As I write this at the tail end of August, 2020, we’re now almost nine months into the COVID-19 pandemic, and six months since our first case was identified in New Hampshire. There have been around 7,000 documented infections in our state, with over 400 deaths. According to NH Department of Health and Human Services (DHHS) and CMC data, around 10% of those found to be infected have required hospitalization, and nearly 30% of those patients have been admitted to CMC. Our in-hospital mortality rate of approximately 25% reinforces the observation that this is a serious, life-threatening illness, even as we have become better at .jpg.aspx?width=350&height=233)
treating it and its complications.
In contrast to where we started, when we had literally nothing in our armamentarium, we now have two treatments that have been clearly demonstrated to alter the course of this disease. The antiviral remdesivir has been shown to significantly decrease the time to recovery in those patients with severe infection, although a mortality benefit was not proven. Still, getting patients off of oxygen and out of the hospital an average of four days sooner is a sizeable benefit. The key to being able to realize this benefit is understanding that nearly every patient with COVID-19 who requires oxygen may be a candidate for treatment, and then making a request for either pulmonary or infectious disease consultation.
The second medication which did show a mortality benefit is dexamethasone.The authors of the RECOVERY trial need to be commended for pursuing this when the early advice from many of us was to avoid steroids. Any patient requiring oxygen because of their infection may potentially benefit from this treatment, the effects of which were particularly striking among those requiring mechanical ventilation (29.3% mortality with dexamethasone vs 41.4% mortality without it).
Still being evaluated are convalescent plasma (for more severe cases) and interleukin-6 inhibitors and similar biologic agents, meant to block the “cytokine storm” that can accompany the infection. However, I have doubts whether any these treatments will significantly alter the mortality curve of the pandemic at large. While early attempts at treatment included such off the shelf medications as hydroxychloroquine and azithromycin, the results of several, randomized controlled trials have failed to demonstrate any benefit from these agents, which have consequently been removed from our treatment protocols.
There are multiple SARS-CoV-2 vaccine trials currently underway, some entering Phase 3. Earlier results showed excellent antibody responses (better than what is typically seen following natural infection), and the side effect profiles have been acceptable. We hope to have some data from at least a couple of the trials by mid-fall, 2020. However, scaling up production and then distributing the vaccine to the population would likely take at least six months, meaning that our hopes for a vaccine for this current school year will almost certainly not be realized.
While we understand a lot more about the epidemiology of this disease, there are still many unanswered questions (such as the role of potential airborne spread). However, we now know that a significant proportion (probably in the neighborhood of 30-35%) of patients remain asymptomatic, but can transmit the infection. Additionally, there is very strong evidence that universal wearing of face masks can prevent transmission. Early on in the pandemic, there was a critical shortage of masks, so public health authorities didn’t embrace this strategy, choosing instead to focus on protecting healthcare providers and first responders. We’ve now had to work particularly hard to regain the public’s trust, but I’m encouraged by what I see when I go to the grocery store!
We also know that patients with COVID-19 do not appear to transmit the infection past 10 days from symptom onset (we use a 20-day time frame for severely ill patients and those who are immunocompromised, to be on the safe side). Even though viral RNA can be detectable in recovered patients for up to three months following infection, we have not been able to recover infectious virus in these individuals (past 10 days), and there is no clear evidence that any of them has been re-infected. How long this immunity will last is another area of debate, but recent evidence shows longer-lived T-cell responses may provide protection against reinfection for many months, and SARS-CoV-2 doesn’t mutate nearly as fast as does influenza virus, so there’s reason for hope.
Which brings me to my last point. As we enter the fall and flu season nears, it is incredibly important that all of us, and all of our patients, be immunized against influenza. CDC director Robert Redfield has warned that we may be in for the “worst fall…we’ve ever had.” Remember, two of the most common symptoms of the flu are pretty much indistinguishable from those of COVID-19 (fever, cough), so every healthcare worker, every teacher, every student, every restaurant worker, etc., who falls ill with the flu will need to be tested for COVID-19, or be quarantined (a positive flu test doesn’t rule out co-infection with SARS-CoV-2). It’s also critically important that we do what we can to keep our hospitals emptied of flu patients, in case we see a second wave of COVID-19 as our schools and colleges open back up.
We’ve made remarkable progress in caring for those with COVID-19, and everyone here at CMC deserves congratulations for their efforts, professional attitude and camaraderie. Keep up the good work, don’t lose hope, and we’ll get through this!