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Friday Night Update from Arlington, Va. ER: ‘BA.4 and BA.5 Variants Are Incredibly Contagious’, More So Than Measles ‘and Become World’s Most Infectious Virus’


Thanks as always to Dr. Mike SilvermanChairman of the Department of Emergency Medicine at Virginia Hospital Center in Arlington, for such great updates!

A good friend of mine had COVID this week. It’s the second time she’s had it and she’ll tell you that she kicks his ass. And suddenly the emergency department feels like it’s seeing an increased number of patients not only coming to the emergency room, but also having to be admitted. Our figures confirm this. Across the emergency department, we diagnosed about 30% more people with COVID last week than 2 weeks ago. Our percentage positivity rate has increased from around 10% to almost 14% over the same period. We have also seen an increase in the number of patients currently hospitalized as well as an increase in the percentage of patients requiring “covid isolation” in the emergency room and ending up in hospital. These are all important trends to know and follow. The BA.4 and BA.5 variants are incredibly contagious and now cause 80% of new infections in the United States. We are still trying to determine if they are more virulent, causing more morbidity (disease).

It’s been almost 2 years since I’ve talked much about R naught. R-value zero is the reproduction rate of the virus, that is, the number of new people infected by each infected person. The original Wuhan strain was around 3.3. With the first social distancing and masking interventions, we are seeing a drop in this rate. The goal was to get it below 1, and eventually the virus would die out. Of course, that never happened. Ebola and the 1918 pandemic flu each had null R values ​​of around 2. Measles was long considered the most contagious virus with a value of 18. The delta variant rose to 5.1 and then the omicron reached 13. These new subvariants (BA. 4 and BA.5) are currently estimated at around 18.6, overtaking measles and becoming the most infectious virus in the world. It is certainly a cause for concern when it comes to spreading. There is also a new variant strain called BA.2.75 that the World Health Organization has started tracking and may set its own record. Needless to say, we should probably reconsider mask usage, especially indoors. Unfortunately, as many others have said, I think it’s likely that none of us will ever escape infection, no matter how hard we try.

Currently, a second booster is recommended for people over 50. This week, the president said he may recommend a second booster for everyone in the near future. I’ve long anticipated that boosters will be recommended this fall, just as we get an annual flu shot. The question will be about the timing. There are additional questions about the benefits of the second booster. We know that immunity wanes over several months. We also know that boosters increase our antibody response. But other than in the 60+ age group and for immunocompromised people, there are not many studies that show the benefit of a second booster in terms of preventing hospitalization and death. for healthy young people.

On the list of drug shortages, we must add diazepam (Valium). We still have drug shortages affecting us in the emergency room. More recently there has been a shortage of Ativan, which we use for acute anxiety/panic as well as agitation and more importantly alcohol withdrawal. Our alcohol withdrawal protocol switched to valium a few weeks ago and now we are going to change it again. We still have options but there is some comfort and knowledge for doctors and nurses with Ativan (and even Valium) because we have been using them for years. On the positive side, the shortage of IV contrast has improved significantly. Our hospital offer is good. And even though the Shanghai factory closed last weekend (for mass testing), it looks like global supply is picking up.

The other big news that impacted the world of emergency medicine this week was a statement from the Secretary of Health and Human Services clarifying what can happen under emergency conditions to pregnant women in the States that do not allow abortion. You may recall that ER doctors in many states struggle to treat people with ectopic pregnancies and wasted valuable time talking to hospital attorneys to make sure it would be legally safe to intervene to save someone’s life. HHS clarified that federal law prevails over state abortion laws when women have medical emergencies associated with pregnancy. The Emergency Medical Treatment and Active Labor Act, which everyone in the ER world knows as EMTALA, is around the corner from what we do, which is ER docs . This law stipulates that any patient who presents to the emergency room has the right to a screening and stabilization medical examination, regardless of their ability to pay. In part, this law was created to prevent patient dumping — decades ago, some private hospitals took uninsured patients and put them in ambulances and sent them to public hospitals. But this law was really put in place to ensure that we do the right thing in a timely manner for patients. Stabilization includes all tests and procedures necessary to rule out an emergency medical condition. That doesn’t mean that if you go to the ER to get an MRI for your knee pain, you’re going to get it. But it does mean that if you come in with an acute knee injury and the doctor is concerned you might tear your popliteal artery, you can get a CT scan to rule this out, whether or not you have insurance. On the pregnancy side, for patients with an ectopic pregnancy, doctors can legally intervene to prevent the woman from dying from an ectopic rupture (which is ultimately unavoidable if the ectopic is not treated) without worrying about breaking any state law. EMTALA will also impact the patient who has a hemorrhagic miscarriage. Of course, Texas lawmakers have already begun challenging EMTALA in court saying it violates states’ right to regulate the procedure within its borders.

The coronavirus is not done with us yet.

Science matters. Get vaccinated (or your booster). Keep a mask handy.

Mike