December 30, 2020

I was going to write the next one of the Accidental Plague Diaries tomorrow and reflect on New Year’s Eve and the end of 2020 but the news that’s been pouring in all day locally has been such that I am compelled to let me fingers dance across the keyboard an evening early while I try to wrap my head around it. We’re going up in proverbial flames and I feel like I have a cracked and ancient squirt gun with which to beat them back.


Let’s start with UAB, my home institution. I try to be circumspect in what I say about work but sometimes the word does have to get out. Six months ago, at the summer peak, UAB hospital had about 100 inpatients with a Covid diagnosis, then, as the pandemic came under control, this dropped to about 65 inpatients at a time. With the current surge, fueled by Thanksgiving travel and spread from domestic contacts, UAB has much larger numbers with even higher numbers expected throughout the next few months. We’re a strong and resilient institution with some of the best facilities and personnel on the planet but there’s only so much we can do. Nursing school faculty and students have been pressed into service. I’m on the volunteer list to be called in despite the fact that I haven’t practiced inpatient medicine since the last millenium and don’t even know how to work the inpatient charting system. However, it’s my duty and my call as a physician to be part of the team if they need me.


For most of my time during the pandemic, I’ve been able to help buck my patients up through lockdowns and quarantines and I was relieved that relatively few of them became ill. I had a few here and there who did. Some were miserable and recovered. Some were barely affected. A few were hospitalized. Two or three died. This past few weeks, it has been different. I’ve been fielding calls about diagnoses in my long term patients three or four times a day. I lost four over the holiday weekend. I know of about ten scattered around various regional hospitals. There’s not much of anything I can do for them other than wait. I’m not much of a one for prayer in general but I think a great deal about them and their families and what they are going through. My patients have mainly been at home. They’re pretty compliant with masks and other basic safety measures. Almost all of them have gotten ill at home because of a younger family member coming into the house who hadn’t been as vigilant.


In the state of Alabama, there were slightly over 5,000 new cases of Covid diagnosed today per the Department of Public Health. This was out of just over 7,000 tests administered for a positivity rate of 71%. This means that pretty much only symptomatic people were being tested and we have not been able to even begin testing asymptomatic carriers to tell where the disease is spreading. Today may be an aberration, but the rolling average for the last week is 41% which is still horrific. In order for a pandemic to be controlled, positivity rate needs to be routinely and reliably under 5% and when it’s over 10% most public health authorities state it’s time to take drastic measures. I haven’t heard a peep out of the governor or ADPH recently and I doubt most of the rest of the public has either. With this kind of wide spread, the numbers of acutely ill are going to keep increasing to the point where the health system simply can’t handle it, but flatten the curve is so April. We’ve moved on.


But wait, we have a weapon, a vaccine! Alabama has been allocated 128,000 doses in its initial shipments. There are 300,000 Alabamians in the highest priority group (health care workers and long term care facility residents). More vaccine is promised but we’ve still got a major distribution problem. As of today, only 20,354 vaccines have been administered since the first Pfizer vaccines became available on December 14th. That’s only about 1,200 vaccines a day. At that rate we’ll have the first priority group done around Labor Day. From what I can tell, vaccines are getting to the state from manufacturing plants but, as the federal government has basically abandoned its role in further distribution to the state level, which has neither the expertise nor the systems to take on so mammoth a project, things are, shall we say, slow to roll out. The holidays, of course, aren’t helping. There are those who say it can’t be done any faster. To them, I point to the fact that in 1947, New York City was able to vaccinate all 5 million of its residents for small pox in about a month. It can be done, but without effective leadership it’s like recruiting a thousand volunteers to your search and rescue operation and then not supplying them with maps and just telling them to look where they feel like.

The new variant that was first discovered in England has seeded in this country with case reports from both California and Colorado. Fortunately, it doesn’t appear to cause any worse clinical disease and is as susceptible to the vaccine as prior strains but it is more transmissable. The most recent figures from England suggest that it is 56% more transmissable than the usual. This doesn’t seem like much. For instance, measles is about 1200% more transmissable than Covid, but our brains, which are wired for nice linear math, don’t really get what exponential numbers do until we’re being overwhelmed by them. Let us say I have a population of 100 people with Covid and, for sake of argument and easy math, the disease has a transmissability of 1.0 (its R0 figure) meaning each person can tansmit the disease to one other person. Let us say then that they are no longer infectious so our original cohort of 100 infects 100 more who then infect 100 more and so on. At the end of ten cycles of this, there will be ten infected cohorts or a total of 1,000 infected people. If we up the R0 to 1.56, which is the difference between the two strains, our initial cohort infects not 100 people, but 156 people. These 156 then infect 1.56 times as many or 243. After ten cycles of this, you don’t end up with 1,000 infected people, but rather 15,000 infeccted people. This new strain is not good news and, as we have decided to abandon most mitigation strategies for the holidays, watch out.


I think that’s enough math for this evening. The more I consider this, the more I just want to pour myself another eggnog and bury my head under the pillow.

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