Update, Friday, Nov 19: On Friday the FDA authorized both the Pfizer and Moderna boosters for all adults. The decision came after many states had already moved on their own to recommend the shot.
Original Story, Thursday, Nov 18. At Thursday’s Yale New Haven Health System Covid press conference, chief clinical officer Dr. Tom Balcezak talked about boosters, masking and vaccinating school children, as well as new drugs, including the oral anti-viral pill.
As of Thursday there were 72 patients Covid-positive in-patients across the health system’s five hospitals, including 16 in ICU units, with nine of them on ventilators. A year ago there were 321 in-patients.
“Clearly the work around vaccines has had an impact,” Balcezak said. Still, he referred to a “stubborn set of numbers” that are not decreasing in terms of in-patients.
The number of inpatients across the health system has been in the 50-72 range for weeks, and 90% of the in-patients have been unvaccinated.
He said the good news was that Connecticut leads the nation in terms of percentages of people over the age of 12 who are vaccinated, with 82% vaccinated.
He said vaccinations remain the best way to prevent illness, hospitalization and death.
“It’s not a panacea,” he said. “It doesn’t prevent it but it reduces the risk substantially.”
Connecticut is experiencing an increase in case numbers and positivity rate, but despite some evidence that over time immunity from the vaccine does wane slightly – hence the reason for the booster – but that’s not what is driving hospitalizations.
“What’s driving hospitalizations are the unvaccinated. Again, 90% of admissions and almost all of our severe illness in hospital is driven by folks who are unvaccinated.”
Balcezak said his personal opinion was that it was better to wait for the CDC and FDA authorization and approval for boosters before their broad release.
“We are providing boosters to certain populations through the Yale New Haven Health System – to individuals in high risk categories, above age 65+ or in high risk occupations,” he said. “There are some we know who have not been truthful answering those questions and have gotten boosters, and that’s probably okay. We have plenty of vaccine available and we know it’s safe and effective, but before we open up for widespread use by everybody, I think we should probably wait for that FDA clearance.”
Waning Efficacy, Booster Shots
Balcezak talked about breakthrough cases and vaccine efficacy after six months, noting it has been determined that over time the the risk of breakthrough infections increases.
“Israel is one of the most vaccinated places on earth, and they got their population vaccinated earlier than the rest of the world,” he said. “From that evidence it’s been determined that over time the protection conveyed by the vaccines does slightly go down.
Still he said, although efficacy does slightly wane, people remain protected from severe disease. Second, he said the waning was the reason boosters were recommended.
Balcezak said it was not unusual that protection or immunity from many vaccines wanes over time. For example, he said Tetanus vaccine a booster is required every ten years.
While Connecticut leads in vaccination rates, the state trails other states with percentage who have had booster shots. In Connecticut 82% of the population age 12+ are vaccinated, but just 18% of the population have had a booster.
Balcezak said, “I don’t understand why we are the most vaccinated state in the nation, and yet we’re slow to get boosted,” Balcezak said. Maybe it’s because the FDA hasn’t cleared boosters for everyone. Maybe we’re rule followers here in the Nutmeg state, and we’re waiting for regulatory agencies to say it’s okay. Once they do, I think you’ll see a lot more people go out and get it.”
Pediatric Vaccines, Masking School Children
The Yale New Health System has vaccinated over 3,500 children between age 6 and 11 for Covid-19. Soon they will be administering second doses to this age group.
With children getting vaccinated, Balcezak was asked when masking requirements might be dropped for school children.
“We don’t have enough penetrants into that population 6-11 to say that population is protected. If you look at the testing within the Yale New Haven Health System, the majority of our positive tests are in kids 6-11 because up until a short while ago they weren’t able to be vaccinated.”
“Unless and until we get the majority of those kids vaccinated I don’t think we can talk about taking masks off in schools,” he said. “I know it’s controversial, but I’m giving it to you from a scientific medical perspective.”
“The vaccine is protective to kids and the side effect profile is extremely low,” Balcezak said. “Remember, long term side effects of Covid-19 in children is pretty substantial.”
There are a number of side effects that can happen to children who contract Covid-19, including long Covid and the Multisystem inflammatory syndrome in children (MIS-C).
“Protecting a child with a vaccine also protects against long term side effects, whereas there are almost no long term side effects from the vaccine,” Balcezak said.
Pfizer Request for FDA Approval of Oral Anti-Viral Pill, “PAXLOVID“
Balcezak said there is limited data that shows the pill, PAXLOVID, decreases the viral load in people, and would be likely be given to patients with mild disease before they are hospitalized. The Yale New Haven Health System may change their treatment protocol for in-patients to include PAXLOVID.
“Already we have the monoclonal antibody, which has been demonstrated to reduce severe Covid,” he said.
“It’s appearing that if given in a certain time frame, this has a big impact on hospitalization, but vaccines are still important,” he said.
Thanksgiving and Covid-19
Balcezak said there has been a small, 7-10% increase in Covid in Connecticut in recent weeks. And while the current Covid numbers are far lower than a year ago, concerns are that in the coming weeks is that as it gets colder, people will gather indoors and humidity levels will fall, resulting in more transmissibility of the virus.
“With the holidays coming, as people come from out of town to Connecticut, because we are the most vaccinated state in the nation, we will dilute our population with folks who are less likely to be vaccinated,” he said.
A Crush of Patients
Yale New Haven Health president Christopher O’Connor said the health system had never been busier, and referred to a crush of patients.
He said it was difficult to discern what was attributable to pent up demand and what was the result of new onset illness, but he said the busy trend was nationwide.
In addition to being busy with patients, he said it was taking longer to fill jobs.
“We have an unprecedented vacancy rate withing the system. We have over 3,500 open positions. Like other industries we’re seeing workforce hires are taking longer,” O’Connor said. “Our staff is tired. And, to be candid, exhausted.”
He said whereas in the past, staff might be more willing to pick up extra shifts, after two years of the pandemic, that was difficult.
Fluvoxamine
A Wall Street Journal article suggested that Covid-19 patients taking the anti-depressant Fluvoxamine, an SSRI, were less likely to require hospitalization than those who didn’t.
“In a world where we have very few effective treatments, any little piece of information, knowledge or improvement in outcome is interesting to study and understand why,” he said. “But remember, we have an incredibly effective tool to prevent it in the first place.”
Three Layers of Protection: Masks, Vaccination and Testing
Balcezak said continuing mask mandates were one of three “layers of protection.”
“If you can do two of things, you’re pretty well protected. If you do none of those things, then you’re exposed. You have two choices: Either get vaccinated or you’re going to get Covid. It’s just a matter of time.”
He said the good news was that the majority of Covid infections for vaccinated people were relatively benign and the mortality rate was between 1% and 2%.
“But are you willing to take that risk?” he asked. “If you’re not, then your best chances are vaccination and masking, or vaccination and testing before you have a large gathering, or simply masking up,” he said.
As for people who question the efficacy of masks, Balcezak said there was good scientific data to support that using masks in crowds helps reduce transmission.
He said data showed there is a ‘dose effect,’ which is dependent on the type of mask being worn.
“Masks are most effective at preventing transmission because it’s source control. Meaning if you’re the one wearing a mask, you’re less likely to pass on germs to other people, and if you’re wearing a mask you might be somewhat less likely to get those germs.”
He said the common blue masks have a layer in them that makes them better than cloth or a bandana, but an N95 or KN95 mask is even better.