by Michael D. Cohen MD

Worldwide Pandemic

As I write this in mid-July the pandemic has again changed direction and cases are rising throughout the world. Deadly surges are beginning or continuing in Africa, Latin America and South Asia. Indonesia is having their worst pandemic yet. New estimates suggest that the true number of deaths in India may have exceeded three million. This third wave is being driven by the Delta variant that spreads from person to person much more aggressively than any prior versions of the virus. Even relatively well-vaccinated nations in Europe, North America and the Middle East are seeing modest, but growing, surges in cases. Israel is one of the most vaccinated countries, but they recently renewed their indoor mask mandate for everyone.

A study of the effects of COVID on people with HIV infection is of worldwide and local importance for HIV positive prisoners. The researchers reviewed outcomes for people living with HIV infection from 37 countries, many from Sub-Saharan Africa. Over 90% were on treatment for HIV with antiviral drugs. They found that people living with HIV are more likely to get severe COVID disease, get hospitalized, and die from the infection. The risks were especially severe for people with HIV who are over 60 years old. There was a 30% greater risk of death for those with HIV infection and COVID compared to those without HIV. Because of their greater risk for severe disease, people with HIV infection should be prioritized for COVID vaccines, even when they are receiving antiviral treatment. When people with HIV do get COVID, manufactured antibody treatments that have been shown to reduce the risk of hospitalization and death when given early in the course of the infection should be provided.

U.S. Pandemic

As of July 20, 2021, U.S. death figures have surpassed 608,000. New cases have been at historic lows, but with the spread of the Delta variant, cases, hospitalizations and deaths are now trending up again. Though still at relatively low levels, over the past two weeks, cases doubled, hospitalizations were up 46% and deaths were up 42%. These trends suggest danger ahead. If they continue at this pace of increase, by the time you read this in mid-August the numbers will be worse. As people move indoors in the Fall and Winter we may see another deadly surge.

The much more infectious Delta variant is now causing the majority of new cases here. A physician who treats COVID was quoted in the New York Times, “If you are unvaccinated, you are at great risk from Delta, Delta is extremely contagious and we’ve seen it tear through country after country, and it will do the same wherever there are pockets of unvaccinated people in the United States.”

There are about 2,500 counties in the United States. The CDC reports that there are about 1,000 U.S. counties where less than 30% of the population is vaccinated. The Delta variant is spreading rapidly among unvaccinated people. Currently, almost everyone dying from COVID infection in the U.S. is unvaccinated. For example, in Los Angeles 98.8% of COVID deaths in the past 6 months were among the unvaccinated. A trend toward two Americas is being discussed: one vaccinated where the pandemic has diminished to manageable levels; the other unvaccinated where COVID is surging and hospitals are again overwhelmed with sick and dying people. All studies are showing that vaccines are highly effective at preventing severe disease, hospitalization and death from COVID, including the Delta variant.

Most of the new U.S. cases are occurring in regions where vaccination rates are low such as Las Vegas, rural Utah, rural Arkansas, Cheyenne, Wyoming, Louisiana and the Missouri Ozarks. In Missouri, for example, one medical center has reopened the COVID unit that was closed in May. The Delta variant is causing over 90% of their cases. The “Birthplace of Route 66” festival was cancelled there due to the surge.

Hospital staff in these regions are suffering from burnout as the pandemic keeps coming back and they see no end to the long hours, human suffering, and death that they have faced daily for more than 18 months. Health care professionals had to respond to the winter surge in regions where people refused to wear masks. Now they are seeing it start all over again among their neighbors who refuse to get the vaccine. Exhausted, frustrated and experiencing PTSD, now there are staff shortages as people left hospital work or even died from the disease they were helping to treat.

To combat the new increases in cases, some jurisdictions have re-imposed mask requirements. Los Angeles County now requires all people to wear masks in indoor public places. Many jurisdictions still require unvaccinated people to wear masks in public indoors.

Prison Pandemic

A front-page story in the New York Times this month pointed out that COVID deaths among incarcerated people may be severely undercounted. For example, people with COVID released from jails who die from the disease after release are not counted because they are no longer “in custody.” Also, if a person with COVID infection dies, but the death certificate fails to list COVID as the cause or contributing factor, it is not counted as a COVID death. Advance planning for future pandemics will be hampered by such incomplete data on illnesses and deaths among prisoners.

More than 4,000 older or chronically ill federal prisoners convicted of non-violent crimes who are at higher risk for severe COVID disease were released to home confinement during the pandemic emergency. A recent legal opinion from the Department of Justice has indicated that they can be returned to prison after the “emergency” is over, regardless of how well they managed home confinement during the pandemic. Advocates are lobbying President Biden to grant them executive clemency without results.

Also of interest is the fact that some states have achieved higher vaccination rates among people incarcerated in their prisons than among the public in the free world. In North Dakota, for example, more than 80% of prisoners are vaccinated, while only 42% of the general population has accepted the vaccines. Over 70% of prisoners in Kansas and California have received at least one dose of a vaccine. Kansas prioritized prisons as higher risk congregate living settings early in the vaccine rollout. They also provided information about the vaccines to prisoners’ families as well as to the people in prison. In California medical staff helped build trust by meeting with prisoners and answering questions about the vaccines. Rhode Island asked formerly incarcerated people to help develop their vaccination program for the state prison.

Thoughtful peer pressure may help increase vaccination acceptance among incarcerated people. After all, almost everyone wants in-person visits to resume, more time out of cells for recreation, easier movement within the facilities, and easier access to commissary, health care, meals and programs that pandemic lockdowns curtailed.

Breakthrough Infections Among Vaccinated People

The vaccines were approved for emergency use because studies showed they prevented severe disease, hospitalization and death. Since approval, studies have also shown that the vaccines also prevent most infections too, but not all infections. Vaccinated people who do get infected have mild disease, generally with no symptoms at all. Even though infections in vaccinated people are uncommon, with millions of people vaccinated an uncommon event may produce thousands of cases. For example, if only 1 out of 100,000 vaccinated people gets infected, out of 350 million vaccinated people, there will be 35,000 breakthrough infections.

Professional athletes are a highly vaccinated group of people. News reports of breakthrough infections among baseball’s New York Yankees have caused some confusion and consternation. If vaccines work, why did some Yankees get infected? Breakthrough infections are not noticed among the general public because there are no symptoms and we are not getting tested much anymore. But professional athletes are the most tested group of people in the U.S. as part of the routine efforts to prevent exposure during games and in crowded locker rooms. So, all of the breakthrough infections among athletes are being diagnosed.

Vaccine Boosters

There has been news recently about the possibility of needing booster doses of COVID vaccine. Sometimes booster doses of other vaccines are recommended. For example, adults need a tetanus-diphtheria booster every 8 to 10 years and adolescents need a booster dose of pertussis. These are needed when the immune response has weakened over time and people become susceptible to the disease again. Pfizer has initiated efforts to obtain FDA approval for booster doses of its vaccine, but FDA and other infectious disease authorities say such a request is premature as there is no evidence (yet) to support giving booster doses to the general public. Our immunity from the vaccines still seems to be long lasting.

However, there is accumulating evidence that people at higher risk for severe COVID disease due to weak immune systems do benefit from additional doses of vaccines. In France and Israel, people with immune compromise are routinely given an extra dose of vaccine.

It is important to consider that giving booster doses to highly vaccinated populations in the U.S. and Europe will take doses away from the rest of the world. Public health policy makers have pointed out that we need to get routine initial vaccine doses out to the rest of the world as soon as possible to control the pandemic and reduce the occurrence of new, more dangerous variants.

Vaccine Side Effects

A warning has been added to the Johnson and Johnson vaccine regarding a very rare side effect called Guillain-Barre syndrome. With over 13 million doses of the J&J vaccine administered, only 100 cases of Guillain-Barre have been reported so it is extremely rare. COVID disease is much more likely to cause side effects, complications and death than any of the vaccines, so the vaccine is still the best option.

This syndrome occurs with many viral infections, and with flu vaccine, among other associations. One of the first patients I helped care for in medical school in 1975 was a man from the Sacramento county jail with Guillain Barre after flu infection. This condition begins with weakness in the muscles of the feet and then moves up the body to the calf, thigh, and maybe as far as the chest. When it reaches the chest, the muscles that help us breath can be affected and the patient may need to be put on a mechanical ventilator. Over time the muscle weakness gets better and most patients recover completely over a few weeks.

New or Long-Lasting Health Problems After COVID

The occurrence of longer-term com­plications of COVID infection is a continuing problem that is not yet well defined or well understood. A recent study looked at the health records of more than two million Americans who had COVID. They found that a month or more after the acute infection got better about 25% of patients had sought care for a new medical problem. Many had pain, fatigue, trouble breathing, high blood pressure or persistent loss of their sense of smell. There are also new reports of problems with memory after COVID and evidence of injury to the brain.

Conclusion

The best prevention is to be vaccinated. The disease is a known risk and long-term complications of disease are common. The vaccines are effective, low risk and serious complications are very rare. Masks help prevent you from getting infected and help prevent you from spreading it to others if you do get infected. I am vaccinated but I still wear a mask indoors to help protect me from any new variants that may come along, to keep masking part of normal daily life and to support and protect people with weak immune systems and children who cannot get vaccinated yet. 

Dr. Michael Cohen is a medical doctor and former chief medical officer for the New York State juvenile prison system. He is also the author of the Diabetes manual distributed by HRDC.

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