials
• 1 case in Janssen and 1 in placebo • May receive COVID-19 vaccination if they have
no contraindications to vaccination • Persons with a history of Bell’s palsy
(temporary facial paralysis) • Cases of Bell’s palsy following vaccination in
both trials not found to be causally related to vaccination
• Post-authorization safety surveillance will further assess any possible causal association
• May receive COVID-19 vaccination if they have no contraindications to vaccination
• https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/underlying-conditions.html
https://theconversation.com/what-is-herd-immunity-and-how-many-people-need-to-be-vaccinated-to-protect-a-community-116355
Vaccination rate thought to be needed now that the Delta variant is predominant: • Maybe around 85%
of the population vaccinated
https://www.straitstimes.com/singapore/health/those-who-refuse-covid-19-vaccine-endanger-themselves-and-others
Pfizer/BioNTech FDA Full Licensure • CDC ACIP recommends approval (unanimous) August 30,
2021 • Prevented a COVID infection with symptoms about
90%–92% of the time, at least for the first 4 months after the second shot.
• Israel and other studies indicate lower efficacy with the Delta variant (est. ~74.6%)
• Protection against hospitalization and death was 95-100%
• Data collection and new studies ongoing regarding • Waning immunity • Efficacy with Delta variant
• 11% with pain, swelling, needing to visit hospital or ER for pain, high fever, vomiting that requires IV fluid, persistent diarrhea, severe headache, or severe muscle/joint pain
• Anaphylaxis ~ 5 cases for every 1 million shots given • Myopericarditis
• After vaccine, within a week, younger men under age 30 • MILD, 1-2 day hospitalization in the great majority
• 6 – 34 x risk of moderate-to-severe myocarditis with the actual infection (prolonged hospitalizations, ICU)
Boosters?
Additional Dose in mod-severe immunocompromised • Active chemotherapy, immunosuppressive
drugs, prednisone more than 20 mg per day, those without spleens
• Patients on hemodialysis • Available now – with self-attestation • TALK TO YOUR FIRST DOCTOR IF YOU ARE ON
A CHEMOTHERAPY REGIMEN https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2021-08-30/09-COVID-Oliver-508.pdf
• Hospitalization in adults older than 75 – decreased efficacy but more than 80%
• Long-term care facility residents - ~ 50% effective with Delta variant • Continuing to review data – will decide in September after FDA
approval • May be: LTCF residents, HCP, adults either over 65 or over 75
Avoid the 3 Cs: Closed spaces with poor ventilation Crowds Close contact with people outside your social bubble