Dear Patients,
As I have done recently, I am again forwarding the report our Medical Director, Marjorie Newman, MD, sends out to our medical staff. It is a bit more technical than some other reports we have sent, but it is so good at capturing what is going on that I am attaching it in basically the same form we use it internally.
She reviews some disturbing trends about variants of the virus in our country and concerning trends in Europe about the trajectory of their battle with COVID-19. What happens in Europe often has preceded what will happen here. Europe's vaccination rates, however, have been behind ours and we can only hope that our race to vaccinate people will allow us, this time, to follow a different path than those on the other side of the Atlantic Ocean.
You'll read about the dramatic decline in cases nationally, in our State and our County and also right here at Sansum Clinic. Dr. Newman, without exaggerating, mentioned today that there were more positive cases at Sansum Clinic in a period of a few hours one day in January than there were in all of Santa Barbara County yesterday. She reviews the great progress being made with vaccine distribution, though we still have a very long way to go. She reviews how to navigate the complicated changes with vaccine distribution and the importance of using the My Turn system going forward.
She discusses the changes in how we can safely interact as we enter new terrain of an increasingly vaccinated population.
There is much to allow us to hope that we have turned an important corner in our battle with COVID-19. At the same time, we are not done with this illness and we need to continue be careful while we get as many people vaccinated as we can.
We've come a long way since the first of these letters, when vaccinations were only theoretical and we knew much less than we do now. Get vaccinated when you are eligible and realize that things are better, but it is not yet over and continuing to be careful will allow us all to get closer to a full return to normal.
Kurt Ransohoff, MD, FACP
CMO
March 16, 2021
To: Colleagues
From: Marjorie Newman, MD
Re: Weekly COVID-19 Update
Overview: The US has reported over 29.5 million COVID-19 cases and over 535,000 deaths since the beginning of the pandemic. Over the past week, there has been an average of 55,200 new COVID-19 cases per day, which is a decrease of 19% from the average two weeks earlier. As mentioned previously, although we had been seeing a sharp decline in new cases throughout the nation over the prior few weeks, it appears that further decreases are occurring much more slowly. While many states have seen significant declines in new cases, others, especially on the East Coast, have seen infections plateau at relatively high levels (~6,000 new cases per day occurring in New York and New Jersey ~4,000 new cases per day). The death rate has continued to fall from the peak earlier this year. However, thousands of people continue to perish from the virus each week.
Also of note, COVID-19 case numbers have increased again in Europe and as a result, new restrictions have been imposed in Italy, France and Germany in an effort to stop a third wave of infections. Unfortunately this spike in cases is also occurring at a time when many European countries have temporarily suspended the use of the AstraZeneca COVID Vaccine as a precaution based upon reports of thrombosis (blood clots) and cerebrovascular events resulting in four deaths after administering 1.2 million vaccines. It is unclear if these incidents were related to the vaccine and investigations are underway to determine that. Of note, the AstraZeneca vaccine has not been reviewed by the FDA for an emergency use authorization (EUA) and is not one of the vaccines that are being used in the US.
With the plateau in positive cases in the US and new more contagious variants of the virus circulating, there is the potential to push case counts upward again, as evidenced by what is happening in other parts of the world. That in combination with the rolling back of restrictions in many parts of the US, with more individuals traveling and Spring Break looming, has experts again expressing concern about the potential for another surge in cases and a change in the trajectory of the pandemic if we become complacent with recommended public health measures (e.g., masking, restrictions on the size of gatherings, etc.) or falter in our vaccine efforts. Ultimately, as more vaccines are distributed and administered, vaccinations will play a critical role in keeping infections down, preventing hospitalizations and deaths and even reducing the chance of future mutations if all countries are able to vaccinate large segments of their populations. As a result, over the next several weeks vaccine efforts and individual behaviors will impact the trajectory of the pandemic both domestically and internationally.
The graphs below depict the daily confirmed new COVID-19 cases in the US, Italy and France (based upon a 7 day moving average).
United States: Cases have plateaued at ~55,000 cases per day.
Italy: Cases are on the rise again, averaging over 26,000 cases per day.
France: Cases are on the rise, averaging over 25,000 new cases per day.
The good news is that the pace of vaccination in the US continues to increase with more than 2 million doses of vaccine being administered on average each day and more people becoming fully vaccinated as a result of the Johnson & Johnson one-dose vaccine. As of March 15th 21% of the US population has received at least one dose of vaccine and 12% of the US population has been fully vaccinated (up from 9% last week). Now with three available vaccines in the US (Pfizer, Moderna and Johnson & Johnson), many states have expanded eligibility criteria to get more people vaccinated more quickly.
Variant Update:
Variants of Concern: These variants have been shown to be more transmissible, may cause more severe disease or may decrease vaccine efficacy.
- There are now 50 states reporting the B117 (UK variant) with a total of 4,690 cases that have been identified based upon genomic sequencing. The majority of cases are in Florida (738) and Michigan (616), Massachusetts (371), California (343), Colorado (303), Maryland (209), Connecticut (174), and then 100 or fewer cases reported by state in the remaining 43 states. The UK variant is more transmissible and has been determined to cause more severe disease. Recent studies indicate that this variant results in a higher viral load and that the RNA persists longer, which might have implications for quarantine duration. According to the CDC, this variant has likely grown to account for more than 20% of new US cases. However, of note, there is not yet enough genomic sequencing being performed throughout the US to be certain how widely this variant is spreading but data suggests that its share of total cases is growing at a trajectory similar to that seen in countries where it has fueled surges.
- The B 1.351 variant (South African variant) has been found in 23 states with a total of 143 cases reported (3 cases were reported in CA). This variant is concerning because it may decrease vaccine efficacy.
- The P1 variant (Brazilian variant) has been identified in 11 states and there have been a total of 25 cases (13 cases are in Florida). The CDPH has indicated that one case has just been reported in CA as of yesterday.
California Confirmed COVID-19 Cases:
As of March 14th since the pandemic began there has been over 3.6 million positive COVID-19 cases reported in California and 55,235 deaths. The number of new cases reported on March 14th was 2,772, the number of people hospitalized was 4,112 and the number of new deaths reported was 140. Over the past 14 days there has been a 38% decrease in the number of new cases per day, a 42% decrease in the number of people hospitalized, and a 4% decrease in the number of deaths. Over the prior week, there had been an average of 3,400 new cases per day, down from an average of 4,400 new cases per day last week.
According to the overall statewide metrics, the state positivity rate is now 2% (7 day average), with 6.4 new COVID-19 positive cases per day per 100,000 and overall ICU capacity at 30%.
The two graphs below from the California Department of Public Health website (as of March 14th) depicts the trend in positive cases and total deaths due to COVID-19. Again, the good news is that the number of new positive cases per day continues to decrease now with under 3,000 new cases reported per day and the number of deaths per day continues to trend downward.
Impact on hospitals and ICUs in CA: On March 14th the number of current hospitalizations due to confirmed and suspected COVID-19 cases in California is 3,812 which is a 4% decrease from the prior day. The number of COVID-19 patients requiring ICU support is 959 which is a decrease of 40 from the prior day along with an increase in the statewide ICU bed availability from the prior week, with now 2,187 ICU beds available, up from 2,000 beds available last week. Consequently, we are continuing to see a noticeable decrease in hospitalizations and ICU bed use with hospitalizations continuing to trend down and ICU bed availability trending up as indicated in the graphs below.
Vaccination Progress in CA: As of March 14th 20.3% of Californians have received one dose of vaccine (up from 18% last week) and 9.7% have received two doses (up from 8.5 % last week) – similar to the national data.
Santa Barbara County:
According to the Santa Barbara County Public Health Department website, as of March 16th there are currently 199 active infections in the County (down from 272 active infections last week) and down 29% from the prior two week average. There are 39 patients in the hospital and 13 in the ICU (7 patients are on ventilators and 0 ICU surge beds are in use). The number of people hospitalized is down 20% from the prior two week average. The cumulative death count is now at 429, up from 424 last week. The test positivity rate in Santa Barbara County is now reported as 3.6% down from 5% last week. Currently only 8% of patients on our hospitalist’s census are COVID-19 positive, and adult ICU availability in the County is now at 40%.
Santa Barbara has now advanced into Red Tier (substantial spread), with an adjusted case rate of 9.7 per 100,000 and a test positivity rate of 3.6%.
COVID-19 Vaccinations in the County: As of March 16th 128,005 vaccines have been administered, with 9.6% of the County now fully vaccinated up from 7.9% last week.
As a result of the positive trend in lower case rates and more people getting vaccinated, the Santa Barbara County Public Health Officer released an updated Health Officer Order on March 12th, which outlines the loosening of some restrictions related to certain businesses, recreational activities and limited gatherings. For more information, see the full Health Officer Guidance on the Santa Barbara County Public Health website.
The graph below reflects our Sansum Clinic weekly COVID-19 testing data for the week ending March 14th. We continue to test fewer people through our Urgent Care and our Pediatrics Department which is due to the decrease in the number of people who are presenting due to symptoms or close contact exposures. For the week ending March 14th we tested approximately 240 individuals for COVID-19 and our percent positive rate for Sansum Clinic has decreased again from last week and is now at 2.9% down from 5.5 % last week and down from 15% four weeks ago, and clearly significantly down from a high watermark of nearly 27% in mid-January. Clearly things are continuing to move in the right direction!
This second graph below represents the monthly trend of positive tests performed at Sansum Clinic since the onset of the pandemic in March 2020. Now, one year later, you can see the undulating trend line with three notable surges in positive cases; one in March 2020 at the onset of the pandemic, the second in July 2020 and the third and most severe surge, which began at the end of November 2020 through January 2021 and now, thankfully, with the significant decrease in positive cases starting in mid-February to present.
COVID-19 MONTHLY TREND SINCE THE ONSET OF THE PANDEMIC (March 2020 to March 14, 2021)
Demographic Data For Sansum Clinic’s Testing through 3/14/2021
Age Group Positive Negative Total Tests (18,338)
0-17 167 1,430 1,597
18-29 525 2,385 2,910
30-49 674 3,986 4,660
50-69 665 5,005 5,670
70 and over 244 3,257 3,501
Sex Positive Negative Total Tests (18,338)
F 1,193 9,301 10,494
M 1,082 6,762 7,844
Total 2,275 16,063 18,338
COVID-19 Vaccination Update:
- Vaccination Update for Sansum Clinic: As of March 14th Sansum Clinic has administered 8,573 vaccines and nearly 3,000 individuals have completed their two-dose vaccine series. We have administered more than 85% of the vaccine doses that we have been allocated and will again be administering Moderna as well as Johnson & Johnson vaccines this week. We plan to have vaccine clinics this week in the evenings, as well as Friday afternoon, Saturday and Sunday.
- My Turn, the state-wide COVID-19 Vaccine registration platform is now up and running and as a result, all vaccinating providers must transition to this scheduling platform for their vaccine clinics between now and the end of the month. Consequently, any person who is eligible to receive vaccine (individuals age 65 and older, those between the ages of 16-64 with comorbid conditions that place them at high risk, those who work in direct patient care, childcare, teachers, food service workers, etc.), may log on to the My Turn platform at https://myturn.ca.gov/ to register for a vaccine appointment at any health care facility that is administering vaccine, including at Sansum Clinic. Once a person logs into My Turn he/she will answer a few questions, attesting to the veracity of the answers, to determine eligibility and if eligible, and if vaccine appointments are available, he/she will be able to schedule an appointment. If the individual is not yet eligible or there are no appointments available, the individual can still register and will be notified when eligible or when an appointment opens up. Over the next few weeks, Sansum Clinic will be migrating away from using our Epic scheduling system for our COVID-19 Vaccine Clinics to using the state-wide My Turn platform for scheduling vaccine appointments and as a result, this will allow us to provide vaccine appointments to all eligible members of the community.
- Johnson & Johnson COVID-19 Vaccine: We have heard that some individuals expressed concern over the efficacy of the Johnson & Johnson (J&J, also known as Janssen) COVID-19 vaccine when compared to the Moderna and Pfizer/BioNTech COVID-19 vaccines, and as a result, have expressed hesitancy about getting vaccinated with that formulation. As a result, we wanted to provide a bit more information which may help put all of this in perspective and explain that the Johnson & Johnson COVID-19 vaccine is an excellent vaccine option and one should not hesitate or delay getting vaccinated regardless of which EUA authorized COVID-19 vaccine option is available.
Johnson & Johnson (aka Janssen) COVID-19 Vaccine and how it compares to the other two vaccine formulations:
- J&J vaccine uses an adenovirus vector to gain entrance into human cells. The J&J genetic recipe for the spike protein is carried into cells by a genetically engineered type 26 adenovirus (common cold virus), which has the SARS-CoV-2 spike gene encoded into it. What happens next is similar to mRNA vaccines: the spike protein is made, and our immune cells take it up and initiate the process of inducing anti-SARS-CoV-2 antibodies and T cells.
- It is the only vaccine for which we have good clinical trial data about its effects on mild and severe disease from the South African variant.
- The J&J vaccine is well-tolerated, with few side effects, and is easy to transport and distribute because it does not have extensive cold-chain requirements.
- The vaccine has the great benefit of being a one-dose vaccine – One and Done, as they say.
- Studies demonstrated that 28 days after vaccination the vaccine was effective in 83.5% of individuals in preventing severe disease and was 100% effective in preventing death from COVID-19. Individuals will have protection with J&J vaccine sooner than they will with either of the other vaccine formulations (Moderna, Pfizer).
- No trials compared the efficacy between all three vaccines in the same study or at the same time: All of the phase 3 trials for the three currently EUA approved vaccines differed by calendar time and geography. Meaning that the three vaccines were tested against different circulating variants and in settings with different background incidence of transmission. As a result, it is impossible to compare the vaccines efficacy against each other. J&J vaccine was studied when the virus was surging and when more variants were circulating, compared to when the Moderna and Pfizer vaccines were being evaluated for efficacy.
- All three authorized COVID-19 vaccines demonstrated efficacy (range 65-95%) against symptomatic lab confirmed COVID-19.
- All three authorized COVID-19 vaccines demonstrated high efficacy (> 89% against COVID-19 severe enough to require hospitalization).
- In all of the vaccine trials, no participants who received any of the three COVID-19 vaccines died from COVID-19.
Interim Public Health Recommendations from the CDC for Fully Vaccinated People (in non-healthcare settings):
Last week, the CDC released the first set of public health recommendations for fully vaccinated people. The CDC prefaced the guidance by noting that the currently authorized vaccines in the United States are highly effective at protecting vaccinated people against symptomatic and severe COVID-19. Additionally, a growing body of evidence suggests that fully vaccinated people are less likely to have asymptomatic infection and potentially less likely to transmit SARS-CoV-2 to others. How long vaccine protection lasts and how much vaccines protect against emerging SARS-CoV-2 variants are still under investigation. Until more is known and vaccination coverage increases, some prevention measures will continue to be necessary for all people, regardless of vaccination status. However, the benefits of reducing social isolation and relaxing some measures such as quarantine requirements may outweigh the residual risk of fully vaccinated people becoming ill with COVID-19 or transmitting SARS-CoV-2 to others. Additionally, taking steps towards relaxing certain measures for vaccinated persons may help improve COVID-19 vaccine acceptance and uptake. Therefore, there are several activities that fully vaccinated people can resume now, at low risk to themselves, while being mindful of the potential risk of transmitting the virus to others. Also of note, the CDC indicated that this interim guidance will be updated periodically based upon the level of community spread of infection, the variants that are circulating, the proportion of the population that is fully vaccinated and the rapidly evolving science and observational data regarding vaccine efficacy.
For the purposes of the below guidance, people are considered fully vaccinated for COVID-19 ≥2 weeks after they have received the second dose in a two-dose series (Pfizer-BioNTech or Moderna), or ≥2 weeks after they have received a single-dose vaccine (Johnson and Johnson [J&J]/Janssen). However, people should discuss with their provider if they have any questions about their individual situation, such as immunocompromising conditions or other concerns.
The recommendations below apply only to non-healthcare settings.
In non-healthcare settings, fully vaccinated people can:
- Visit with other fully vaccinated people indoors without wearing masks or physical distancing. Indoor visits between fully vaccinated people who do not wear masks or physically distance from one another are likely low risk. For example, if you are fully vaccinated, it is likely a low risk for you to invite other fully vaccinated friends to dinner inside your private residence.
- Visit with unvaccinated people from a single household who are at low-risk for severe COVID-19 disease indoors without wearing masks or physical distancing
- Refrain from quarantine and testing following a known exposure, if asymptomatic. However, fully vaccinated people who do not quarantine should still monitor for symptoms of COVID-19 for 14 days following an exposure. If they experience symptoms, they should isolate themselves from others, be clinically evaluated for COVID-19, including SARS-CoV-2 testing, if indicated, and inform their health care provider of their vaccination status at the time of presentation to care.
- For now, fully vaccinated people should continue to:
- – Take precautions in public like wearing a well-fitted mask and physical distancing. In public spaces, fully vaccinated people should continue to follow guidance to protect themselves and others, including wearing a well-fitted mask, physical distancing (at least 6 feet), avoiding crowds, avoiding poorly ventilated spaces, covering coughs and sneezes, washing hands often, and following any applicable workplace or school guidance. Fully vaccinated people should still watch for symptoms of COVID-19, especially following an exposure to someone with suspected or confirmed COVID-19. If symptoms develop, all people – regardless of vaccination status – should isolate and be clinically evaluated for COVID-19, including SARS-CoV-2 testing, if indicated
- – Wear masks, practice physical distancing, and adhere to other prevention measures when visiting with unvaccinated people who are at increased risk for severe COVID-19 disease or who have an unvaccinated household member who is at increased risk for severe COVID-19 disease. For example, if a fully vaccinated individual visits with an unvaccinated friend who is 70 years old and therefore at risk of severe disease, the visit should take place outdoors, wearing well-fitted masks, and maintaining physical distance (at least 6 feet).
- – Wear masks, maintain physical distance, and practice other prevention measures when visiting with unvaccinated people from multiple households
- – Avoid medium- and large-sized in-person gatherings
- – Get tested if experiencing COVID-19 symptoms
- – Follow guidance issued by individual employers
- – Follow CDC and health department travel requirements and recommendations
All people, regardless of vaccination status, should adhere to current guidance to avoid medium- or large-sized in-person gatherings and to follow any applicable local guidance restricting the size of gatherings. If they choose to participate, fully vaccinated people should continue to adhere to prevention measures that reduce spread, including wearing a well-fitted mask, maintaining physical distance from others, and washing hands frequently.
Risk of SARS-CoV-2 infection during public social activities such as dining indoors at a restaurant or going to the gym is lower for fully vaccinated people. However, precautions should still be taken as transmission risk in these settings is higher and likely increases with the number of unvaccinated people present. Thus, fully vaccinated people engaging in social activities in public settings should continue to follow all guidance for these settings including wearing a well-fitted mask, maintaining physical distance (at least 6 feet), avoiding crowds, avoiding poorly ventilated spaces, covering coughs and sneezes, and washing hands frequently.
Although the risk that fully vaccinated people could become infected with COVID-19 is low, any fully vaccinated person who experiences symptoms consistent with COVID-19 should isolate themselves from others, be clinically evaluated for COVID-19, and tested for SARS-CoV-2 if indicated. The symptomatic fully vaccinated person should inform their healthcare provider of their vaccination status at the time of presentation to care.
We hope the above information has been helpful and, as always, please don’t hesitate to reach out for any questions.
Marjorie Newman MD
Medical Director
Sansum Clinic
Kurt N. Ransohoff, MD, FACP
CEO and Chief Medical Officer
Sansum Clinic