Plateaus do not last forever.
As we approach the end of this pre-Derby Week and a change of seasons, the best we can say about the status of Kentucky’s Covid-19 epidemic is that our rapid decline of new cases has ended and that our case and hospital utilization rates have “plateaued” –albeit at levels well above last Summer’s or before last Fall’s epidemiologic explosion. Of concern are early hints of renewed epidemiologic expansion. Daily new case numbers and Kentucky’s calculated Test Positivity Rate are both inching up. The 7-Day average new case number is beginning to peek above the 14-Day curve– another hint of epidemic expansion. With two reporting days left this week, we are on track to match the 4000-plus weekly case numbers of mid-March. Kentucky’s current situation largely mirrors the national situation, but we are in a better place than states and regions where the Covid-conflagration has reignited. Our vaccination programs are going well and from my person-on-the-street perspective, much self-imposed masking and social distancing practices can be seen. In my opinion however, we remain vulnerable to things we cannot control– or choose not to.
Kentucky still contains viral hotspots as judged by national criteria. New cases arise throughout the state ready to breakout again. The more contagious viral mutations roam freely among us. We are travelling and encouraging out-of-state visitors again. The fact that no vaccine or disease treatment is perfect, permanent, or risk free is likely to interrupt vaccine administration programs for those who would benefit most– and that indirectly includes all of us! We are all tired of the restrictions the virus has imposed on our lives which have impoverished us both emotionally and financially. Many of us are in denial or have given up trying to do what history and science tells us is effective to bring the current plague under acceptable control. We continue to have unacceptable differences in access to the healthcare and social support necessary to maintain social cohesion and justice necessary to maintain the health of the body politic.
Where we go from here is indeterminable. We will only know when we get there. When I was asked last week if I thought it was safe to run a proper Kentucky Derby, I did not have a supportable answer one way or the other. It was and remains my opinion that another disease “surge” is more likely than not. More to the point, we lack the tools or surveillance structure to demonstrate that a given large-scale event is “safe” or not. If cases flair again, how do we tell if it was a Derby, returning Spring vacationers, out-of-towners, new viral strains, or anything else? Certainly other large-scale events are still being postponed.
My belief is that we should continue on our present course and that it is very premature to let our full guard down. I agree with incremental steps. I could even support more mandatory vaccinations or other requirements for full participation in societal events such as school or employment. I cannot find fault with the recent CDC decision to take a close look at a rare complication of the Johnson & Johnson (Janssen) and AstraZeneca vaccines. Nothing we do in medicine, public health, or living together is absolutely risk free. It is only a matter of justice and social cohesion that we share that unavoidable risk of being alive.
I updated KHPI’s tracking data on the Tableau Public website as of April 15 for your inspection.
Peter Hasselbacher, MD
Kentucky Health Policy Institute
April 16, 2021
Today is Thursday April 22 with two days left in KHPI’s reporting week. For the part of the week so far, new cases, deaths, and testing have pretty much kept at their recent plateaus. However, as we approach a busy season and some concerns about the pace and acceptance of vaccinations, it is of note that the state’s calculated Test Positivity Rate has been creeping up as appears also to be the case for hospital, ICU and ventilator utilization. I have updated the data on KHPI’s Tableau Public website.
Much is being written and debated about the “pause” in administration of the Johnson & Johnson vaccine that was being counted on for administration for special populations. I hope to say more about that later. Let me say here that it was imminently reasonable for the reviewers at the CDC and FDA to call for more information and analysis. I believe the issue is not so much about the safety of the vaccine. The tiny risk of a very specific and rare side effect of a vaccine, shared in my opinion with the Astra Zeneca vaccine. The benefit of the J&J vaccine still overshadows the risk of Covid-19 which itself is a systemic multi-organ disease.
The term “blood clot” is being widely used, but loosely. We are not talking about the kind of bland lower-limb venous blood clots of the kind in the legs that can come from sitting too long in an airplane, following total hip operations, or from taking birth control pills. Yes, these kinds of clots can cause pulmonary emboli, or if there is a hole between the two sides of the heart, strokes. Rather the “blood cots” that are being associated with cerebral sinus thrombosis are associated and accelerated by consumptive activation and depletion of blood platelets that causes occlusion of both veins and arteries in multiple organs throughout the body. This is the kind of run-away disseminated intravascular coagulation that is seen with the septic shock of bacterial septicemia, or for that matter with Covid-19 itself. This is our complex blood clotting system running amuck. One of the reasons the post-vaccine patients reported so far are having relatively high mortality is that some have been treated as though they are having the “usual” venous occlusions with heparin and with other modalities which are exactly the wrong thing to do and would predictably make matters worse in these rare specific cases. It is entirely proper to take a step back to evaluate the actual incidence of the issue and to make sure that healthcare professionals know how to recognize it and treat it appropriately.
Peter Hasselbacher MD, April 22, 2021