This is another in a series of conversations between Dr. Jarone Lee, a frontline critical care and emergency physician at Massachusetts General Hospital and associate professor at Harvard Medical School, and Dr. Paul Hattis, a fellow at the Lown Institute who participates in CommonWealth’s Health or Consequences Codcast.
PAUL HATTIS: How are Massachusetts General Hospital and the overall Mass General Brigham system coping with the recent COVID surge?
JARONE LEE: First, I do hope this is one of the last interviews we will have to do about COVID surges. The next few weeks will likely be the worst in terms of Omicron-related cases, hospitalizations, and deaths. Unfortunately, this surge is coming at a time when our hospitals across Massachusetts are struggling with bed capacity and staffing challenges. Despite these capacity challenges, at MGH we continue to be able to treat all the COVID and non-COVID related disease coming into the hospital.
We are now clearly seeing an uptick in hospitalizations for people sick with COVID, but there has only been a minor increase in COVID patients in our ICUs. Even though COVID infection is more widespread than ever, COVID-infected people are requiring less hospitalization and ICU care because many are fully vaccinated. They rarely need oxygen support or hospitalization for their breakthrough, symptomatic cases.
One interesting thing to note is that we are seeing a good proportion of patients that are incidentally COVID positive in the hospital. They are often asymptomatic from COVID and require hospital admission for some other reason, such as heart attacks or car accidents. Since we test all patients for COVID, this is how we detect their COVID infection. At Mass General, the incidentally infected COVID patients account for around 30 to 40 percent of all COVID-infected patients who are hospitalized. There is likely a much higher proportion of severe COVID patients occupying beds in other regions of the US where vaccination rates are lower.
When the state reports the total number of hospitalized people with COVID, currently it includes both those truly sick from COVID as well as those who are incidentally infected. Thus, the state-reported COVID hospitalization numbers overstate the true burden of the virus in terms of caring for sick COVID patients in our hospitals. Starting soon, the state is going to report these two groups separately.
HATTIS: Are you treating patients differently now than you were earlier in the pandemic?
LEE: The new variant, while clearly seeming to be more contagious, also appears to be less severe and might have less lung involvement. But I say this cautiously as it is still early with our learning about Omicron in the US. Looking at predictions based on other areas of the world can be problematic. For example, South Africa is very different from the US. It’s population characteristics are very different, and is in the midst of summer, not winter.
Of the patients that have COVID now and need ICU care, their care needs are like previous pandemic cohorts. They require high-intensity and complex care and most require some form of mechanical ventilation. Like prior patients with COVID in the ICU, their lungs are severely damaged, and we typically need to use multiple different therapies to keep blood oxygen levels in a safe range. This includes putting them on their abdomen or on lung bypass machines, also known as extracorporeal membrane oxygenation (ECMO) machines.
In terms of total number of sick COVID patients in our ICUs, the next few weeks will be important as to whether our current bed capacity is adequate. In anticipation of possibly needing additional bed capacity, our system continues to plan for opening surge ICUs, and we have started pre-positioning and re-distributing medical equipment, such as ventilators and dialysis machines, between our hospitals in case any of them experience a large surge.
HATTIS: What is the proportion of ICU patients with COVID who are fully vaccinated?
LEE: The short answer is that it remains a low proportion in the ICU—probably under 10 percent. Many of these vaccinated patients with COVID in the ICU are primarily people who are immunosuppressed for some medical reason. These folks could be undergoing chemotherapy for cancer or are taking immunosuppression for organ transplants. Many of these patients tried to do everything right, including getting their vaccination, but still got infected by COVID—highlighting the need to protect immunosuppressed people by using masks, distancing, and testing.
HATTIS: Can you tell us about your use of the monoclonal treatment Sotrovimab, its availability, and who is prioritized for access to it right now?
LEE: Sotrovimab is a monoclonal antibody treatment for COVID-19 that works like others that have been employed during the pandemic, such as the combination of casirivimab and imdevimab, better known as Regen-Cov made by Regeneron. Like the other monoclonal antibody treatments for COVID-19, Sotrovimab is authorized under an emergency use authorization through the Food and Drug Administration, and continues to be an investigational drug, not fully approved for use. Sotrovimab seems to be the only monoclonal currently available that is effective and reduces the need for hospitalization against Omicron. Unfortunately, because of limited supply, priority for this drug is for the highest-risk individuals.
HATTIS: Massachusetts is now about to receive its first doses of the new Pfizer antiviral drug Paxlovid. What is its availability and who are the candidates to receive this oral treatment?
LEE: Paxlovid, an oral medication given for 5 days, seems to greatly reduce the need for hospitalization, maybe up to 90 percent, if given to high-risk patients within the first 72 hours of their COVID illness. Like the monoclonal, it appears to work only during the early infection stage and its benefit if given after hospitalization is unknown. Like the monoclonal antibodies, Paxlovid is approved by the FDA under an emergency use authorization and is still considered experimental and is likely to be in very short supply for the near future.
Another anti-viral drug against COVID was also recently approved under an emergency use authorization sby the FDA – Molnpiravirm made by Merck. It is analogous to Paxlovid, and from early, limited studies also appear to have some value in reducing hospitalizations. Lastly, giving remdesivir–a drug used for sick COVID patients since 2020–early in COVID could also reduce hospitalization of high-risk patients. Instead of a five-day course, remdesivir is given only for three days and, like the others, must be given in the early stage of the illness.
HATTIS: Beyond your MGH role, you also help as part of a national cohort of doctors who, via tele-health, are supporting hospitals and clinicians around the country in COVID patient care management when they have limited critical care expertise.How does that system work?
LEE: Thank you for asking and yes, unfortunately, there are large areas of our nation that normally do not have ICU beds and access to critical care expertise. To support these critical access hospitals, the U.S. Department of Defense with Office of the Assistant Secretary for Preparedness & Response offer a rapidly deployable, lightweight, tele-ICU consult service to any U.S. hospital that requires assistance – called the National Emergency Tele-Critical Care Network (NETCCN ). Overall, NETCCN has supported 37 hospitals from 18 different states and U.S. territories, equating to nearly 5,000 patient care days. Personally, I have helped cover multiple hospitals across many states over the last two years. Currently in the Northeast, we are spinning up to support multiple hospitals in Vermont with their current COVID surge. As a recent Globe article highlighted, frontline clinicians are tired, especially those working in ICUs. A major, and unexpected, part of what we offer with NETCCN is that we can provide relief to front line clinical staff, and ultimately help reduce burnout by offering backup and relief coverage, as well as overall support.
HATTIS: What’s happening with your son?
LEE: He is fully vaccinated. He received his second dose on his seventh birthday in November. We were able to watch the fireworks on Boston Common this New Year’s Eve. Without prompting, our son asked us why the fireworks all look like COVID. A sign of the times.