Holy Name Medical Center in Teaneck, New Jersey, was once the epicenter of the state's first COVID-19 outbreak. MedPage Today spoke with its chief of infectious diseases, Suraj Saggar, DO, in mid-March 2020, when doctors were still struggling to understand this novel pathogen and figuring out how best to care for patients.
MedPage caught up with Saggar earlier this week, to see how things have changed on the front lines in the last 20 months, and to understand how hospitalists are preparing for the new unknowns of the Omicron variant.
After the spring of 2020, Saggar said, the work went "from a sprint to a marathon." Things calmed down over the summer of 2020, and then there was a bit of a surge in the fall of that year and into the winter of 2021.
Soon enough, the vaccine brought "encouragement and hope," Saggar said, with "vaccine euphoria" taking over into the spring and early summer as cases fell to all-time lows.
Then, Delta hit. The surges were "uneven," Saggar said. "Our area wasn't affected as much ... as other parts of the country with lower vaccination rates."
The nation's Delta surge calmed down by mid-fall. But now, Omicron threatens to disrupt the peace yet again.
"It's unclear if that will definitively equate to an increase in hospitalizations," Saggar told MedPage Today. "We're seeing hospitalizations mainly in the unvaccinated population. We are seeing breakthroughs, but these patients are not as sick."
"Even being fully vaccinated, including boosters, we know people may still get illness," he said. "But [vaccines] still have good protection against moderate to severe to critical disease."
At the moment, Saggar said, the hospital is doing just fine: "We're keeping ahead of it. We're in a much better place than we ever were before."
Holy Name didn't have to re-open its extra COVID wards after the first surge, he said, but this remains an option if they're needed.
"The hospital retrofit a lot of regular floors with negative pressure rooms" during the first surge, Saggar said. "The hope is to not have to use those. Having said that, it's always in the back of our minds, and we're being vigilant about case numbers and staying one step ahead of this pandemic."
The bigger challenge, he said, would be staffing those units if they're needed, especially in terms of nurses and respiratory techs and therapists.
"We've seen a lot of older nurses who have taken early retirement, and younger nurses have decided this isn't for them," he said. There's also the lure of higher pay by doing locum tenens nursing work. Some nurses can make enough money working just a few months, and then take some time off, he said.
As for treatments, there are now good options for early disease, Saggar said. Monoclonal antibodies can be helpful, "though we have to adjust which ones we're using in real-time based on variants. But given early, they are highly effective," he said.
The promise of having an oral antiviral in the near future is reassuring, he said. While Merck's data on molnupiravir are "a little disappointing," Pfizer's data on Paxlovid (nirmatrelvir + ritonavir) are better.
Still, both therapies have a high pill burden. Pfizer's drug, for example, is six pills per day for 5 days, for a total of 30 pills, he said. That requires high compliance -- especially when stopping short could increase the risk of resistance.
Patients also need to take antivirals within 5 days of symptom onset for optimal efficacy, he said, so there's a "smaller window of opportunity."
"Based on all that, you feel much better about early COVID," Saggar said. "The issue is when people get to the severe or critical level, and there, we're really out of options."
Saggar said for these severely ill patients, specialists will treat with a range of therapies, including anticoagulation, steroids like dexamethasone, and other immunosuppressants like the IL-6 antagonist tocilizumab (Actemra) and the JAK inhibitor baricitinib (Olumiant).
"Those have varying degree of success," he said. "Once you get to critical-level hypoxia -- they're on six liters or more -- or they're [otherwise] progressed, and once they're vented, that's a really big problem," Saggar said. "We really have very few effective options at that point."
While these patients account for a small proportion of COVID-19 cases overall, Saggar notes that a "small percentage of a large number is still going to equate to an absolute number that's not palatable," referencing the more than 800,000 deaths from COVID-19 in the U.S.
Holy Name is preparing for a "significant surge in the next few weeks to months," he said. The question is, how long will it last?
"Will it turn out that it's truly more infectious but less virulent?" he questioned. "What does that mean in terms of hospitalizations? Maybe we'll have people taking time off of work and school, but not necessarily flooding the hospitals."
"You just don't know what will happen next," he said. And that's been the hardest part of the pandemic: "The ebb and flow makes it difficult."
"Do you plan a vacation, or do you not plan a vacation? How are things going to be in March and April? Will it be a lot worse? Will it be like this every year, where spring and summer are better, then we get to fall and winter and we have a new variant, and new concerns?"
"The uncertainty," he said, "is what makes it difficult."
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