Two Minutes to Go

Dear Members of the Baylor College of Medicine Community,

In this week's NCAA championship game, Baylor dominated Gonzaga. Congratulations to the Bears – it was a great season, and they deserve to celebrate. With just over two minutes left in the game, Baylor was up by 19 points. How many Baylor fans turned off the game at that point thinking "game over, time to get ready for bed?" The obvious answer: Zero. If you watch any college basketball, you know two minutes is an eternity, and fortunes can swiftly change. With a big lead and two minutes to go, a team's confidence builds, but they still need to focus on playing the game to the end.

We are in the final two minutes of our championship game versus SARS-CoV-2, a tenacious competitor. We have not been dominating. We trailed for most of the game, but now have pulled even. Our focus now needs to be on playing until the buzzer sounds. I remain a COVID-19 optimist, and believe we are nearing the end of the crisis – the point where the virus is still with us but has receded into the background to the point it can be managed like any other serious seasonal illness, without major social and economic disruption.

The CDC – hard-wired to be cautious and conservative – signaled a bit of optimism this week with some additional relaxation on restrictions for those who are fully vaccinated. In addition to prior guidance allowing people to remove masks and relax distancing in small groups of vaccinated people, the agency signaled it was safe for the fully vaccinated to resume domestic travel without testing or quarantine. The need to avoid larger gatherings and for masking and distancing in public remains.

I return today to an increasingly persistent question: If we are vaccinated, why can't we return to normal now? Why can't we take off the masks, stop worrying about distancing and crowd elbow-to-elbow into indoor spaces?

First, the metrics we use to track our progress are still a mixed bag, on balance trending slightly in the right direction. Nationally, the drive to vaccinate is going well. We are inoculating an eye-popping 3 million people a day. Currently, over 168 million people in the US have received at least one dose of vaccine, and about 20% are fully vaccinated. The more infectious viral variants continue to spread, increasing infection rates nationally. Impatience with distancing practices is also growing, another factor placing upward pressure on infection rates.

Across the country, since mid-March the number of daily new cases and deaths have been slowly increasing, with a high degree of regional variability. In the Greater Houston Area, the story is a little more encouraging. In mid-February, we were experiencing an average of 930 new cases per day compared to 924 this week. Obviously, we would rather see declining numbers rather than this plateauing. On a positive note, the hospitalization rates are clearly improving. In mid-February, we were admitting an average of 172 COVID-19 patients to TMC hospitals. Today that number is down to 116. Overall, these numbers reflect we have achieved a tenuous equilibrium with the virus; we are making progress, but not dominating.

Another reason to sound a note of caution: In the past week I have learned of two new cases of COVID-19 in our area in people who were fully vaccinated (at the time I wrote this, confirmatory testing was not available on the second case, but the clinical presentation was strongly suggestive of COVID-19). I am sure there are more. The fact that we are seeing disease in vaccinated individuals may be surprising and alarming to some, but this is entirely expected. Remember, an intervention that is – exceptionally – 95% effective, has a 5% failure rate. As long as we are in an environment with a relatively high prevalence of disease, we will see a significant number of vaccinated people become infected.

I will close with an analogy to illustrate why it is important to get the overall viral prevalence in our community down to very low levels before we contemplate relaxing our distancing and masking practices, even if vaccinated.

When I was recently married, my wife and I visited Ocracoke, a beautiful barrier island off the North Carolina coast. We took a day trip to the nearby island of Portsmouth, which was uninhabited. The main attraction was an abandoned fishing village dating from the 1930s. It could only be reached by small boat.

We found the island, tied up the boat and followed the trail inland in search of the village, which we soon found. So far, so good. It was a beautiful day, shorts and T-shirt weather. The long-abandoned buildings – homes, a church, a sea rescue station – were a desolate and interesting window into a different time. It was a great day, until the flies came. Huge, biting flies in swarms. Thousands. Ever few seconds we would experience another painful bite. Thousands of flies. Dozens of bites. With an escalating sense of panic, we ran as quickly as we could back to the boat and left the island.

Here is my SARS-CoV-2 analogy. The island had an extremely high prevalence of biting flies. Put yourself in this situation for a minute, and assume you run back to your boat, where you have a great insect repellant that is 95% effective. Would you – in your shorts and T-shirt – slather on repellent and head back to the village? Probably not. Even with your great repellent, in an environment with thousands of flies, the 5% failure rate would still result in a miserable afternoon. The risk is intolerable.

If I had to go back, I would certainly wear repellent (get vaccinated), but I would also insist on extra layers of protection: long pants, long sleeves, and a hat (continue good masking and distancing behaviors in public). I would not consider returning to Portsmouth in my summer beachwear protected by repellent alone absent serious interventions to decrease the insect population. That is, until the island had a low prevalence of flies. To truly return to normal, we need to be vaccinated and see very low viral prevalence in the region.

Our path forward remains clear. Continue the drive to widely vaccinate the community as rapidly as possible. Reach herd immunity. Wait for our community viral numbers to go down and stay down. Until that point, even if vaccinated exercise caution when in public.

Two minutes to go. Keep your head in the game.

James T. McDeavitt, M.D.
Senior Vice President and Dean of Clinical Affairs

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