Santa Monica Primary Care

29 June 2021 Blog: Recommendations without Data, on Delta [Also available at: https://drbretsky.com/29-june-2021-blog-recommendations-wi/] I was hopeful that with widespread availability of vaccinations that I would be able to move onto other blog topics than COVID-19. However, I have had an increasing number of questions regarding the Delta variant (B.1.617.2 first identified in India). To add a confusing wrinkle, the Los Angeles County Health Department is now recommend...Continue reading

15 Jun 2021: Re-opening Day [Also available at: https://drbretsky.com/15-jun-2021-re-opening-day/] To a moderate degree of fanfare, California reopened from COVID-19. As aptly summed up by the LA Daily News (link: https://www.dailynews.com//la-county-joining-california-s/):...Continue reading

23 May 2021 Blog: Approaching Containment, Hoping for Elimination [Also available on: https://drbretsky.com/23-may-2021-blog-approaching-contain/] What a year it has been. Here in Los Angeles County we experienced a pandemic high of COVID-19 cases the week of 1/5/2021 at 145.0 new daily cases per 100,000 population. For the most recent week of data ending 5/18 we have dropped to 1.8 new daily cases per 100,000. Viral containment is generally defined as fewer than 1 new da...ily case per 100,000 and we should be there within the next 2 weeks. Similarly mortality has plummeted from 2.76 deaths per 100,000 the week ending 1/12 to 0.04 deaths per 100,000 last week (Figure 1 below). A number of factors account for this dramatic turn around, but none more powerful than the role of vaccination. It is for this reason that mortality rates declined more precipitously than did case rates. However, mortality rates have been flat - low at 0.04 per 100,000 - but still flat for the past three weeks. With vaccination as our best and most effective preventive measure, then it is here that our public health officials need to focus their efforts. There remains a significant disparity in vaccination rates, with Latinx and African-American residents under the age of 65 less likely to be vaccinated. Over 75% of White and Asian residents over the age of 65 have been vaccinated, compared to 63% and 66% of African-American and Latinx residents. This difference is even more marked among those under the age of 65. Whereas 70% and 62% of Asian and Caucasians have been vaccinated, these drop to 39% and 44% for African-American and Latinx individuals (source: http://publichealth.lacounty.gov//v/vaccine-dashboard.htm). This remains our health officials’ greatest responsibility at this point, as we have made tremendous strides towards viral containment. But to move from containment to elimination, we must address these glaring disparities.

18 May 2021 Blog Post: CDC, Masks and The Science [Also available at: https://drbretsky.com/18-may-2021-blog-post-cdc-masks-and-/] I - like most of you - was completely caught off guard by the CDC guidance this week stating that if you have been fully vaccinated then you can resume activities without wearing a mask or staying 6 feet apart. As somebody who has been wearing a N95 for my entire workday since March of 2020, nobody had more reason to be thrilled on an indiv...Continue reading

11 May 2021 Blog Post: On Containment and Go For Zero [Also available at: https://drbretsky.com/11-may-2021-blog-post-on-containment/] If you missed it yesterday, a Bengal Tiger was on the loose in a Houston neighborhood. I found it interesting that somebody would keep one in their backyard, but also sort of terrifying (link: https://www.nbcdfw.com//video-shows-tiger-in-fron/2628266/)...Continue reading

2 May 2021 Blog: Further Decrease in COVID-19 Mortality Rates In Los Angeles County [Also available at: https://drbretsky.com/2-may-2021-blog-further-decrease-in-/] Today Los Angeles County reported no new COVID-19 related deaths. The last time we had a zero count was March 18th, 2020. Today’s count is an additional manifestation of the continued divergence between case rates and mortality rate (Figure 1 below).... The peak in cases occurred the week of January 5th (at 143.7 new daily cases per 100,000) and deaths occurred a week later at 2.66 daily deaths per 100,000. However, since that time these rates have plummeted and, for the week ending April 27th, there were 3.1 new daily cases and 0.04 daily deaths, both per 100,000 population. Although we have covered this topic before, we are continuing to see a greater rate of decline in mortality rates than cases. Case rates have remained relatively steady for the last month and a half: 4.4, 4.2, 4.4, 4.5, 4.0 and 3.1. However, in that same time period mortality rates have been: 0.20, 0.17, 0.11, 0.09, 0.05, and 0.04. This is directly attributable to the efficacy of the COVID-19 vaccine which provides essentially 100% protection against hospitalization and death. But the relatively flat COVID-19 case rate represents the continued laissez-faire attitude of the County Health Department in terms of actually containing COVID-19 [Note: "containment" is formally defined by the Harvard Global Health Institute as fewer the 1 new daily case per 100,000 - in Los Angeles we are typically 4-5 times above this goal]. Without a focus on containment and then eradication, we will ultimately transition from a pandemic to an endemic state. One would rather, of course, eliminate the virus entirely but when a virus becomes endemic (an example is HIV), it will continue to circulate in the population, causing sporadic infections. Contact tracing is the solution to eliminating COVID-19 entirely from our population, but the County continues to have absolutely abysmal case follow-up rates. Although there were only 1,291 cases in the past week, the Health Department only completed 594 interviews (46%). This is only slightly better than its performance through the entire pandemic - 44.8% of more than 470,000 cases. In spite of this, there is only good news when it comes to our current COVID-19 state in Los Angeles County. At the height of the pandemic, there were over 24,000 active cases per 100,000 population. Now? 27 active cases per 100,000 - a 99.9% decrease.

In what is the right decision, the ACIP (CDC's vaccine advisory committee) has recommended lifting the pause on the Johnson & Johnson vaccine by a vote of 10-4 (with one abstention due to participation in ongoing clinical trials). This is indeed the right decision. Although certainly tragic for those 15 cases of vaccine-associated thrombosis, the risk/benefit analysis unambiguously falls in favor of the J&J vaccine. All of the confirmed case were in women (although one male i...n the clinical trial has a thrombosis event). The highest risk strata were women between the age of 30-39 years with 1.18 cases per 100,000 vaccine doses. The background general population incidence of cerebral venous thrombisis is estimated to be 0.22-1.56 per 100,000 population. It has a 3:1 female to male ratio and affected women tend to be younger (median age 34) than men (median age 42). Some women in this highest risk group may indeed opt for Pfizer or Moderna which would certainly be a reasonable choice. However, for others it is critical we have this "one and done" vaccine option available and pay careful attention to any unusual symptomatology arising 7-14 days post vaccination. To date in Los Angeles County we have had over 1.23 million COVID-19 cases and 23,736 deaths within a 10 million population.

22 April 2021 Blog Post: Continued Decline in COVID-19 Rates in Los Angeles County [Also available at: https://drbretsky.com/22-april-2021-blog-post-continued-de/] COVID-19 case rates continue to decline in Los Angeles County and now stand at 3.6 new daily cases per 100,000. The last time we had a case rate this low was March 24th, 2020 and our total case count stood under 3300. A year, 1.23 million cases and 23,702 deaths later we are left with the strangest looking epi...demic curve I have ever seen (Figure 1) Visually, I am struck by how small in magnitude our July 2020 surge seems when compared to the massive outbreak of cases we sustained from November 2020 through January 2021. However, from the week ending 1/12/2021 we began to have a steep decline in cases. The last month has been relatively flat in terms of case numbers. 3/23/2021: 4.4 new daily cases per 100,000 population 3/30/2021: 4.23 4/6/2021: 4.38 4/13/2021: 4.44 4/20/2021: 3.60 Deaths, on the other hand, remain in a consistent sustained decline from a peak of 2.66 daily deaths per 100,000 the week ending 1/12/2021 to 0.04 currently - seen in Figure 2 below. Plotting case rates and mortality rates shows that mortality rates are in a steeper decline than case rates. This, as I have discussed before, is most consistent with a vaccination effect which strongly protects against hospitalization and death (effectively 100% protection). Further, by prioritizing those at highest risk of severe disease initially, we have more strongly influenced mortality rates as a result. This is seen in Figure 3 below. So this is all very encouraging news. With such a low population case rate and now evidence of effective immunity among our most vulnerable, we can feel more confident about pushing reopening strategies and discontinuing some of our corona-theater such as temperature checks and outdoor masking.

13 April Blog Post: J&J Vaccine Induced Thrombosis Also available at: https://drbretsky.com/13-april-blog-post-jj-vaccine-induce/ I have had several questions about today’s pause in Johnson & Johnson COVID-19 vaccine administration after 6 cases of a specific type of stroke among the 6.8 million individuals receiving the vaccine. Termed cerebral venous sinus thrombosis (CVST) this exceedingly rare outcome has occurred only among women aged 18-48 with symptoms beginning 6-1...Continue reading

With all the (appropriate) focus on how vaccines can help open schools, business and recreation safely - we shouldn’t forget about testing. Today we will do almost 150 rapid antigen tests in an outdoor setting.

11 April 2021 Blog Post: "Decoupling" COVID-19 Mortality from Cases [Also available at: https://drbretsky.com/11-april-2021-blog-post-decoupling-c/] While there are known differences in overall efficacy of the three major COVID-19 vaccine available on the US market, Pfizer, Moderna, and Johnson & Johnson, on one metric they all perform flawlessly - they all prevent COVID-19 mortality at 100% efficacy.... As we watch Michigan struggle with rising case loads (currently 9 of the top 10 affected metropolitan areas are in Michigan, source: https://www.nytimes.com//five-ways-to-monitor-coronavirus-), it logically leads to concerns about the same potential uptick in cases occurring here in Los Angeles. One interesting difference between Michigan and our region is that, until now, Michigan did not suffer a mid-summer surge in the same way that we did here. This, I suspect, leaves a sizable susceptible population. The vaccine rollout in Michigan is equivalent to that here in California with 76% of accolocated vaccine having been distributed in both state (California ranking 30th and Michigan 31st). Here in Los Angeles County new COVID-19 cases have continued to decline, now for the 12th week in a row and stand at 3.8 new daily cases per 100,000. There is some plateauing to this decline, however, with its initial steep decline slowing in late February. However, death rates have continued to plummet and are now at 0.08 new daily deaths per 100,000 population.down from a high of 2.66 in mid January. The shape of this curve has turned even more sharply downwards over the last month (Figure 1 below). The decoupling of case and mortality rates most certainly represents a vaccine effect for two reasons. Firstly, with 100% efficacy against death, a vaccine effect in the population will first show among the outcome against which it provides greatest protection (similarly, hospitalizations should also show such a pattern). Secondly, we have targeted initial vaccination efforts among those at highest risk - particularly the elderly who have shown the highest COVID-19 mortality rates. It is for this reason that we see an amplified effect of vaccination. At this point it seems that we continue to head the right direction as a County and can look towards additional reopening measures.

8 April 2021 Blog Post: COVID-19 Mortality Rates in Los Angeles County [Also available at: https://drbretsky.com/8-april-2021-blog-post-covid-19-mort/] We have come full circle in one year’s time - COVID-19 mortality rates for the last week of March 2021 are identical to those of the last week of March 2020, 0.1 daily deaths per 100,000 population (Figure 1). It took a lot of work to arrive back where we started.... In general, mortality rates have tracked with case rates throughout the entire pandemic (Figure 2 below) - with a slight 2-3 week delay. In other words, as cases begin to rise, soon thereafter deaths begin to rise Lending visual credence to the more cases, more hospitalizations, more deaths adage we have experienced since the earliest outbreaks in Italy, for example. A couple of trends are notable looking at these two juxtaposed graphs (plotted on a log scale so they can be compared directly - note that this will smooth out some of the peaks most particularly in mid-summer). But what we can see is that deaths rise swiftly in the early days of the pandemic, quickly reaching a peak of 0.4 daily deaths per 100,000 that holds as a maximum until after Thanksgiving 2020. So why did they rise so quickly and then flatten? Well, initially we had no idea what we were doing - no idea that individuals did better if we delayed placing them on ventilators or if we started steroids earlier. By that point there were no monoclonal antibodies and, from a public health standpoint, we were only learning that older individuals were at greatest risk. All of those factors combined to create a harsh initial reality and high mortality rate. By December, however, we had completely overwhelmed our healthcare system with cases which had been rising since September but then jumped with Thanksgiving travel (note Los Angeles County put in travel restrictions after Thanksgiving but should have done so beforehand). So our early September ratio of 7.8 new daily cases per 100,000 to 0.2 daily deaths became 140 / 2.7 at our January peak. In fact, our mortality rate ratio (cases:deaths) went from 39 to 52 again likely indicative of an overwhelmed system. But look at the two curves after January - we can now see a bit of a plateau in case rates over the last month, but death rates have still dropped sharply nearly approaching zero. While a less punished healthcare system and better treatments are no doubt part of this trend, consider too the potential effect of vaccinations which began in earnest in January among our most vulnerable. With 100% effectiveness against hospitalization and deaths, we may indeed be seeing the efficacy of these vaccines (primarily Pfizer and Moderna) in action. See - not all doom and gloom from this writer. Acknowledgements: thanks to @tdubey from Twitter for pointing out the contribution of vaccination (even just first doses) on the mortality rate curve

7 April 2021 Blog: Towards More Aggressive Reopening in Los Angeles County [Also available on: https://drbretsky.com/7-april-2021-blog-towards-more-aggre/] In near simultaneous statements, Governor Newsom announced plans for a wide reopening of the state (link: https://abc7news.com/newsom-update-green-tier-california//), while Los Angeles County officials revealed that COVID-19 case declines have ‘stalled’, risking such plans (link: https://patch.com//las-coronavirus-c...Continue reading

22 March 2021 Blog: COVID-19 Metrics at Historic Lows in Los Angeles County [Also available at: https://drbretsky.com/22-march-2021-blog-covid-19-metrics-/] There is increasing discussion across the US about the potential for a 4th wave of COVID-19 infections - but there is no indication of such occurring at this time in Los Angeles County. ... Such an instance would occur due to the intersection of increasingly contagious variants and inadequate population immunity. Because population immunity is a function of natural infection and vaccination, any such 4th surge in COVID-19 cases would be the direct result of a failed vaccine rollout. Why? Because, without exception, all known variants have been shown to be susceptible to the neutralizing antibodies provided by the three vaccines on the market - Pfizer, Moderna and Johnson & Johnson. Earlier this week, published in Lancet, a Danish study estimated that the net effectiveness of natural COVID-19 infection against a subsequent re-infection was about 80% at six months. However, among those over the age of 65 years, this rate of protection dropped to 47%. While Los Angeles experienced its greatest surge in early January (Figure 1), during which at least 25% of the population became infected, our chief defense against a 4th surge is a swift, effective and encompassing vaccination effort. As a County, we are currently in our 10th straight week of decline. Prevalence (the estimated proportion of individuals with active infection) in Los Angeles is now less than 1 in 1,000 (actually 0.98 per 1000 population for those keeping score at home) which is the lowest rate it has been in 52 weeks (Figure 1). New (incident) cases are at a level also not seen since March 2020 - 4.7 new daily cases per 100,000 population (Figure 2). Mortality is down to 0.2 daily deaths per 100,000 (Figure 3), a rate last seen in April 2020. Yes testing rates are falling but so are positivity rates which are beneath 2% - a historic low. The most recent estimate for Rt (effective reproduction number) for Los Angeles County stands at 0.59 (source: http://metrics.covid19-analysis.org) indicating that each new COVID-19 case will lead to less than one additional case - meaning that on its current trajectory, COVID -19 will eventually disappear. So, at this writing, there is no evidence that we are heading for a 4th wave here in Los Angeles. Continued improvement in case numbers, however, will be dependent on a County government led vaccine rollout which, once again, will only focus on delivering second shots this week.

22 January 2021: COVID-19 Update for Cases and Deaths, Los Angeles County Post also available on https://drbretsky.com/22-january-2021-covid-19-update-in-l/ Both case rates and mortality rates in Los Angeles County have dropped sharply over the last two weeks (see graphs below).... We saw the highest incident case rate the week ending December 22nd, 2020 (the County reports to the State on Tuesdays, so the "week end" is a Tuesday) at 137.7 new daily cases per 100,000 population. For the week ending this Tuesday, that rate has plummeted to 81.4. A similar trend is seen in mortality rates (remember: more cases lead to more hospitalizations which lead to more deaths). A maximum mortality rate was seen the week ending January 5th, 2021 (also remember deaths will lag by 2-3 weeks from a case peak) of 1.34 daily deaths per 100,000 population. We now have 0.23 daily deaths per 100,000 population in Los Angeles County. The magnitude of the drop offs is striking, and hopeful. However, I suspect that there is an element of delayed reporting as well - perhaps from the recent holiday or from the Health Department now being occupied with a vaccine rollout. Until next week's numbers, lets keep an eye on the raw values reported today: 81.4 case rate, 0.23 mortality rate for the week ending 1/19/2021. Let's see if these revise upwards in the weeks ahead. Also I have additional concerns about the B.1.1.7 variant for both case rates (more infectious/transmissible) and mortality rates (information from the UK today suggest that is may be more lethal as well). More on this tomorrow...

I received the following question on our website (drbretsky.com). I thought it was worth posting. Question: Will the new Executive Order by Chair of LA County Board of Supervisors Hilda Solis, ordering LA County to make Covid -19 vaccinations available to residents over 65, starting January 21st, speed up vaccines arriving at medical groups, like Dr. Bretsky’s office? I am trying to avoid pharmacies and the Stadiums!... My Answer: The Executive Order widening criteria of who is eligible for vaccination did not come with a request or mandate to increase vaccine supply. So, in essence, it is an empty gesture. At the writing, the County of Los Angeles has unilaterally decided to provide vaccines through 5 sites - each of which at maximum capacity will vaccine 4,000 patients a day. Because the vaccine is a two dose series, it will take the County 2.7 years to vaccinate the 10 million residences of the County. There has been no additional allocation to individual physician's offices (ours has been State and CDC certified since December 17th, 2020) or health systems (can refer to recent statements by Providence and UCLA Health).

This is disturbing since LA County vaccine roll-out has prioritized grocery stores. https://www.nbclosangeles.com//ovid-outbreaks-sky/2507053/

14 January 2021: On Vaccine Distribution So today I have had a lot of questions about vaccine distribution as well as excited calls from patients who have been able to make appointments at Ralphs. This came as a surprise to me as Los Angeles County has not yet moved into a phase where those over 65 years of age are even eligible to receive vaccine - the Health Department is still working to vaccine healthcare workers and expects that this process will take until "the beginn...Continue reading

11 January 2021: Current COVID-19 Outlook in Los Angeles [Also available on https://drbretsky.com/11-january-2021-current-covid-19-out/] You may have already heard the news that Los Angeles will transition the Dodger Stadium testing supersite into a "mass vaccination center by week’s end. This move is occurring as the COVID-19 vaccine rollout has failed by all measures.... Although an attractive option to transform a testing center into a vaccine center, this move is misguided and is emblematic of a panicked decision made by an overloaded Public Health Department. In doing so, Los Angeles is hoping to shift resources from one priority to the next. The problem is, however, that Los Angeles has missed the point that there are now two concurrent and equality pressing priorities which need to be addressed simultaneously. This is illustrated by the fact that we are now back near the highest case rates ever (Figure 1) at 130.5 new daily cases per 100,000 population (previous high: 135.9). Testing rates are down 30% from their 12/22/2020 peak (Figure 2) and removing the largest coronavirus testing site in the nation will only serve as a further bottleneck I agree that testing sites are a natural venue for vaccination - but these efforts need to be concurrent, not mutually exclusive. Dodger Stadium has multiple entrances and is perfect to run two efforts. But the problem? Too few resources. For some reason, Los Angeles and the Health Department have insisted upon taking over the entire community vaccination effort themselves. There is no reasonable historical expectation that they should be able to manage this effort. Health Departments only provide 1% of the annual influenza vaccinations so to task them to suddenly provide vaccines to all except those on staff at hospitals is far outside of their scope of expertise or capability. But at the end of the day, the fact that Los Angeles cannot get out of its own way on this issue is costing lives. The most recent mortality rate is now 1.34 daily deaths per 100,000 population which is the highest it has been since the start of the pandemic. This rate has increased every single week since 11/10/2020. At this point we need the County, the City and the Public Health Department to do everything well. Sacrificing testing for vaccination is the epidemiologic equivalent of robbing Peter to pay Paul. If they cannot manage it themselves, then they need to ask for help.

Bullet points from my TV interview with Spectrum News 1 SoCal yesterday: 1. Rapid antigen testing can and should be widely deployed in healthcare offices. 2. Vaccine roll out has been, bottom line, way too slow.... 3. If we cannot rapidly and effectively vaccinate healthcare workers at their workplace, how do we expect to be able to vaccinate the general public? 4. Primary care offices (which include Internal Medicine, Family Medicine, Pediatrics, and OB/GYN) need to be included in the vaccine distribution process if we are to be successful in any mass vaccination campaign.