Medical Discussion of Coronavirus

[StarTrekDoc]

It's difficult to say if we're at that point now. It looks like we are at the plateau of this peak on a national level and by the time any of the federal actions take effect things may well be looking better. It's hard to say how further mutations will change the equation. The 1918 flu had 3 peaks and it looks like we are on our third so who knows. My guess is that even in hindsight it won't be clear whether the federal interventions were warranted balanced against the loss of choice that you mention..

Somewhat related, I think one group that might have a legitimate argument against vaccination (or at least against multiple injections) are those who have already had COVID, especially if they still demonstrate antibodies. The CDC notes those people can catch COVID again but of course that is also the case with vaccine, and the question really is will the risk of serious illness in those with prior infection be reduced similar to the vaccine. You'd think we would have some idea of that by now.

If the epidemiologists had time to breath that would be a very good cohort to track.

Yes, 1918 had several large peaks and fortunately mutated to a less aggressive form and believed to be 1 of the 4 common circulating human coronaviruses. With COvid19 follow this path? Perhaps.

We do note that natural immunity wanes and recurrences happen typically after 90 days. It's not long lasting and we know immunized immunity overall outperforms natural immunity; so still the benefit of immunization is beneficial -- eg ; pneumovax, shingrix, varicella. And with virus that have higher mutations an updated vaccine to account for this drift - eg influenza. Covid will be that latter.

Remember, we had the mRNA tech for 10 years. It just wasn't economically viable to use it agains the common daycare virus. -

[Nysoz]

FYI Anesthesia machines are not meant for long term ventilation- we looked into it during the initial wave, similarly looked into splitting vents. I believe earlier in this thread (extremely early- first 30? pages) some of us discussed this. I'm honestly too tired to look back at the detailed reasons of why anesthesia machines dont make for great long term vents, so I apologize for not giving a concrete reason.

For some reason I think the anesthesia machines don’t give as much peep as the vents? Yeah this thread moves quick so I’ll admit I haven’t read through all the pages.

[pierre]

We do note that natural immunity wanes and recurrences happen typically after 90 days. It's not long lasting and we know immunized immunity overall outperforms natural immunity; so still the benefit of immunization is beneficial.

Do you have data to support this statement? This paper from Israel would suggest the opposite.

https://www.medrxiv.org/content/10.1101/2021.08.24.21262415v1

Results SARS-CoV-2-naïve vaccinees had a 13.06-fold (95% CI, 8.08 to 21.11) increased risk for breakthrough infection with the Delta variant compared to those previously infected, when the first event (infection or vaccination) occurred during January and February of 2021. The increased risk was significant (P<0.001) for symptomatic disease as well. When allowing the infection to occur at any time before vaccination (from March 2020 to February 2021), evidence of waning natural immunity was demonstrated, though SARS-CoV-2 naïve vaccinees had a 5.96-fold (95% CI, 4.85 to 7.33) increased risk for breakthrough infection and a 7.13-fold (95% CI, 5.51 to 9.21) increased risk for symptomatic disease. SARS-CoV-2-naïve vaccinees were also at a greater risk for COVID-19-related-hospitalizations compared to those that were previously infected.

Yes, natural immunity wanes, but it is still better than vaccine induced immunity.

[StarTrekDoc]

Do you have data to support this statement? This paper from Israel would suggest the opposite.

https://www.medrxiv.org/content/10.1....24.21262415v1



Yes, natural immunity wanes, but it is still better than vaccine induced immunity.

Interesting read. Have to dive into it more;

Most immunologists believe there's MORE than just Ab protection; that there's a significant humoral mechanism that works which this paper would support.

My initial concern is selection bias in retrospective papers -- the natural immunity; based on averages - killed off 2% of the highest risk people while the immunized still have them there. I would be interested to see how they accounted for that high risk group.

Irrespectively - the data supports that natural immunity + mRNA single outperforms everything.

So if any policy change would happen based on this paper would be: COVID+ person on the block? go have a covid block party, get mild disease, and then get immunized for most optimal protection -- oh, btw, don't die with the first infection.

[Rando]

Do you have data to support this statement? This paper from Israel would suggest the opposite.

https://www.medrxiv.org/content/10.1101/2021.08.24.21262415v1

Yes, natural immunity wanes, but it is still better than vaccine induced immunity.

The CDC links to this study:

https://www.cdc.gov/mmwr/volumes/70/wr/mm7032e1.htm?s_cid=mm7032e1_e&ACSTrackingID=USCDC_921-DM63289&ACSTrackingLabel=MMWR%20Early%20Release%20-%20Vol.%2070%2C%20August%206%2C%202021&deliveryName=USCDC_921-DM63289

I have some questions about how well controlled this Kentucky study is, but I'm still willing to believe that the vaccine gives better protection., As I said earlier the question has really changed from protection against infection to protection against severe disease. My gut feeling is the CDC is being kind of rigid here, as if prior infection is meaningless when it likely has some impact.

[FIREshrink]

Do you have data to support this statement? This paper from Israel would suggest the opposite.

https://www.medrxiv.org/content/10.1....24.21262415v1



Yes, natural immunity wanes, but it is still better than vaccine induced immunity.

"Better" is a judgment.

Longer lasting - not yet proven

Broader, ie against variants - intuitively yes, not Conclusively demonstrated

more powerful -ie faster acting, fewer breakthrough cases, etc - i haven't seen data either way

mRNA plus contracting delta is my current strategy, there are some papers showing broad, robust immunity that IMO is also likely to be durable. Need to get boosted first.

[pierre]

"Better" is a judgment.

Longer lasting - not yet proven Broader, ie against variants - intuitively yes, not Conclusively demonstrated

more powerful -ie faster acting, fewer breakthrough cases, etc - i haven't seen data either way

mRNA plus contracting delta is my current strategy, there are some papers showing broad, robust immunity that IMO is also likely to be durable. Need to get boosted first.

How are you going about contracting delta? Are you just assuming that with masking and other precautions, you’ll still get it?

[Zaphod]

If the epidemiologists had time to breath that would be a very good cohort to track.

Yes, 1918 had several large peaks and fortunately mutated to a less aggressive form and believed to be 1 of the 4 common circulating human coronaviruses. With COvid19 follow this path? Perhaps.

We do note that natural immunity wanes and recurrences happen typically after 90 days. It's not long lasting and we know immunized immunity overall outperforms natural immunity; so still the benefit of immunization is beneficial -- eg ; pneumovax, shingrix, varicella. And with virus that have higher mutations an updated vaccine to account for this drift - eg influenza. Covid will be that latter.

Remember, we had the mRNA tech for 10 years. It just wasn't economically viable to use it agains the common daycare virus. -

Immunity from natural infection also seems to scale with severity, or at least had heard that and its very biologically plausible. There will be a lot of alpha people who think theyre immune that just get wrecked by delta reinfections. With the differences in viral load the average infection with wild type/alpha was probably milder, more asymptomatic.

Even though I never felt terrible with my breakthrough and would describe it as "weird", I am so thankful I was vaxxed and shudder to think what might have been.

[Zaphod]

Do you have any camps that are vaccinated but anti mandate? Those seem to be classified under the identity politics as the "enemy within". Or do you lump them in with "guvment can't tell me what to do."? In today's world, it's best to view the as type 1 or type 2. It is really too complicated to unpack individuals. Single issue is how people vote and make decisions. The important thing is to pick the right issue. The "crazies" need to be cancelled.
Please tolerate my sarcastic comment. Need another coffee.

There are lots of those, trying to sound erudite and nuanced, but similarly ineffective and missing the point.

[FIREshrink]

How are you going about contracting delta? Are you just assuming that with masking and other precautions, you’ll still get it?

Ahem, well i wouldn't say I'm trying. But there will come a point where the curve representing my willingness to take precautions and the curve representing the spread of the virus will intersect and I'll be infected. I haven't eaten inside in a restaurant since late February 2020, and I'm tired of take out and eating outside. This virus is here to stay, i just hope to get it when hospitals aren't inundated and when my vaccine immunity is sufficient that any breakthrough symptoms will be mild. I will probably eat in a restaurant when local cases are < 10/100,000 per day but that was only true briefly early this summer so I didn't have the chance.

[Jaqen Haghar MD]

So I’m back taking my week of call and it’s been a cluster.

Still with 12 patients in 8 bed icu. 4 icu nurses with 3 patients each. There’s intubated patients in our step down unit. Intubated patients in our er with bed holds.

We ran out of vents so got some more, now those are used up. Talks of using our anesthesia machines as vents and putting people in pacu.

Consults for trach/pegs as well as dialysis access on these BMI 50+ covid patients.

Hernias and appys in the er waiting that can’t be put in a room cause of all the bed holds and nursing shortage.

Had a perforated diverticulitis that waited in the er for 8 hours before they were able to get a room and evaluated.

It’s a wild time to be in medicine for sure.

When it hits your area in earnest, you can expect 6-8 weeks of the biggest wave yet. It moved fast through here. A quick tidal wave, a big mess for a while, and now the wave is receding. Far worse than the first three waves. Swamped every single hospital. There are no mask rules in public here, and no restrictions so nothing to slow things down. Now it seems to have fizzled out again. I still have a few covid admits per shift, but it’s clearly dropping off fast. We’ve got 80 something Covid patients just camping out in the hospital now, but no more ED holds, ED volume is falling.

It inspired a lot of people to get vaccinated. But there are still plenty of the last holdouts.

Now, we wait a few months and see if there is a 5th wave….

[Jaqen Haghar MD]

Ahem, well i wouldn't say I'm trying. But there will come a point where the curve representing my willingness to take precautions and the curve representing the spread of the virus will intersect and I'll be infected. I haven't eaten inside in a restaurant since late February 2020, and I'm tired of take out and eating outside. This virus is here to stay, i just hope to get it when hospitals aren't inundated and when my vaccine immunity is sufficient that any breakthrough symptoms will be mild. I will probably eat in a restaurant when local cases are < 10/100,000 per day but that was only true briefly early this summer so I didn't have the chance.

I got my vaccines and I’ll get the booster before too long. We’ve gone back to eating out in crowded bars and restaurants where no one is wearing a mask. I don’t wear masks in public anymore, for the most part. the stores and businesses are packed shoulder to shoulder. I wear a mask in the hospital, and that’s about the only precaution I take, other than my usual gloves, while seeing covid patients.

Now it’s just a matter of keeping my antibodies up I guess…. No problem there.

[StarTrekDoc]

So Cal - we peaked about two-three weeks ago with ~1800 cases/day then and have had a steady plateau at 900-1100 cases/day until this week nice little drop in the 700s -- but back with labor day cases popping up Friday heading into the weekend.

Let's see how well we fair to get back down in Sept restarts before the November bumping again with Mu or other variant.

FIREshrink - we've definitely resumed much of our high desired activities-- eg Disneyland over Labor Day weekend. We still haven't directly poked the proverbial bear by going maskless indoors. The biggest test yet -- Shang Chi tonight at the theatres. -- with our Vogmasks of course!

[G]

Yeah, we've been eating out and in shoulder to shoulder crowds, sans masks/respirators. Aside from one strikingly poor lapse of judgment on my part, we did pretty much nothing publicly until vaccinated. I'm seeing that perhaps I went too far--my child now prefers to eat in the car and pretty much refuses to touch door handles....

Interesting to hear what others are going through professionally. Our new cases and cumulative death rate curves are impressive although not as steep as last fall; it just sure seems worse with no beds/nurses available. All of the ERs in the region are a disaster, all on divert most of the time...and citizens don't seem to care--until they show up and find out that they probably have a 6 hour wait ahead of them, sitting next to a bunch of coughing COVID patients (assuming there is an open chair), and culminating in a super-private hallway treatment experience.

[MaxPower]

It's difficult to say if we're at that point now. It looks like we are at the plateau of this peak on a national level and by the time any of the federal actions take effect things may well be looking better. It's hard to say how further mutations will change the equation. The 1918 flu had 3 peaks and it looks like we are on our third so who knows. My guess is that even in hindsight it won't be clear whether the federal interventions were warranted balanced against the loss of choice that you mention..

Somewhat related, I think one group that might have a legitimate argument against vaccination (or at least against multiple injections) are those who have already had COVID, especially if they still demonstrate antibodies. The CDC notes those people can catch COVID again but of course that is also the case with vaccine, and the question really is will the risk of serious illness in those with prior infection be reduced similar to the vaccine. You'd think we would have some idea of that by now.

Just had a 37 year old lady die today in my hospital of covid. Had initial infection in August 2020. Not vaccinated and caught it again this August. Spiraled precipitously downward in the last week and spent 9 days prone because they could get her supine or her O2 sats dropped. Not immunocompromised either. Overweight snd recently had a baby. That’s it.