COVID-19: The Battle Continues

By late summer 2021, things were looking depressingly familiar: COVID infection rates were rising, ICU and ED beds were running scarce, wall times were climbing, and mask mandates were returning. A year and a half into the pandemic, it was a scenario no one wanted to see. 

Of course things weren’t, and aren’t, exactly the same now as in 2020. We know much more about SARS-CoV-2 now, how it’s spread and how to stifle it. Most significantly, we have a successful vaccine that reduces its severity and consequences, even as the virus has mutated. Summing up the situation to date, the CDC concludes, “Vaccines are highly effective against severe illness, but the delta variant causes more infections and spreads faster than earlier forms of the virus that causes COVID-19.” 

However: By the end of September, only around 56% of the U.S. population had been fully vaccinated. That number is rising with employer mandates, as vaccines are extended to children, and as persuadable holdouts are finally convinced, but a hard-core contingent continues to say no—even as they suffer the brunt of the cost, comprising a large majority of those hospitalized and dying as the virus has rebounded. 

CDC Director Rochelle Walensky, MD, has said COVID is now a “pandemic of the unvaccinated.” That perspective drives current messaging. 

“What we’re hearing now from the CDC, is ‘get vaccinated, get vaccinated, get vaccinated,’ and of course last year there was no vaccine, so that’s a big difference,” says Alex Isakov, MD, MPH, a professor of emergency medicine at Emory University and executive director of the school’s Office of Critical Event Preparedness and Response (CEPAR). “But last year at this time CDC was advising not gathering in indoor spaces with people, and today they’re simply saying, ‘Well, if you’re fully vaccinated, you can gather in indoor spaces, but take that extra precaution and wear a mask.’ And while we’re seeing recommendations for face masks and vaccination, we’re not yet seeing anything like the lockdowns of last year. I hope we don’t ever have to go back there.” 

The emphasis on vaccination is well placed: Abundant data has now demonstrated how it’s mitigated the spread of COVID with strikingly few problems or adverse events. But that also makes it frustrating that so many in society—and, vexingly, in the emergency services and even EMS—spurn the science in favor of anecdote, falsehood, and hubris. 

“There has been a lot of misinformation out there about the vaccine,” says Douglas Kupas, MD, FAEMS, FACEP, medical director for the National Association of Emergency Medical Technicians and a longtime emergency physician in Pennsylvania. “If people have received misinformation and misunderstanding, it’s difficult to blame them directly for that in the current climate. But as people get more knowledgeable, and particularly when they see what COVID can do, they change so much. When people who haven’t been vaccinated end up in the hospital with serious COVID, or when they see it in a family member who’s critically ill, they can be very quick to change their tune.” 

So that brings us back to education—not a sexy or easy answer, but still the key to convincing the most vaccine-averse. 

“I’m a big proponent of providing education, and that can come in many ways,” says Isakov, who also directs Emory’s Section of Prehospital and Disaster Medicine. “It can come in the form of webinars, it can come in phone conversations, it can come in one-on-one conversations in firehouses or ambulances. The key is to answer people’s questions.

“I don’t think the people in our EMS community who aren’t vaccinated are all antivax diehards. In my view it’s because they probably still have questions about the vaccine that haven’t been answered: Is this safe? How effective is it? What are the long-term consequences? Why is it necessary if I’ve already recovered from COVID? I think we need to work to answer those questions, and through doing that we’re going to get an increased percentage of the population vaccinated, whether it’s EMS personnel or the general population.” 

EMS docs have reported good success with that kind of approach. Many national organizations and educational platforms like EMS World have provided targeted resources explaining the vaccine and science behind it, and many individual departments have tapped the expertise of both their own physicians and national experts. 

“When the vaccine initially came out and a lot of EMS providers were reluctant, what was most effective to my mind was medical directors doing education directly,” says Kupas. “Many organizations produced [materials]. NAEMT did a panel that went through the science behind it that’s still available in a recording people can listen to. 

“It’s pretty incredible that we can just use our body’s ability to replicate RNA and make an antibody response to a particular virus. The science is really amazing and probably the future of the way we develop vaccines. Previous flu vaccines, for instance, weren’t very effective, because we could never really target them—we had to guess what strain of flu was going to be predominant six months or a year ahead. Now we’re talking about being able to respond in real time and make a flu vaccine much more quickly that’s more effective than the old vaccine. So people just need to educate themselves on the science and get it from sources that really understand it.” 

Vacation’s Over

What we know about the delta variant is that it is the most transmissible mutation of COVID yet—perhaps as much as 60% more so than the alpha variant. The viral load of those infected with delta may be up to 1,000 times higher than in previous versions. It’s having more of an impact on children, likely due to vaccinations among adults. The vaccine is effective at reducing symptom severity and the risks of hospitalization and death, but breakthrough cases among vaccinated people can occur. Vaccine effectiveness appears to wane somewhat over time, but we haven’t studied it long enough to say for sure. 

The good news for EMS is that you won’t have to do much differently in a delta surge than you did for COVID classic. The same PPE and protective measures systems embraced in 2020 should be sufficient against any new spike of any known variant. 

That doesn’t mean additional surges will be easy—the diversions and ED waits might be familiar too. Some places have already seen case numbers higher than anything seen in 2020; others have again run out of ICU beds and other critical resources. In many places in-person school resumed sans masks and distancing, and the impending winter will send people from outdoors back in. 

Bottom line, even if you’re familiar with the routine, things still may get pretty hairy. “We have a big surge that’s already here in many places,” Kupas said in August, “and is coming to just about everywhere else.” The following weeks proved that correct. 

Last year provided an unparalleled opportunity for systems and leaders to learn, he notes. If you haven't, it's worth revisiting those plans, reinforcing and reinvigorating them, and honing in on what was most effective. 

“We had this little vacation from this over this summer, and there was a lot of dropping of the masking and that sort of thing,” Kupas adds. “But really, in EMS, as part of healthcare, we should be following what healthcare is doing. And I think you’d be hard-pressed to find hospitals in the country that are not having all their people take precautions, wearing masks and limiting capacity and those sorts of things. EMS is healthcare—we should be doing those same things.” 

Willing Hosts

The greatest danger of COVID’s current phase, as many healthcare leaders have noted, is the emergence of a mutation that’s not susceptible to our vaccines. The more unvaccinated people remain, the more host opportunities for just such a twist. 

“Whatever happens with delta,” says Isakov, “we know that with more and more transmission, we’re going to see the evolution of other variants, with other transmission characteristics, with other capacities to make you more or less ill. And as they emerge we’re all going to rely on the public health experts to help inform us about what measures work and how effective they are at preventing transmission and preventing us from getting seriously ill and needing to be in the hospital.”

Globally health authorities are watching closely for such eventualities and tracking how the various COVID strains move among both the unvaccinated and vaccinated. That will inform guidance as situations evolve—including the potential need for a vaccination booster. 

Vaccine mandates may not be popular in emergency services, but they're here in some places and coming in others. Even where law and labor terms allow them, though, it’s an area where services should proceed cautiously and exhaust other options first. 

“At some point there may be value in a requirement for vaccine,” says Isakov. “But every agency, I think, has to consider first whether their employees’ questions have been answered adequately; whether they’ve made genuine and good-faith efforts to get those questions answered; and whether they’ve provided incentives for people to get vaccinated. It may just be a matter of when is the right time to implement a requirement.” 

Full FDA vaccine approval, he notes, may help convince both reticent individuals and departments weighing stronger action. 

The Pandemic and Beyond

In the meantime, buckle up, because—on top of the past year and a half, with frustrations high and not remitting yet—this thing continues to take tolls on patients and providers alike. 

“COVID has had a mental health effect on everyone in healthcare, and certainly EMS providers are not immune,” says Kupas. “We know many are suffering the strain of delivering healthcare in these conditions. Every system should be talking with their people about the risks and making sure people understand they’re not alone. And if people recognize signs of burnout, depression, that sort of thing, they should know where to turn to for help. We as EMS managers, medical directors, and administrators should be making sure of that, and really, I think every provider also has that responsibility to watch out for their partner.” 

EMS providers have performed heroically throughout the pandemic, Kupas notes—in caring for the patients of a novel disease; in braving contagion and illness and deaths themselves; and in delivering treatments from vaccines to monoclonal antibodies. In short, they’ve proven their value and legitimacy as part of the healthcare system, which should have ramifications beyond COVID-19. 

“We’ve been at the tip of the spear on this, and I think we can be proud of how EMS stepped up,” he says. “Our future in EMS is increasingly going to be tied to how valuable we are to the healthcare system, and this is just one more example where we’ve shown our value as healthcare providers. And the more we view ourselves as healthcare providers and act like healthcare providers and are linked as healthcare providers, the more likely we are to be viewed by others in the healthcare system as part of them. 

“Every threat is an opportunity. And clearly there are parts of healthcare that are looking at and understanding and turning to EMS far more than they did two years ago. They realize we have skilled providers who are connecting with patients every day who can help with many of the things needed during a pandemic and beyond.” 

John Erich is the senior editor of EMS World.