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delta variant

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After seeing enough cases of vaccinated people testing positive amid a surge in the Delta variant that has become the dominant strain of the virus in Suffolk County, local health officials support the federal government’s plan to provide booster doses eight months after the first course of vaccination.

Several studies have pointed to the benefit of boosters, highlighting how people who are vaccinated have lower antibody levels over time and are more susceptible to the highly transmissible Delta variant.

Centers for Disease Control and Prevention Director Rochelle Walensky and Food and Drug Administration Acting Commissioner Janet Woodcock said in a joint statement on Wednesday, Aug. 18, that the government is prepared to offer booster shots for all Americans beginning the week of Sept. 20 and starting eight months after people received their second shots.

A recent study by Mayo Clinic researchers looked at records for 25,0000 vaccinated and unvaccinated patients in Minnesota. The study showed 76% effectiveness in the Pfizer vaccine protecting them from infection, but 42% effectiveness in July during COVID, Sunil Dhuper, chief medical officer at St. Charles Hospital, explained in an email.

At the same time, Health Ministry of Israel data showed a similar progressive decline in the effectiveness of the vaccination in protecting patients from infection over a six-month period, particularly amid Delta variant surges.

Still, the vaccinations continued to provide protection against more serious forms of the disease, with a much smaller 10% decline in the effectiveness of vaccines in protecting people against hospitalizations, Dhuper said.

In physician practices, urgent care centers and emergency departments, doctors are seeing a “sizable number” of breakthrough cases, Dhuper continued.

Adrian Popp, chair of Infection Control at Huntington Hospital/ Northwell Health, said Huntington Hospital has seen breakthrough cases, although most of them are “mild” and are “diagnosed incidentally when patients get admitted for other issues.”

Dhuper urged residents to take precautions similar to the ones they took last year before vaccines were available, including social distancing, wearing masks and washing hands carefully, especially in indoor settings.

At this point, boosters will likely be available for the Pfizer/ BioNTech and Moderna vaccinations. The Food and Drug Administration is still looking at data for people who received the Johnson & Johnson shot.

Once the FDA provides Emergency Use Authorization for a booster for the general population, medical health experts anticipate a much smoother roll out than the initial struggle with finding vaccinations.

“As all who have been vaccinated in New York State have a [Centers for Disease Control and Prevention] vaccine card,” Sharon Nachman, chief of the Division of Pediatric Infectious Diseases at Stony Brook Children’s Hospital, said in an email, “It should be straightforward to each person to get a booster at the eight-month mark.”

At the same time, parents are focused on the timing and availability of vaccines for children under the age of 12. Results from the trial are “expected in December 2020,” wrote Popp.

Medical experts continue to urge residents to receive their shots.

“It is hoped that the booster will cut down on these infections and thus transmissions,” Nachman said.

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At the same time that the United States battles against the more infectious Delta variant of the COVID-19 virus, hospitals in Suffolk County are experiencing similar trends among those infected and who need medical attention.

The Delta variant accounts for over 80% of those infected in the county, according to Dr. Gregson Pigott, commissioner of the Suffolk County Department of Health Services. The percentage of positive tests has climbed from below 1 percent earlier in the summer to between 2 and 3 percent.

“People over 65 find themselves more vulnerable and more ready to accept the vaccine. Younger people can consider themselves invincible. That is leading to greater hospitalizations than we’ve seen among those who are under 65.”

— Dr. Sunil Dhuper

Those figures are likely even higher “given that it is all dependent on the numbers of persons being tested and why,” Dr. Susan Donelan, medical director of Healthcare Epidemiology at Stony Brook University, explained in an email.

Meanwhile, the percentage of law enforcement members in Suffolk County who are vaccinated is lower than that for the county as a whole. According to the county Police Department, through May, 47% of law enforcement had received a vaccine compared with 57% for the county. Acting SCPD Commissioner Stuart Cameron is encouraging members to get vaccinated.

Health care workers are concerned about the general ongoing trends with the virus.

“The numbers are alarming,” said Dr. Sunil Dhuper, chief medical officer at St. Charles Hospital. “There’s a heightened level of awareness amongst the staff of what’s happening locally and at the state and national level.”

Unlike those who contracted the virus and needed hospitalization in 2020, the majority, about 53%, are between the ages of 19 and 64, according to Pigott.

Additionally, about 99% of patients hospitalized for COVID complications are unvaccinated, according to Dr. Adrian Popp, chair of Infection Control at Huntington Hospital/Northwell Health and associate professor of medicine at Hofstra School of Medicine.

He added that the vaccinated patients are either asymptomatic or have mild symptoms, which means that the risk of hospitalization or mortality is significantly lower even among those with breakthrough infections than for those who are unvaccinated.

The lower number of hospitalized patients who are over 65 likely reflects the comfort level they have with the inoculation.

“People over 65 find themselves more vulnerable and more ready to accept the vaccine,” Dhuper said. “Younger people can consider themselves invincible. That is leading to greater hospitalizations than we’ve seen among those who are under 65.”

The percentage of people fully vaccinated in Suffolk County is 57.8% as at Aug. 4.

“The vaccine has been shown to be safe and effective,” Pigott wrote in an email. “We encourage all residents to get vaccinated to protect themselves and their loved ones, and so that new vaccine-resistant variants of SARS-CoV-2 [the virus that caused the pandemic] do not have the opportunity to emerge.”

Area hospitals have been watching the infection and vaccination trends in the area closely.

St. Charles and Northwell are currently engaged in corporate discussions about when to start testing patients who are vaccinated but might be carriers.

The New York State Department of Health guidelines recently suggested that as long as the positive testing rate was below 2%, hospitals didn’t need to test patients if they are vaccinated when they have elective surgeries.

“We are very concerned about that now,” Dhuper said.

St. Charles Hospital is considering whether to start doing nasal swabs for all patients getting elective surgery to prevent putting patients and employees at risk.

Meanwhile, at Huntington Hospital, employees who do not get the vaccine will need to be tested weekly or biweekly, according to Popp.

As for people concerned about being around others who may have the virus without displaying symptoms, he added that it is “difficult to know when you are exposed.”

The only way to know if someone is infected is to get tested with the COVID PCR nasal swab.

While the Centers for Disease Control and Prevention hasn’t changed its definition of exposure, which includes being within 6 feet for more than 15 minutes indoors with an infected person, Popp recognized that “one can argue that transmission of infection may occur in less than 15 minutes.”

The Huntington Hospital doctor added that riding in an elevator or sharing a car ride with an infected person for under 15 minutes is “very risky due to the small, enclosed space without ventilation associated with the Delta variant that is 50% more transmissible.”

Better treatment

Doctors, nurses and other health care professionals have benefited from their experience with the virus. Hospital administrators feel prepared to handle the variety of symptoms patients have when they need medical attention.

“We now have clear parameters regarding the use of remdesivir, steroids, and other agents,” SBU’s Donelan explained in an email. “Proning is now a proven patient management technique. The role of anticoagulation is well understood.” The proning term means putting a patient in a prone position so the individual is lying face down.

Dhuper said the length of COVID stays at St. Charles have declined because of better treatment and the overall better immune status of those who contract the virus.

“We have come up with better management in terms of who needs to be ventilated, and who needs to be in a prone position prior to ventilation,” he said.

As for the implications for schools, which will reopen for the fall within the next month, medical care professionals urged parents and educational administrators to remind students of the same messages from earlier in the pandemic.

Students should wear masks, social distance, wash their hands and, most importantly, get vaccinated if they are 16 and above, Popp urged.

Current drug trials are underway for children under 16, with results expected in December, Popp said, which means that students in that age group will attend in-person classes with the same protections, albeit amid a more transmissible form of the virus than last year.

Dhuper reminded residents that the response to the virus can range from asymptomatic to extended hospital stays or death.

“People have to know that [these outcomes] can happen in any age group,” he said. “It all depends on the viral load and the immune response. The bottom line is that you have to protect yourself, and you have to protect your family and the community around you. The only way we can be ahead of the curve is by taking the vaccine.”

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Starting on July 23, Tokyo will host the Summer Olympic Games with athletes from around the world without any spectators.

Medical director of Healthcare Epidemiology at Stony Brook University Hospital

Already postponed a year amid the COVID-19 pandemic, the games will look much more like the National Basketball Association bubble games and Major League Baseball’s empty stadiums than the current version of professional American sports.

“There is tremendous vaccination disparity throughout the globe,” said Susan Donelan, medical director of Healthcare Epidemiology at Stony Brook University Hospital, in an email. “Despite what many Americans believe, the global pandemic is very much alive and problematic. Superimpose this on the fact that another state of emergency has just been declared in Tokyo due to rising COVID-19 cases, and it is not difficult to understand how this decision was arrived at.”

Indeed, the Olympics draw athletes from close to 200 countries and territories, with thousands of competitors representing themselves, their families and their countries.

In Japan, just over 15% of the population is fully vaccinated, which is still “low compared with 47.4% in the United States and almost 50% in Britain, according to Sunil Dhuper, chief medical officer at St. Charles Hospital. “That greatly increases the probability of an explosion in the number of Covid infection cases especially if the Olympic stadiums are packed or even at 50% capacity.”

While people in the United States are increasingly relaxing restrictions after the increasing availability of vaccines, health officials throughout the world have not only had to contend with the uneven availability of the vaccine in different countries, but also with the spread of the more infectious delta variant.

The original virus, or so-called wild type, came from Wuhan, China. Over time, viruses mutate, typically during replication, when they incorrectly copy one or more of the base pairs in their genes.

Sunil Dhuper, chief medical officer at St. Charles Hospital

While most mutations are harmless, some can make a virus more problematic. Termed variants, viruses that differ from the original can produce different symptoms or have different qualities.

The delta variant, which started in India in December of 2020, has become the dominant strain in the United States and, likely in Suffolk County, in part because an infected person can transmit it much more easily.

The delta variant “concentrates in the upper respiratory cells, which is one of the reasons why it transmits so much easier among people and why it’s a concern,” said Adrian Popp, chair of Infection Control at Huntington Hospital/Northwell Health and associate professor of medicine at Hofstra School of Medicine.

Indeed, the delta variant is 50% more transmissible than the alpha, or UK variant, which was about 50% more transmissible than the original, Donelan wrote.

Boosters

Amid the spread of the delta variant, companies like Pfizer have been meeting with federal health officials to discuss the potential need for a booster shot.

Pfizer’s rationale for a booster is that the vaccine’s ability to prevent infection and symptomatic disease seems to wane six months after vaccination, citing data from the Israel Ministry of Health, according to Dhuper.

The World Health Organization, however, indicates that “more data are needed before reaching the same conclusion,” Dhuper explained in an email. A recent study in the journal Nature found evidence that the immune response to vaccines is “strong and potentially long lasting,” which is based on the data that the germinal centers in the lymph nodes are producing immune cells directed at COVID-19.

At this point, officials from the Food and Drug Administration and the Centers for Disease Control and Prevention are unwilling to provide an emergency use authorization for a booster.

These government agencies believe people who have been vaccinated are protected from severe disease and death, including variants like delta, Dhuper wrote.

Adrian Popp, chair of Infection Control at Huntington Hospital/Northwell Health

Popp expressed confidence in the CDC to determine when a booster might be necessary, as the national health organization reviews data for the entire country.

Someone who is vaccinated in the United States should have “decent immunity” against this altered virus, according to Popp. The immunity will vary from person to person depending on the underlying health and immunity.

Indeed, Popp said several vaccinated people who have come to Huntington Hospital recently have tested positive for the virus.

The hospital discovered the cases, all but two of which were asymptomatic, because they tested for the virus for people who were coming to the hospital for other reasons, such as a broken hip. Two of the cases had mild symptoms, while the others were asymptomatic.

“The effectiveness of the current COVID vaccines is quite high,” Dhuper wrote. “In fact, it is much higher than some other vaccines we commonly receive.”

He contrasted this with the annual flu vaccine, which has an effectiveness of around 40 to 60% from year to year.

Dhuper also explained that antibodies are only part of the immune response that makes vaccines effective. T-cells and memory B cells are also involved. Some researchers have found that T cells in the blood of people who recovered from the original version of COVID-19 recognized the three mutant strains of the virus, which could reduce the severity of any subsequent infection.

Based on the available data and current information in Japan, Popp said he would likely participate in the Olympics in Tokyo if he were a member of an Olympic team.

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