I represent an emergency room doctor in a lawsuit over the death of a patient with classic signs and symptoms of COVID-19. I have been following the data and science on the novel coronavirus, as suggested by the medical experts.
As we lawyers know, we never looked at the world the same after law school. We learned never to accept opinions and conclusions at face value. In today’s digital and electronic world, we are inundated with medical information, some reliable, some spun to serve a personal or political agenda.
I read the daily coverage of COVID-19 information in the New England Journal of Medicine and the Johns Hopkins Center for Health Security website (accessible for free at www.centerforhealthsecurity.org). And I listen to interviews of the experts on TV and the web, but I still have a lot of questions. I can’t call Dr. Fauci or the authors of many of the articles I’ve read, but I have had the opportunity to work with some of the brightest minds in medicine.
I called Michael Pinsky, Professor of Critical Care Medicine and Director of Cardiopulmonary Research at the University of Pittsburgh School of Medicine. I talked with him in January just before the sharp down-turn in COVID-19 cases and deaths. “The numbers are terrible for the elderly,” he said sadly. “A 70-year-old who gets COVID-19 has about a 1 in 30 chance of becoming symptomatic enough to require hospitalization. Of those 70 and older, about 25% develop severe hypoxemia [low blood oxygen] requiring ICU care, and a third of those require mechanical ventilation. We know the mortality rate is greater than 50% for ventilated patients.”
His advice? “Get the vaccine now, get a booster when scheduled, and upgrade your cloth mask.” I spoke with him recently to get his take on governors rescinding state-wide mask mandates. “It’s too damn early,” he said in a pained voice. “Pray for our country,” he added.
I called Dr. Bruce Farber, Chief of the Division of Infectious Diseases, and the Jane and Dayton Brown Professor of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell.. I asked him about an NPR report that Germany, France, and Austria, fearing new variants, were introducing rules and recommendations urging their citizens to wear N95 masks in public and confined spaces. “If you want to protect yourself, as well as others, buy an N95 mask, and make sure it’s not a knockoff,” he responded.
Dr. Farber is not optimistic about herd immunity by early summer, as some have predicted. “There are too many people hesitant to get vaccinated,” he said dismayed. “People of color, persons in the military, and surprisingly our own health care workers are sitting on the sidelines.” On March 3, 2021, an article in the New England Journal of Medicine (NEJM) analyzed “39 nationally representative, randomized polls,” and issued a warning that a substantial number of Americans are “currently undecided” about taking the COVID-19 vaccine.
Let’s assume you’re in that group of seniors 65 and older and queued up for the vaccine, are you out of the woods? Not sure yet, but Dr. Pinsky feels early research is promising. “Of the elderly vaccinated patients, sickened by COVID-19, none have progressed to hospitalization.” The CDC tracks age and mortality. This information is what the experts like Dr. Fauci call data. The CDC graph illustrates that individuals 65 and older are at a greater risk of death. Doctors are thrilled by the early results of all three company’s vaccine trials. Infected patients don’t progress to hospitalization and death. Less promising was the data on efficacy for seniors, though the experts were elated by the elderly’s immune response to the COVID-19 vaccines. “It’s certainly much better than the response of people 65 and over to the influenza vaccinations, but there is room for improvement,” Dr. Farber observes. “We know that immune function declines with age.”
The CDC also tracks age and underlying health conditions. Heart disease, chronic lung disease, and diabetes significantly raise the risk of dying from COVID-19. The CDC graph compares individuals with and without comorbidities. Currently, the data involves unvaccinated people, but it reveals an interesting statistic about aging. Individuals 60 to 69 years of age between January 22nd and May 30th with underlying health conditions accounted for 16.7% of COVID-19 deaths. Those same individuals with no comorbidities accounted for 2.4% of COVID-19 deaths. In the next age bracket, 70 to 79, 31.7% with comorbidities died from COVID-19, while only 10.2% without underlying disease died. Staying active and healthy has a protective benefit.
One of the highest-risk areas where most people don’t wear a mask is in their home. Jack Kelly, an emergency room doctor in the Einstein Healthcare Network and Professor of Emergency Medicine at the Sidney Kimmel Medical College, says he sees many people infected with COVID-19 contracted at home. “Be careful who comes into your home,” he warns. In his experience, “in-door environments are the most unrecognized threat for COVID-19 infections.” On March 8th, the CDC released guidelines suggesting that people fully vaccinated against COVID-19 can now gather together in their homes. This is great news, but Dr. Kelly says there are two wild cards yet to play out: it’s unknown whether fully vaccinated people unknowingly transmit the virus; and whether new variants will circumvent the vaccine. Dr. Kelly remains cautious and states “this opportunistic virus feasts in confined spaces, restaurants, offices, and our homes.”
When I called Dr. Kelly to interview him for this article, he questioned why I limited the target audience to 65 and over. Dr. Kelly works in the ICU as well as the emergency room. People 55 and older are nearly as vulnerable as the 60-to-70-year-olds he told me. And obesity leads the march of underlying health conditions sending patients to the morgue.
Vaccines are not a cure. Vaccinated patients can still get infected. They may get sick but are unlikely to require hospitalization or die. Dr. Pinsky foresees Americans wearing masks in public into late fall, “at least until we vaccinate a minimum of 80% of the population, the number needed to ensure herd immunity.” As of March 9th, a little over 32 million people have been fully vaccinated. Our current population is estimated at 330 million which means we need a combination of COVID-19 survivors and people fully vaccinated to reach herd immunity—around 260 million people. After we reach herd immunity, “COVID-19’s evolutionary biology predicts future management will require yearly shots to protect against new strains of the virus,” Dr. Pinsky believes.
What to do?
Many experts are suggesting double mask. The “CDC conducted experiments to assess two ways of improving the fit of medical procedure masks: fitting a cloth mask over a medical procedure mask, and knotting the ear loops of a medical procedure mask and then tucking in and flattening the extra material close to the face. Each modification substantially improved source control and reduced wearer exposure.” The quality of medical procedure masks varies. Higher-grade surgical masks are manufactured with the tuck in place. Double-mask should serve as suitable protection in high-risk areas.
Restaurants? The wise will not go to indoor restaurants until you and your companions are vaccinated. Ventilation is the problem.
Vaccination is the only way out of this pandemic. But why are infectious disease specialists saying we must still wear masks? The jury is still out on whether vaccination prevents asymptomatic transmission of the virus. In addition, “for those people who are immunosuppressed due to organ transplantation, cancer chemotherapy or any treatment for the many other autoimmune diseases, the level of immunity from the vaccine may be less than was reported from the initial studies. These folks need to continue to be very careful until we know more, including anyone over 65,” Dr. Farber says.
The early data is mixed on the threat of the UK Variant. Experts worry that a 4th wave may hit this fall, spurred by new variants and mutations attacking the unmasked and unvaccinated. Just as troubling are the concerns that the current vaccines will not be as protective against the threat of a new variant.
Best current advice? Get the vaccine, upgrade your mask, gather with friends and family wisely, and stay vigilant.
