Public health measures to track and battle virus, variants

Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

Host Amber Smith: This stage of the pandemic is different from the beginning or even from a year ago. Here to help us understand is Dr. Christopher Morley. He's professor and chair of public health and preventive medicine at Upstate. Welcome back to The Informed Patient, Dr. Morley.

Chris Morley, PhD: Thank you so much for having me back, Amber. It's always great to talk to you.

Host Amber Smith: Now, two years ago as the COVID-19 pandemic was just getting started, we learned about the basic reproductive number. It was called r naught. It was supposed to be a way that scientists tell the average number of susceptible people that each infected person is likely to infect. But we don't really hear about this number anymore. Does it still matter?

Chris Morley, PhD: It does still matter. We don't watch it as, as closely as the sole indicator. One of the reasons we watched r naught so closely early on is because it was the indicator that told us what this brand new virus was going to do. And, uh, the thing that turned out to really matter is the r naught is the value that tells us what a virus does when it's unimpeded. R T, or the reproduction rate at a particular given time, tells us how the virus is responding in real time to the impact of society's interventions, like distancing, masking or the introduction of vaccination, because the reproduction rate will change. So the RT is a measure of how quickly or slowly the viruse is reproducing. And one of the things that's key about measuring R T is that it's how we assess variants against one another.

Chris Morley, PhD: We don't talk about it as much, in public, because we pretty much understand in broad strokes the dynamics. And in our region in Onondaga county, we settled into an R T of about 1.3 when we were hitting a bad surges. And when we got things under control, we would settle down below 1, because at that point, if a person is infecting less than one other person on average, an R T of around .8 is essentially when we were in our lulls.

Chris Morley, PhD: Unfortunately, the omicron variant now has an RT that we're calculating of almost 1.7. It was about 1.68 the last time the biostatistician, Dr. Dongliang Wang in my department calculated it the other day. So, that's markedly higher than we've seen in the past. That value is a way to express how much worse omicron is.

Host Amber Smith: Is there a number that tells how deadly a virus is or how,if it's going to put you in the hospital, or kill you?

Chris Morley, PhD: We do look at population adjusted rates. So when we look at how deadly or how risky something is for severe illness, hospitalization is one way to measure the severity of a virus or its morbidity. And hospitalizations per hundred thousand allow us to compare hospitalization rates across different viruses, different illnesses, across different variants of the current virus or against regions.

Chris Morley, PhD: The hospitalization rate is another important metric that we look at, and we understand what those are by adjusting for population. And currently we have a hospitalization rate of about 33 people per hundred thousand in hospitals right now in Onondaga County. Similarly, if you look at the death rate per hundred thousand, that's the way to assess, rather than taking the raw number of deaths, it's a way to express it as a rate within the population. Right now we're about 1.6 deaths per day as a seven day average. So we're losing about a one to two people every day.

Host Amber Smith: So those are numbers that are based on reality. They're not a projection. So you kind of have to wait until time has passed to be able to look back and see what happened. Are there numbers to project, or predict?

Chris Morley, PhD: So there are a lot of models. We've done modeling, other people have done modeling, to try to assess where we're going as a trajectory over the course of the pandemic. And here's the problem. Early on, we didn't know much about the virus, so it was tough to predict. And every time we get one of these new variants, and particularly with omicron, it's been tougher to model. Now that doesn't mean people aren't trying, but by and large, what we are turning our attention to is looking at other regions that, unfortunately, have suffered the introduction of omicron earlier than we have. We basically, the best predictors for what's going to happen here is by looking at comparative states. So a lot of people, for example, looked at what happened in South Africa, but understanding whether that's a good comparison or not means looking at the population dynamics, the age distribution in the population, at how many people have been infected or vaccinated, and what kind of measures the population is taking against the vaccine, as well as the seasonality. So there are things that are different about South Africa. South African is about to enter summer. A lot of their population is younger than ours. And, they also have been more universally exposed. By some accounts, over 80% of people have been, had some exposure to the virus. So the dynamics of how the pandemic will play out there with the new variant will be different. Where we're watching closely are in a European states who are entering winter, just like we are and who have similar vaccination rates and similar age distributions as, as Western societies. So we're watching particularly the UK, the United Kingdom, very closely for how things play out there. Typically we'll rely on those real world experiments that are playing out before our eyes, before I start modeling, because the modeling is based upon our assumptions. And we don't know what assumptions to make about the new variant.

Chris Morley, PhD: We're learning more every single day. But at this point we -- luckily for us, unfortunately, for other states and countries -- have real-world examples to look at.

Host Amber Smith: This is Upstate's The Informed Patient podcast. I'm your host, Amber Smith. I'm talking with Dr. Chris Morley, who leads the department of public health and preventive medicine at Upstate.

Host Amber Smith: I'd like to ask you how cases are tracked in New York state. Does the health department, the state health department, get the numbers of positives from all of the county- and all of the state-run testing sites on a daily basis?

Chris Morley, PhD: Yeah, that's right. And I do want to sort out that many antigen tests, especially those at home kits, don't go to the state, but basically any certified lab that's doing a PCR test. And any clinical tests that's using using antigens should be referring to the state. With very few exceptions, most of the tests that we see go on are transmitted to the state. The state is the central repository.

Host Amber Smith: So how do researchers know if they can trust the numbers from particular states? Because I'm sure the way New York state does it is different from all the other states. So how are you able to compare?

Chris Morley, PhD: We like to assume that most public authorities are honest brokers of the data, and I want to say that in practice, it looks like most are., I really don't want to get in hot water calling out particular individual municipalities or states, but when you have things that look patently false, like suddenly there are zero cases in an entire state in a day, that is highly suspicious. And I don't feel constrained by saying that if you see a state of millions of people reporting almost no COVID when every other state in the country is still reporting cases,that's suspicious. That's not happening at the moment, but that has happened in recent times. And that's just a signal that maybe something isn't right.

Host Amber Smith: Early in the pandemic, contact tracers were being used to help find people who might be sort of unknowingly exposed. Are contact tracers still being used with this omicron variant? It seems that omicron has sort of just taken over.

Chris Morley, PhD: Yeah. At this point there are still contact tracers employed. The, job is massive, though. I, want to recognize the fact that at this point, we are dealing with such a level of case production in the county. And this is true, not just in our county, in Onondaga county, where I'm speaking to you, but across the state and in most parts of the United States at this point. We are dealing with such a surge of cases that it's just, it outstrips the ability to do all the sorts of contact tracing that we were, especially during lulls. So at this point, what I think you have to shift your attention to is away from trying to figure out where a single case came from and look to monitoring the fact that we have a massive number of cases. And responding to those as a society, understanding what a risky behavior is and how we need to alter those, as opposed to trying to trace an individual source.

Chris Morley, PhD: At this point, if somebody's coughing, if somebody believes they've been exposed, you've probably been exposed. And if you're coughing and symptomatic, the odds are strong, they are very high that you should assume you have come in contact with SARS CoV-2 and are experiencing COVID-19.

Host Amber Smith: Now at the beginning of the pandemic, I mean, stores were closed. They were ordered closed. There were, talk about mask mandates. Things seem a lot looser now, but it's still important for people to take their initiative, to protect themselves. So I wanted to ask you what is important for people to be doing now if they want to avoid becoming infected.

Chris Morley, PhD: I really appreciate that question because the impact of the pandemic has been a multi-headed Hydra. It's impacted so much. Obviously, it's impacted our health, but it's impacted our functioning as a society as well. And I want to recognize that. So when we initially did studies, and I spoke to you about it over a year ago about the impact of distancing and close-down measures, they were effective at shutting down the virus, but they came with a cost.

Chris Morley, PhD: And so in order to function, we've learned a lot more about the virus. I mean, most of us aren't washing our groceries anymore, and we've learned how to function together without, before omicron, without rapidly transmitting virus to one another. We have crawled back to a semblance of functionality. And there are tools, we do have tools at hand, and the first, obviously, is vaccination.

Chris Morley, PhD: I do want to talk about that for a moment, if you'll allow me, because a lot of questions arise about vaccination. And I hear them in the form of challenges, like "I got two. Why do I need a third?" Or "I did everything they told me. Why do I need to do this?" or "How many vaccines do they expect me to get?" I understand that the messages potentially have been cloudy and we're learning as a scientific body how to move forward. But the bottom line is that we get flu shots every year. Flu shots every year are intended for exactly what happens with COVID. We have new strains and new variants, and strains compete with one another. Then mutate. And we have a new flu vaccine every year. We haven't gotten to the point where we're reformulating vaccines specifically for variants yet, but we also have the other factor of waning immunity. A vaccine protects you only for so long, so different vaccines last for different amounts of time.

Chris Morley, PhD: So you should get a tetanus booster every 10 years or so. We should probably update flu, with or without new variants every year. And so there are different periods of time that vaccines last. What we're learning is that the baseline for vaccination against COVID-19 is probably a three-shot regimen. And and we probably need boosters going forward. We probably run out of antibodies after a period of time. And additionally, not everybody forms the same T-cell memory, so we will need boosters to keep our immune systems humming and ready to fight the next wave of COVID.

Chris Morley, PhD: So my answer to people is, you have experienced this, you have experienced multiple vaccinations. It's not different. This isn't strange. Vaccination is really important, including boosters and including just doing your best to listen to the advice of scientific and medical professionals, and get vaccinations when you're supposed to, and be prepared for more. That's just going to keep happening.

Chris Morley, PhD: I would also urge people to modify their expectations about what vaccinations do. Although every one of us, at this point, with this surge, probably knows somebody who, despite being vaccinated and boosted, came down with COVID and is experiencing symptoms. But here's what's not apparent, what's not obvious just by watching people around you. What's not apparent is that the hospitalizations we're experiencing are, by and large, still people who are either unvaccinated, and the odds of being hospitalized if you're unvaccinated are five times that if you're vaccinated. So you're still far more likely to be hospitalized if you're unvaccinated, and those people who are vaccinated and end up hospitalized often have a series of risk factors. So it's basically, there are explanations for why vaccinated people are getting hospitalized at all, and it is much less likely. And in terms of people leaving the hospital, which is also a really big issue, you want to leave the hospital if you go in. If you don't leave the hospital, it's because you have had the most unfortunate outcome of all. And that most unfortunate outcome of all -- death -- is 14 times more likely in people who are unvaccinated.

Chris Morley, PhD: So that's not apparent to the lay watcher who's sitting around watching people who are vaccinated come down with something that looks like a flu. That's not going to be apparent to you, but when we aggregate the numbers and watch them, as public health professionals and as a scientific community, what comes out is a very stark and clear picture that vaccination, when it is done fully and effectively, meaning two shots anda booster, at this point, is really protective against the worst outcomes.

Host Amber Smith: In addition to vaccination, what about masking? Is that still recommended and social distancing? Is that still in play?

Chris Morley, PhD: Absolutely. After vaccination, I would rank the next most important thing we can do is wearing an effective mask. Now that's evolved, and I want to be clear with your listeners that we've had a lot of debate as a scientific community. And unfortunately some of that plays out in front of the public and it's never good watching the sausage get made, but ultimately there is a product, and we know what works and what doesn't work. A cloth mask at this point, in the face of omicron, is probably not very effective. There's multiple reasons for that. One, cloth masks were never ideal, but a good multilayered cloth mask was probably better than nothing for most of the time. To be honest, a good cloth, multilayered, thick mask is probably better than absolutely nothing, but you don't want to be out there with absolutely nothing. It's proving not to be a very effective. It's a little bit too porous and it doesn't stop enough virus for it to stop it from reproducing. Additionally, if you're wearing the same cloth mask, as you have since the beginning of the pandemic, you've probably hopefully washed it several times. It's not a good thing, even if it's brand new. If you've been using it for a while, it's time to retire it.

Chris Morley, PhD: So what do I mean by a good mask? Well, those cheap, paper ear loop masks that look like you're walking into an OR (operating room.) Well, you look like you're walking into an OR for a reason. They are actually really good at preventing you from infecting another person. And the more people wearing those, the more they're preventing infection across the two individuals. They do multiple things. In addition to filtering our particles, they redirect the flow. So even though people will argue that, oh yeah, I can still smell things. I can still feel air come around the sides. That's true. But if you have a blast of SARS CoV-2 COVID-containing air coming out of your mouth or nose going forward, and it gets redirected to the side, that airflow matters. And so if you haven't blast this one full on in the face, and it's redirected and gets mixed in with the solution of air we're all sitting in and gets into the HEPA filters, hopefully we're using in buildings, or when we're outside, that is actually an effective stop. And it also does help prevent you from getting blasted in the face by somebody else's viral discharge.

Chris Morley, PhD: We have had problems and concerns, and the CDC has a website that lists out makers of counterfeit or, or otherwise suspect, K-N95 masks. But the bottom line is retailers like Amazon have taken steps to guarantee that K-N95's that they are selling are checked for compliance. K-N95's are typically often considered non-medical devices, but in public they form a better seal than surgical masks.

Chris Morley, PhD: Um, it is important to make sure that they are sealed. Investing in a K-N95, for example, if you have a thick beard and it doesn't form a seal, you're defeating the purpose. But if you can form a good seal with a K-N95 and adjust the metal clip around the nose so that it's form-fitting, that's really a great level of protection. When I'm walking around in my personal life, I am using a K-N95 now. We do try to use utilize N-95s, which are really the the top tier of personal protective equipment, for medical professionals. And those reasons we're still reserving those. We aren't in the same dire circumstances as we were previously, when we were actually running out. We are still trying to make sure we preserve those masks for people who are treating COVID patients or in clinical settings where they have a high likelihood of exposure.

Chris Morley, PhD: The other issue, in addition to preservation for our medical professionals, is that for an N-95 to be worth the investment, you have to properly fit test them. For most manufacturers, you have to properly fit test them. So if you're wearing a poor fitting N-95, you're really not doing much better than you would be getting with a K-N95 or even a surgical mask. So at Upstate, we do fit test people. We know the brand and size, and if we change brands, people have to be refit tested and we refit test people every year. So as your face changes you're refit fit tested. And that's the appropriate context to use an N 95. Otherwise, I would save them for people who are using them in those contexts, when they're fit tested, when they're most urgent.

Host Amber Smith: Before we wrap this interview up, I wanted to ask you when we will know when the pandemic is over. Are there parameters or numbers to watch that are going to tell us when this is done?

Chris Morley, PhD: That's a great question, and it's one we all ponder. One thing that I would say is obviously, the numerical value of R equals less than one, or is less than one, is a good sign, but that doesn't tend to last. And so what we really need is a good, solid, several month period or even a year where we are basically not seeing these dramatic surges. If this were a visual presentation, I would show you graphs where we see large spikes. And the reason I'm describing that is because I think most of your listeners, if they have access to a computer, can Google basically any line graph of where the COVID epidemic has played out over time. And you'll see that you see large spikes that come down and then you see another large spike, and that's not how a virus or other pathogen that's endemic behaves. You have a, basically a steady state.

Chris Morley, PhD: We do actually have other epidemics. I mean, the flu is an epidemic that we actually devote tremendous amounts of resources to managing the flu epidemic we experience most years. Most people don't see it. They don't understand it. But we have a massive vaccination effort. We have a massive tracking effort. We know how to do it. It's just so ingrained that most people don't understand it's happening. But the problem is that SARS CoV-2 is such a worse virus. And I want to keep saying that it is not the flu, and it is such a worse virus and behaves so differently that that's why we are feeling it.

Chris Morley, PhD: But, when you actually get to the point where something is endemic or is epidemic, but it's a way that you can manage, those fluctuations or those dramatic spikes will be much more blunted or not even appear at all. You'll have a steady state. And unfortunately you just need a period of time where you watch it play out. And you say we haven't had a huge spike in awhile. This is probably turning to an endemic status.

Host Amber Smith: So it started feeling that way toward the end of the summer. But I guess some of us started celebrating a little too soon thinking it was over and it wasn't.

Chris Morley, PhD: Oh, those of us who were watching this didn't feel that way. I don't mean to dispute my on-air host and good friend, but, at the end of the summer, we were watching the last variant, the delta wave, take over in Central New York. We watched that play out at the beginning of August, and by September, we knew we had, well, by mid August, we knew we were seeing something resurge. And by September we understood, we were in a problem area. And we spent much of September, October, November dealing with quite a large surge. We didn't reach the same peak as we did last year. And we didn't see quite as many hospitalizations because of vaccination, but we did see a surge. It was delta driven.

Chris Morley, PhD: And in Central New York, we saw that persist beyond where it persisted in Western New York or in the capital region, for example, similar regions. But where we had the New York State Fair, for example, we had a large gathering. We actually persisted, and we continued to see a surge through September.

Chris Morley, PhD: Unfortunately the omicron variant hit us after we were already experiencing a surge. We were already at several hundred cases a day with delta variant. From beginning in August that surged upwards and through November and December, we were experiencing over a hundred, and almost 200 to 300 cases a day before Omicron hit us. So we were not in good shape. So I think we're a fair ways away from being endemic, unfortunately.

Host Amber Smith: Theoretically, would the pandemic be over if we had a vaccination rate of a hundred percent, since we're just talking theoretically? If everybody was vaccinated in the US, would this be over, or would that not be possible because this is global?

Chris Morley, PhD: There's a lot of ways to answer that. If everybody in the U S had been vaccinated, here's how that would've played out. We still would have had variants evolving in other parts of the world. Where the virus can reproduce, it will introduce new variants. New mutations will occur, and new variants will arise where it can reproduce, and it can reproduce where people are still able to serve as hosts. And we still would have had variants.

Chris Morley, PhD: Would we have had the problem we are having now? Perhaps not. Here's what would have been different. First of all, when we say we are 70, 80, 90% vaccinated, whatever number you want to use, you have to remember that, that immunity wanes. Those people who are vaccinated in December and January and February, first of all, were older, they were more at risk. So you got the double whammy that they're the furthest back. And probably the people who mounted the least robust immune response. So to consider them still vaccinated is probably a fallacy. They needed to be boosted. We didn't have boosters. We didn't have the data to do it, so that's not a criticism.

Chris Morley, PhD: But the bottom line is, if we had been 100% vaccinated all at once in a rapid short cycle of time. If everybody had basically gone out and we had enough supply and vaccinated, everybody, we could vaccinate rapidly, yeah, you would've had a much more effective wall than we have where we're talking about a number that actually is kind of meaningless because it's trailed out over the course of the year. I hope that explanation makes sense.

Host Amber Smith: It does. And I appreciate you taking time for this interview. My guest has been Dr. Christopher Morley. He's professor and chair of public health and preventative medicine at Upstate. The Informed Patient is a podcast covering health science and medicine brought to you by Upstate Medical University in Syracuse, New York. I'm your host, Amber Smith, thanking you for listening.