I updated the data visualizations on KHPI’s Tableau Public Website with Kentucky’s Covid-Tracking numbers as of the end last week (Saturday December 5). It was once again not a good week. Three of the seven days had the highest daily case-counts of the entire epidemic. The Seven- and Fourteen-Day rolling averages of new cases also reached new highs with the 7-Day average surging past the 14-Day one indicating accelerating growth. Weekly new cases at 23,883 leapfrogged to a new record high that was 31% higher than the previous week. Hospitalizations remained high amid increasing concerns of limiting pressures on staff and beds. Along with these other objective measures of epidemic expansion, weekly deaths increased to 177, or 74% higher than the previous week. Total deaths in Kentucky have been increasing exponentially– more sharply so in recent weeks. At the current rate of increase, total deaths are doubling every 10-11 weeks. Even at the present rate, we could see 3000 aggregate deaths by mid-January. Expectations are that due to the arrival of winter’s indoor weather and its holidays, deaths will accrue even faster. We are yet two weeks past Thanksgiving Day and have not yet seen the full impact of that holiday week on on cases, hospitalizations or deaths. In my opinion, these numbers do not suggest that we have controlled our Kentucky epidemic nor to show that have reached a new (acceptable?) plateau. It will take weeks to be able to make such claims.
Deaths have not been increasing in parallel with new cases. That represents the success of better understanding the biology of the disease itself and ways to treat the sick. Surely even our haphazard state-wide adherence to proven and recommended public health measures has likely kept things from getting even worse. We have not yet become a “let-nature-take-her-course” epidemic disaster-state like South Dakota, but given the high-powered and effective opposition to even the most reasonable public health preventive measures, there is no intrinsic reason we could not share the status. Today’s headlines rank Kentucky with 12 other states with the fastest spread of Covid-19. The fact that there are 61 semi-independent public health departments in Kentucky with different resources and abilities (or even willingness) to work off the same page is enough of a handicap.
In a few days, it appears we will have available for use at least two vaccines against the virus that causes Covid-19. These are being touted by some as magic bullets that will make everything all right again. Who could not wish for this to be true! However, these vaccines and the potential for additional ones cannot justify continuing to do the same things we are doing now. For one thing, initial availability will be quite limited. People close to the situation stretch availability to the general public well out into the next year. In addition, the physical implementation of such a unprecedented massive vaccination program faces considerable technical and social hurdles. Our fragmented healthcare system is not designed to take care of everyone in the same way. Do we go to our doctor’s office (if we have one)? To the local drug or grocery store? To a hospital? To a parking lot somewhere?
The clinical data that supported recent emergency FDA approval of these first two vaccines in carefully supervised studies has shown that antibodies are in fact generated, and that the emergence of symptomatic Covid-19 was very much less in individuals who received the vaccine than those who received an inactive placebo injection. A figure in excess of 90% effectiveness is reported. I have no reason to doubt this statistic. If Dr. Anthony Fauci says it is correct and the vaccine is acceptably safe to take, I accept both opinions! The promise of effectiveness is made against the reality of dealing with a brand-new disease and new vaccine methodology. It is a basic principle of clinical research that the results found in a controlled clinical trial do not always predict what happens when a treatment or test is released into the general population. There are important factors even with the naturally acquired Covid disease that we are still learning. For how long are infected patients (symptomatic or not) able to transmit the disease? For how long does the protection of an initial viral exposure last? How often is a person vulnerable to reinfection from the same or a different mutation of the virus? What are the long-term consequences for survivors, asymptomatic or not? Does survival from Covid-19 imply freedom to no longer follow public health measures against spread to others or even reinfection? These considerations apply to vaccines as well.
I do not raise these questions as reasons not to accept vaccination from the Moderna or Pfizer vaccines. What I do suggest is that we need to have better systems to collect clinical data and record long-term outcomes from individuals who contract Covid-19 natively or who are vaccinated. These must be incorporated into vaccination programs from day one. It is just as important to establish that the vaccinations are safe as it is to prove they are effective. There will be future choices of vaccines and some may have different important consequences than others. Safety means more than just a few days of a sore arm, generalized aches, or fever.
The fact that we do not have perfect knowledge has never been an absolute barrier to treating disease. There is no application of medical science or practice that does not require a balance of benefit against risk. I am comfortable with moving ahead as impartial FDA, CDC, and NIH experts and officials recommend. I do argue strongly that to get past our current epidemic, we need a major restructuring of our healthcare systems with a better merging of public health function with personal health. We need to do this now get past our current plague and to prepare for the inevitable next one. We are most certainly all in this together and implementation of our public health approaches must recognize this.
Peter Hasselbacher, MD
Emeritus Professor of Medicine, UofL
7 December 2020