Daniel R. Howard, MD, PA

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The Delta Phase of the Covid-19 Pandemic

It's clear the United States is entering a very dangerous phase of the Pandemic. This will be worse for the unvaccinated, and will be severe in areas with low rates of vaccination. We'll see hospitalizations, intubations, and deaths in the unvaccinated population, likely approaching the levels of some of the earlier peaks.

However, the vaccinated are not completely safe.

There are a lot of breakthrough infections in the vaccinated--it's not the "rare and unusual" event any more, not with Delta being predominant. There was a local cluster recently fairly similar to the Provincetown outbreak reported by the CDC; I'm seeing them in my practice now; and they've been reported in nursing facilities.

Most of these vaccinated folks will not get severely ill, and deaths will be quite rare. However, as those who received vaccinations (or were infected and not re-vaccinated) over 6 months ago see some waning of immunity, and as our elderly and immunosuppressed populations has more exposure, we'll see more hospitalizations of the vaccinated, with some severe cases.

I think that the Pandemic will spread until we have reached herd immunity, which is probably at around 90 % infected or vaccinated based on information coming out of Britain. At that point, we'll probably see a steep drop in cases, as seen in Britain, and in India and Nepal, which are probably in a similar situation.

Vaccination is the key to limiting serious illness, but it doesn't prevent infection, and almost certainly does prevent spread of infection, in those vaccinated. It does decrease the risk of infection a lot though, and that is clearly a big benefit.

Unfortunately, I also think it is almost inevitable that there will be a variant that escapes immune surveillance from immunity from prior infection or vaccines, and therefore "booster" vaccines, updated for the upcoming variants, will be required at intervals, which are yet to be determined.

Life will continue to be very different for the foreseeable future.

Covid-19 Here and in the World

World: 149,461,088 cases worldwide. 3,152,089 deaths. Cases continue to rise worldwide, and we are now at a worldwide point worse with both cases and deaths than we were at the peak of the Winter surge.
Everyone has probably heard about India, where the healthcare system has collapsed at this point. Patients are dying in line at doctor’s offices and ERs. India is reporting 201,000 deaths, but it is believed they may have 10X as many deaths as reported, as even in normal times only 24% of deaths result in a death certificate. Some regions are running out of wood to perform cremation fires, and air pollution is up, despite reduced auto transport, due to wood-burning fires from funeral pyres. The situation is catastrophically bad, worse than any of us can even imagine, and likely to get worse before it gets better.
Brazil is in a similar situation. Both situations are due to the presence of Variant strains of Covid-19.
Many European countries continue to do poorly, despite overall declines in cases in Europe. France, Russia, and Turkey continue to have increased cases.
US: 32,927,352 cases. By reported statistics, the US has the largest number of cases, but we are probably really at this point well behind India, Brazil, and Russia. Cases are now declining nationwise.
587,385 total deaths. Deaths have plateaued for now, but will probably drop as deaths lag cases by at least a couple of weeks.

US Vaccines: 42.5 % of the population has gotten at least one vaccine (which is very highly protective), and 29 % of the population is now fully vaccinated. Israel saw dramatic declines in number of cases, in hospitalizations, and deaths, when they hit 45% of the population fully vaccinated; hopefully that will happen here as well, even though that number is far below what is needed for herd immunity. As I mentioned last week, it may be very difficult now to actually reach herd immunity despite availability of vaccines, due to fairly wide-spread vaccine resistance.

MD: 444,491 known total cases since the beginning of the pandemic. 677 overnight, which is a decline.
8501 total deaths so far. These numbers, as much of the US, are at a plateau, and I think we’re about halfway through Phase 4 of the pandemic here in Maryland.

We are at 1130 Covid-19 patients hospitalized statewide, down about 150 from last week. 269 in the ICU’s across the state, also down significantly.
State-wide 7-day positivity rate 4.04%, down almost a percent since last week, which is a very good indicator.

MD Vaccines: 31% are fully vaccinated. Vaccines are readily available now. I’m vaccinating patients in my office after receiving our long-awaited delivery this week.

CDC New Guidance

Fully vaccinated people no longer need to wear masks outdoors, except in crowds. They released a useful infographic showing relative risks for vaccinated and unvaccinated individuals, which I believe is data-driven and relatively accurate.

Guidance regarding outdoor masking reflects the limited risk of outdoor activities.

Many activities continue to be very risky for unvaccinated individuals. I believe one reason the CDC released these guidelines at this time was to encourage vaccination at a time when vaccine administration is slowing down, probably mostly due to vaccine resistance.

MIT study showed that for indoor spaces, little difference between 6 feet of distancing and 60 feet of distancing. This is almost certainly correct, and is due to aerosolized spread of Covid-19 in interior spaces.

Vaccines and Exercise
There is now good data showing a 50% increase in antibody titers, as well as decreased infection rates, in those undergoing 30 minutes of aerobic exercise 5 times a week. This is one more reason to continue, or to start, a regular aerobic exercise regimen.

Variant Viruses

The situation in India is almost certainly due to the wide-spread distribution of a Variant virus containing double mutations. The variant is B.1.617, and it appears to be both more lethal, and to spread much more rapidly, than other variants noted elsewhere. The two mutations are the E484Q, which is very similar to the E484K (EEEK) mutation, found in the British, Soouth African, and Brazilian variant, and is likely responsible for the poor Covid Outcomes in those countries.

The other mutation is the L452R mutation, found in the California Variant, which almost certainly contributed to the severity of the recent outbreaks there.

This is, however, the first time those two mutations have been found in a single virus variant. Clearly, re-infection occurs with the B.1.617 variant, and studies are ongoingd to determine how much resistance to vaccines occurs with this variant.

This certainly raises the possibility of these types of variants being transported and taking hold in places, such as the US, which are now doing fairly well with the Pandemic. As long as there are areas where viral replication is out of control, various mutations will continue to arise, with some resulting in more lethal or more transmissible viral variants.