Covid = back.

[Birdstrike]

NZ was COVID free for like 5 months. That's the goal.

So, the goal is repeated lockdowns, even when the population is fully vaccinated, forever?

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[FutureInternist]

We have several on ECMO/vents that are in their 20's and 30's. All are either obese or have comorbidities. We in the South like our biscuits and gravy, which is likely an independent risk factor for severe COVID. Seriously though, we only have 1 in ICU that is >50 years of age. The others are younger. So it's hitting younger people moreso probably because a higher percentage of elderly are vaccinated.

Or have already died previously

 

[VA Hopeful Dr]

So, the goal is repeated lockdowns, even when the population is fully vaccinated, forever?

Doubt it, but NZ was pretty low on the list for vaccines. They just hit 30% within the last week or so.

I would hope once they're heavily vaccinated they'll relax, if nothing else because I want to visit.

 

[xaelia]

What’s the vaccination rate there in NZ, and do they have the same vaccines as western countries or is it the Chinese or Russian version?

Doubt it, but NZ was pretty low on the list for vaccines. They just hit 30% within the last week or so.

I would hope once they're heavily vaccinated they'll relax, if nothing else because I want to visit.

We're around 1M fully vaccinated with Pfizer. About 4M eligible. Not great.

We were low on the priority list for supply – substantial numbers didn't start coming in until July. I don't think we were willing/able to pay for advance standing on delivery, plus we were in a fairly good place with respect to COVID-19 morbidity/mortality.

So, the goal is repeated lockdowns, even when the population is fully vaccinated, forever?

A re-opening plan is in place for early 2022, which initially is still fairly restrictive in terms of minimising and controlling the number of cases entering New Zealand and spreading in the community – but expects to control/reduce spread primarily through vaccination uptake, rather than stringent lockdowns. As we've seen, though, the world of COVID turns on its head fairly frequently....

 

[bravotwozero]

Anyone come across any data regarding the nature of the delta variant infections? Is it true that it has a much shorter incubation period than the alpha variant? Does it still cause as much asymptomatic infections as the original strain? Is the mortality rate higher with it?

 

[thegenius]

So, the goal is repeated lockdowns, even when the population is fully vaccinated, forever?

I don't know anymore. I honestly would be happy if we completely suspended our cultural tradition of shaking hands and having everyone wear masks to prevent spread. Those seem like very reasonable and unobtrusive steps. But yea....this thing is going to circulate over and over and over for years and decades until we all have good enough immune systems to make the symptoms mild. I bet this is exactly what all viruses (flu, measles, etc) did when they were introduced into the human race.

I'm still a believer that once we have good data, it's going to show that vaccination reduces spread. It's just hard to study right now. But if it did, I don't think it will ever be by a substantial amount.

 

[ER BlueBlood]

For all the docs working in States with the covid surges, I hope you guys are doing ok and are able to get some time off.

It’s been rough here in texas. Most of my colleagues are getting pretty burnt out,
and absolutely nobody is in any mood for picking up extra shifts, whereas we’d normally be fighting over them.

The rate of spread looks like it might start to slow, but this is worse than the past several waves that preceded it. 870 covid patients total in our hospital system, per our CEO’s email.

Also here in TX. It’s to the point where my ******* unvaccinated next door neighbor (48, no major health issues) is now in the hospital on high flow for over a week and receiving other treatments. The guys wife is telling all the neighbors it isn’t covid, that’s how delusional she is. These are “educated” people as well, educated by American standards (meaning showed up and walked away with a college degree). They claimed Covid was an election hoax and would go away once the election was done. Said they were eating out multiple times a week and who cares etc. 99.9% survival talking point...
Anyway, I am praying we begin to see a slowdown in hospitalizations; Louisiana appears to possibly heading in this direction, perhaps Texas/Houston will follow

 

[Mount Asclepius]

....this thing is going to circulate over and over and over for years and decades until we all have good enough immune systems to make the symptoms mild. I bet this is exactly what all viruses (flu, measles, etc) did when they were introduced into the human race.

Agree. Felt this way from the start. Yet, we’ve acted like this was novel from the beginning. History repeating itself.

 

[rokshana]

What’s the vaccination rate there in NZ, and do they have the same vaccines as western countries or is it the Chinese or Russian version?

Actually their vaccination rate is pretty low…20-30%?

 

[Birdstrike]

I don't know anymore. I honestly would be happy if we completely suspended our cultural tradition of shaking hands and having everyone wear masks to prevent spread. Those seem like very reasonable and unobtrusive steps. But yea....this thing is going to circulate over and over and over for years and decades until we all have good enough immune systems to make the symptoms mild. I bet this is exactly what all viruses (flu, measles, etc) did when they were introduced into the human race.

I'm still a believer that once we have good data, it's going to show that vaccination reduces spread. It's just hard to study right now. But if it did, I don't think it will ever be by a substantial amount.

Agree on the slaking hands part and data showing vaccination reduces spread, at least some.

 

[Birdstrike]

.


A re-opening plan is in place for early 2022, which initially is still fairly restrictive in terms of minimising and controlling the number of cases entering New Zealand and spreading in the community – but expects to control/reduce spread primarily through vaccination uptake, rather than stringent lockdowns. As we've seen, though, the world of COVID turns on its head fairly frequently....

I’m not questioning what NZ is doing, as they should do what works for them.

But I thought NZ’s goal was “lockdowns until total viral elimination.” And that seems impossible now if the vaccinated spread the virus in significant numbers, which we know they do. Then add in asymptomatic spread and it seems doubly impossible.

 

[ER BlueBlood]

Actually their vaccination rate is pretty low…20-30%?

I’m sure the google billionaire who was given special treatment to reside in NZ will track all of them lol

 

[xaelia]

Makes sense, but I thought NZ’s goal was “lockdowns until total viral elimination.” And that’s got to be impossible if the vaccinated spread the virus, wouldn’t it be?

There was a pretty good press conference a couple weeks back detailing the rationale, the balance between business and health interests, etc. The hope is generally the widespread vaccination program reduces the R-value for SARS-CoV-2 below 1, and that, combined with stringent entry criteria, will reduce morbidity and health system burden.

 

[Birdstrike]

There was a pretty good press conference a couple weeks back detailing the rationale, the balance between business and health interests, etc. The hope is generally the widespread vaccination program reduces the R-value for SARS-CoV-2 below 1, and that, combined with stringent entry criteria, will reduce morbidity and health system burden.

I don't know who you get the R value below one with vaccine alone, when those vaccinated are spreading it with viral load as high (or close) as those unvaccinated. But, what do I know. I'm just some dummy on the internet that says stuff.

 

[MechEDoc]

There was a pretty good press conference a couple weeks back detailing the rationale, the balance between business and health interests, etc. The hope is generally the widespread vaccination program reduces the R-value for SARS-CoV-2 below 1, and that, combined with stringent entry criteria, will reduce morbidity and health system burden.

Good luck with that. I can't imagine the r-value dropping below 1. Vaccinate your population, build up health care resources, and then open the flood gates is my view. Look at Iceland's experience. Highly vaccinated, lots of COVID, low morbidity, low mortality and you don't have to live like you're in a penal colony.

 

[xaelia]

Good luck with that. I can't imagine the r-value dropping below 1. Vaccinate your population, build up health care resources, and then open the flood gates is my view. Look at Iceland's experience. Highly vaccinated, lots of COVID, low morbidity, low mortality and you don't have to live like you're in a penal colony.

Yes – Iceland, Singapore, etc. are models for the re-opening.

We're just behind them on vaccination.

 

[WilcoWorld]

Good luck with that. I can't imagine the r-value dropping below 1. Vaccinate your population, build up health care resources, and then open the flood gates is my view. Look at Iceland's experience. Highly vaccinated, lots of COVID, low morbidity, low mortality and you don't have to live like you're in a penal colony.

Penal colony is a pretty funny comparison to make for New Zealand
Was that on purpose?

 

[bravotwozero]

What do you guys think the odds are of a fifth wave with lambda after delta clears?

I sure hope not because I’m frankly just tired, but still it’s something worth considering…

 

[skougess]

What do you guys think the odds are of a fifth wave with lambda after delta clears?

I sure hope not because I’m frankly just tired, but still it’s something worth considering…

100%. That’s why the time is now to decide if we are going to play with endless lockdown game or just say **** it, the free effective vaccine is there if you want it.

 

[thegenius]

What is all this talk about lockdowns? What areas are doing lockdowns?

 

[Porfirio]

Anyone looked into the ROI in funeral homes? Just curious…

 

[ER BlueBlood]

Private Equity is all over those as well, def good returns

Anyone looked into the ROI in funeral homes? Just curious…

vate

 

[deleted875186]

If the goal is to "save lives" with these measures, then the deaths/million people is probably the best comparison:

States with early/strict Lockdowns/mask rules
New York - 2787
California - 1628
New Jersey - 2994
Michigan - 2119
Illinois - 2045

States without strict measures
South Dakota - 2309
Georgia - 2039
Texas - 1840
Florida -1808
Utah - 763

The numbers seem comparable to me. I picked the states with the most egregious/notorious lockdown rules and compared them with CNN's list of villain states. Michigan in particular is a standout to me for anti-freedom nonsense that didn't save lives.

Use your brain, these states have different environments, New York City people are living on top of each other, age of population is different in each state, lots of other factors such as when they had surges and when public health measures were implemented, not to mention how compliant people were to follow masking mandates, I don’t think you can just read off numbers as if they tell the whole story.

 

[Dr Mantis Toboggan]

Use your brain, these states have different environments, New York City people are living on top of each other, age of population is different in each state, lots of other factors such as when they had surges and when public health measures were implemented, not to mention how compliant people were to follow masking mandates, I don’t think you can just read off numbers as if they tell the whole story.

These double vacc’d admits and deaths are a major bummer. For those not seeing them yet, I fear you will very soon.

 

[ER BlueBlood]

These double vacc’d admits and deaths are a major bummer. For those not seeing them yet, I fear you will very soon.

Hearing Israel is getting dicey, not a great sign. Can you elaborate on any data you are seeing?

I hope Gottlieb is right here:

Dr. Scott Gottlieb says the delta variant-fueled Covid surge in the American South has peaked

Former FDA chief Dr. Scott Gottlieb told CNBC it's "pretty clear" Covid cases in the South are rolling over.

www.google.com

 

[Dred Pirate]

Wayne hospital denies rumor that undocumented immigrants, Afghan refugees in COVID unit

A rumor circulating about Wayne UNC Health Care is untrue, according to a spokesperson with UNC Health.

www.wral.com

i love the spokemn's response

 

[MechEDoc]

Hearing Israel is getting dicey, not a great sign. Can you elaborate on any data you are seeing?

I hope Gottlieb is right here:

Dr. Scott Gottlieb says the delta variant-fueled Covid surge in the American South has peaked

Former FDA chief Dr. Scott Gottlieb told CNBC it's "pretty clear" Covid cases in the South are rolling over.

www.google.com

I would like to think that this wave will peak faster and drop off just as fast. The vulnerable population / area under the curve will remain the same, but with a R0 in the 7-8 (delta) range vs ~3 (alpha), then the growth rate is amazing.

Take ten transmission cycles.
R0 3 total affected after ten cycles should be 3^10=59,049
R0 8 total affected after ten cycles should be 8^10=1,073,741,824

Probably lots of lower risk folks are asymptomatic of minimally symptomatic and aren't using health care resources, but we're still seeing lots of people due the increased transmissibility.

 

[bravotwozero]

Pretty much every day in the ED down here:

 

[Birdstrike]

Why are they letting Delta burn through the population when they can have a variant-specific vaccine ready to go in 95 days?

"We have built a process that within 95 days from the day that we identify a variant as a variant of concern, we will be able to have a vaccine tailor-made against this variant," Bourla said.

Delta was raging in India over 120 days ago and has been raging in USA for over 30 days. Yet there Delta specific trials are slated not to be ready until 2022.

 

[southerndoc]

That's interesting that they can have a tailor-made vaccine ready in 95 days, but they are delaying trials. I would prefer that I get a Delta-specific booster if possible.

 

[Birdstrike]

...interesting that they can have a tailor-made vaccine ready in 95 days, but they are delaying trials.

It sure is, isn't it? Maybe I'm not looking in the right places, but I haven't seen or heard anyone else question this. "We can have a vaccine tailor made for any variant in 95 days."

But Delta was killing over 4,000 people per day in India, more than 95 days ago?

And Delta has been present in USA more than 95 days ago (May, actually)?

Why exactly am I seeing no one else question this?

 

[bravotwozero]

Bacterial superinfection detected in 21% of patients with COVID-19 pneumonia

not surprised, but still...thought that number would be a lot higher.

 

[Birdstrike]

Bacterial superinfection detected in 21% of patients with COVID-19 pneumonia

not surprised, but still...thought that number would be a lot higher.

I'm also surprised it's not higher.

 

[Dr Mantis Toboggan]

Bacterial superinfection detected in 21% of patients with COVID-19 pneumonia

not surprised, but still...thought that number would be a lot higher.

Reasonable to use procalcitonin in the ED? If low, no abx?

 

[bravotwozero]

Reasonable to use procalcitonin in the ED? If low, no abx?

I’ve seen a good number of docs use this approach but not my practice as of yet.

If procalcitonin is negative, how confident would you feel in saying there’s no bacterial super infection? I honestly have no idea. Is this procalcitonin test like the d dimer of bacterial infection rule outs?

 

[southerndoc]

I’ve seen a good number of docs use this approach but not my practice as of yet.

If procalcitonin is negative, how confident would you feel in saying there’s no bacterial super infection? I honestly have no idea. Is this procalcitonin test like the d dimer of bacterial infection rule outs?

It's not 100% (like anything else in medicine), but it's pretty reliable. I always give them the first dose of antibiotics when admitting just because it takes quite a few hours to get back.

 

[Dred Pirate]

It's not 100% (like anything else in medicine), but it's pretty reliable. I always give them the first dose of antibiotics when admitting just because it takes quite a few hours to get back.

This is exactly what we do if evidence for bacterial infection - usually for COVID our ED docs don't give abx but our intensivits and hospitalists do. Honestly in the past when the rate was low, we all thought vanc + cefepime for every covid pt was excessive.

 

[Mount Asclepius]

I routinely obtain procals in the ED and get back them back quickly. I don't treat with antibiotics in patients with COVID-19 if absence of productive cough, classic diffuse viral-appearing CXR findings, no leukocytosis and normal procalcitonin.

I've seen procal normal in localized contained infections. You'll often see a normal procal with cellulitis, abscesses and empyemas. The other scenario is early during a patient's disease course. I'm not sure there is benefit to empirically treating with antibiotics until they develop the bacterial infection.

I think of procalcitonin more so as if it's normal then very unlikely bacterial infection, early or contained, but if elevated then highly consider bacterial infection.

Like many lab tests, I think it benefits from trending. The inpatient side will often trend out at least a second one.

 

[Neopolymath]

Reasonable to use procalcitonin in the ED? If low, no abx?

Just a resident but I was taught to use procal as as a tool to support continuing/discontinuing antibiotics but not for initiating them. Maybe I missed something?

 

[thegenius]

Just a resident but I was taught to use procal as as a tool to support continuing/discontinuing antibiotics but not for initiating them. Maybe I missed something?

Last I checked procal was not validated to be used in the ED

 

[xaelia]

Just a resident but I was taught to use procal as as a tool to support continuing/discontinuing antibiotics but not for initiating them. Maybe I missed something?

You missed the marketing teams coming 'round to sell you the assay and devices.

 

[wholeheartedly]

It sure is, isn't it? Maybe I'm not looking in the right places, but I haven't seen or heard anyone else question this. "We can have a vaccine tailor made for any variant in 95 days."

But Delta was killing over 4,000 people per day in India, more than 95 days ago?

And Delta has been present in USA more than 95 days ago (May, actually)?

Why exactly am I seeing no one else question this?

I’d also prefer a variant specific booster.

We knew mRNA vaccines could be adapted much faster to new variants which is good.

I wonder if this is because of some combination of still needing something like FDA approval for the updated formulation (likely a more abbreviated process), maybe things will be different with full approval now.

Could it also be that the efficacy, though very reduced, is still above the minimum FDA said was needed when developing a vaccine?

More likely its probably some political and logistical juggling given the boatload of the current vaccine we already have out there that

 

[thegenius]

I’d also prefer a variant specific booster.

We knew mRNA vaccines could be adapted much faster to new variants which is good.

I wonder if this is because of some combination of still needing something like FDA approval for the updated formulation (likely a more abbreviated process), maybe things will be different with full approval now.

Could it also be that the efficacy, though very reduced, is still above the minimum FDA said was needed when developing a vaccine?

More likely its probably some political and logistical juggling given the boatload of the current vaccine we already have out there that

I wonder if the FDA would say something like this.
"We test the first mRNA vaccine and we have proof that the proteins encoded by the mRNA don't cause any problems."

"There is always the possibility that putting different mRNA into the vaccine would encode proteins that are deleterious for the host."

"ergo, we need to study it."

 

[wholeheartedly]

I wonder if the FDA would say something like this.
"We test the first mRNA vaccine and we have proof that the proteins encoded by the mRNA don't cause any problems."

"There is always the possibility that putting different mRNA into the vaccine would encode proteins that are deleterious for the host."

"ergo, we need to study it."

Even annual flu shot updates for the coming years circulating strains require the manufacturer to submit an FDA application.
i don’t know how complicated or time consuming that process is.

 

[turkeyjerky]

Wait, hold on. Are you guys all giving routine abx to covid admissions? Are there guidelines or evidence supporting this?

I had thought that, basically since 1-2 mo. into the pandemic, the evidence supported the notion that bacterial superinfections were relatively uncommon and typically a late occurrence? Did I miss something? (I'm not sure that the healio study mentioned above is practice changing. Who knows what the significance of a +BAL truly is sometimes)

(Just looked it up on uptodate and my practice is basically concordant w/ their recommendations, not sure if there's new evidence or not though)

 

[bravotwozero]

Wait, hold on. Are you guys all giving routine abx to covid admissions? Are there guidelines or evidence supporting this?

I had thought that, basically since 1-2 mo. into the pandemic, the evidence supported the notion that bacterial superinfections were relatively uncommon and typically a late occurrence? Did I miss something? (I'm not sure that the healio study mentioned above is practice changing. Who knows what the significance of a +BAL truly is sometimes)

(Just looked it up on uptodate and my practice is basically concordant w/ their recommendations, not sure if there's new evidence or not though)

I had been giving 1 dose of zithromax and rocephin on admission, and treating it like a community acquired pneumonia...

 

[turkeyjerky]

I had been giving 1 dose of zithromax and rocephin on admission, and treating it like a community acquired pneumonia...

But why, is my question? Is this something I should be doing, or can I safely continue to ignore/disparage people who do this (I used to work w/ a few docs who would given all discharged flu patients abx b/c of the risk of 'superinfection'. I was pretty comfortable making fun of them behind their backs...)

Historical practice, personal preference, institutional culture/protocol? My system still has some weird protocol for checking Ab titers and giving convalescent plasma if negative, so I understand the latter (I think they must still be sitting on a stockpile or something...)

 

[southerndoc]

But why, is my question? Is this something I should be doing, or can I safely continue to ignore/disparage people who do this (I used to work w/ a few docs who would given all discharged flu patients abx b/c of the risk of 'superinfection'. I was pretty comfortable making fun of them behind their backs...)

Historical practice, personal preference, institutional culture/protocol? My system still has some weird protocol for checking Ab titers and giving convalescent plasma if negative, so I understand the latter (I think they must still be sitting on a stockpile or something...)

I give it for multifocal pneumonia that I'm admitting (O2 sat <88%). I don't give antibiotics like for the COVID diarrhea that was so dry his creatinine was 11.

 

[Mount Asclepius]

I agree distinguishing between viral and bacterial pneumonia can sometimes be challenging. Many of these clearly fit a viral presentation though and I don't think there is good evidence to treat many of these viral pneumonias with empiric antibiotics just because they are sick or critically ill. When I follow their hospital courses, most at our institution aren't ever treated with antibiotics. A select few develop signs of a superimposed bacterial infection and are subsequently treated. It seems it's usually the bounce back following admission where they have complications such as superimposed bacterial pneumonia or PE.

 

[Dr Mantis Toboggan]

I’m not. I was but I quit doing it if it’s just obvious old school covid.

Wait, hold on. Are you guys all giving routine abx to covid admissions? Are there guidelines or evidence supporting this?

I had thought that, basically since 1-2 mo. into the pandemic, the evidence supported the notion that bacterial superinfections were relatively uncommon and typically a late occurrence? Did I miss something? (I'm not sure that the healio study mentioned above is practice changing. Who knows what the significance of a +BAL truly is sometimes)

(Just looked it up on uptodate and my practice is basically concordant w/ their recommendations, not sure if there's new evidence or not though)