Doctor: Policies, messaging factors in Covid-19 surge

HAGÅTÑA (The Guam Daily Post) — Guam’s latest wave of Covid-19 cases is becoming so severe that hospital beds are starting to run out, daily numbers of new cases hover between 100 and 200, and both the unvaccinated and fully vaccinated are ending up at hospitals, but the Delta variant is just one of multiple factors contributing to the current surge.

For an island with a nearly 81% vaccination rate among those at least 12 years old, and with a slowdown in cases beginning around April, why has Guam seen recent spikes in new infections and hospitalizations?

Dr. Hoa Nguyen, former chairman of the governor’s Physicians Advisory Group or PAG, said the high numbers of cases and hospitalizations are due to a combination of factors: the highly transmissible Delta variant; policy decisions; delays in strategic testing; and the kind of messaging that goes out to the public.

The Delta variant of the coronavirus, which moves faster and spreads more quickly, is wreaking havoc across the U.S. and other countries.

Nguyen said when new case clusters stemming from social gatherings and the spread of the Delta variant were confirmed by early August, PAG recommended the immediate reduction of the cap on social gatherings to 25 people.

The governor named Dr. Nathaniel Berg as the new chairman of the advisory group on Thursday. Nguyen had differed with the governor on mandatory vaccination.

The social gathering limit of 25 outdoors and 10 indoors was only later considered, and the governor’s order didn’t go into effect until Aug. 30.

Since that time, new case numbers have reached a record high of 206 in a single day, hospitalizations have climbed and additional deaths have been reported.

Nguyen, of the American Medical Center, said, even to this day, it doesn’t make sense to limit social gatherings outdoors and indoors while at the same time allowing bars to operate at 100% capacity.

Bars and other night establishments, according to Nguyen, have been known sources of case clusters.

“I apologize to the owners of the bars, but, at the same time, we have to place restrictions to make sure the entire island can move forward,” Nguyen said. “If not, the hospital admissions will continue to go up.”

PAG, when Nguyen was chairman, recommended in early August that businesses be given the option of reducing their occupancy if they choose not to check customers’ vaccination status.

The governor instead issued an order requiring vaccinations in the private sector and restricting unvaccinated residents from patronizing restaurants and gyms, among other public places.

Nguyen said fully vaccinated people, much like the unvaccinated, can become infected and can transmit the virus that causes Covid-19, even without symptoms.

Government data shows a number of infections and hospitalizations involving fully vaccinated individuals, but those rates are much higher among the unvaccinated.

The Department of Public Health and Social Services on Sunday reported 93 new Covid-19 cases out of 785 specimens analyzed Sept. 3. The Covid Area Risk Score for Guam was 46.8.

Strategic testing

It took a long time for Guam to shift to “strategic testing,” including the use of rapid testing, in which people can learn within 15 minutes whether they show positive results, so they can immediately isolate at home and limit transmission, Nguyen said.

As a result of the delay in the use of rapid testing, people still roamed around 24 to 36 hours after testing, causing more transmission in August, he said.

“Our people, when you tell them they’re positive, then that’s when they isolate themselves at home. But because we used a test that took a while for results to be known and then notify these people, that kind of created a lot of the transmission of the virus,” Nguyen said.

More than 1,000 people were tested daily in recent weeks, and most of those were at the drive-thru testing at the old carnival grounds at Tiyan.

“It’s not all about the people. It’s about the policy, it’s about the message we send out to the public. It’s not just one single person or a single group that contributed to the numbers that we have today,” Nguyen told The Guam Daily Post.

Nguyen said the change to “strategic testing” alone “will help curb the surge at this point,” as will the recent local availability of monoclonal antibody treatment.

Health officials on Friday told senators the surge in the number of cases should begin to decrease in coming weeks with the treatment option and other mitigation efforts.

Residents who were exposed to Covid-19 are now being referred for monoclonal antibody therapy using the REGEN-COV brand. The treatment can be applied through intravenous infusion or injection.

Breakthrough cases

In August, there were 1,765 positive results for Covid-19.

Of that, nearly 59%, or 1,041 people, were unvaccinated, Department of Public Health and Social Services data shows.

DPHSS data also shows 32%, or 559 people, were fully vaccinated.

The remaining 9%, or 165 people, either had unverified vaccination status or were partially vaccinated.

Dr. Ann Pobutsky, territorial epidemiologist with DPHSS, said Guam saw an increase in “breakthrough cases” of vaccinated people during the surge of cases in August.

The breakthrough case numbers, she said, almost mirror the Covid-19 surge numbers for August, but overall case numbers “are six times higher among the unvaccinated.”

A breakthrough case refers to someone who was fully vaccinated at least two weeks before the laboratory report date and subsequently tested positive for Covid-19.

Pobutsky said perhaps it is better now to talk of “herd protection” instead of “herd immunity.”

Hospitalizations

Covid-19 vaccination provides protection by limiting severe illness or hospitalization and mortality, Pobutsky said.

But even so, according to Pobutsky, “vaccines aren’t 100%.”

As of Friday, 33%, or 17 of 51 Covid-19 patients hospitalized, had been vaccinated.

In August, hospitalizations among the vaccinated made up more than 40% of total Covid-19 hospitalizations.

Pobutsky said what’s important are the overall trend and rates, rather than the daily hospitalization counts that can fluctuate, along with how these change over time, particularly in relation to what else is going on in the community, and not just the hospital.

The surge in case numbers in August, for example, resulted in surges at the hospital, she said.

What has really changed the picture with vaccinations, Pobutsky said, is the decrease in the number of deaths this year in comparison to last year.

With no vaccines until December 2020, there were about 130 deaths, mostly of people with comorbidities. This year, as of Sept. 1, there were 25 deaths.

Of the 25 deaths, nearly all were unvaccinated and only one was fully vaccinated — an elderly woman with multiple severe comorbidities, Pobutsky said.

At the same time, she said, the Delta variant has changed much of the data, since it is more contagious and virulent. Pobutsky said the vaccines were created based on the original virus, not the recent Delta variant.

What’s happening in Guam also is occurring in states with high vaccination rates, she said.

As to whether there’s something unique about Guam’s situation, Pobutsky said even in the states, there is evidence that obesity and diabetes, along with hypertension and cardiovascular disease, are key factors in Covid-19 mortality.

Pobutsky shared materials pointing to Simpson’s paradox, in which a trend appears in several groups of data, but disappears or reverses when the groups are combined.

DPHSS spokesperson Janela Carrera on Friday said more data, over a longer period, will be needed to get a better and more accurate picture of the impact of vaccination in preventing hospitalization in Guam.

Nguyen said when many on island had become fully vaccinated, people began letting their “guard down” and started gathering once again in larger numbers.

“I think the big part is the message that was put out there,” he said. “As we got more people vaccinated, a lot of people think that they will not get an infection. And I think, in hindsight, a lot of education should have been: ‘If you are vaccinated, you still have to be very careful, wear your mask, social distance and wash your hands.'”

As shown by daily infection and hospitalization numbers released by the Joint Information Center, many of the fully vaccinated continue to become infected and hospitalized. Still, the numbers would have been much worse without the vaccine, health officials have said.

‘Curb the surge’

Nguyen said the surge Guam is seeing now is “not going to be the last” because there will be more variants, and Guam should prepare for them.

“The most important thing we could do right now is plan ahead for the next variant, how to curb the surge. Basically, we need to do a strategic testing plan that basically has a rapid notification of positives. … That’s No. 1,” he said. “No. 2, limit the gatherings as soon as we identify a potential surge.”

Third, he said, the message should be about the vaccinated and unvaccinated working together as one group because everyone can transmit the virus that causes Covid-19.

“Remember when we messaged out, ‘segregate fully vaccinated and unvaccinated,’ and we allow the fully vaccinated to gather. … That’s a mistake,” he said, because the fully vaccinated may not have symptoms but they can transmit the virus as well.

Education and planning

The effectiveness of the vaccine also wears off after several months, and Nguyen said Guam, like the rest of the U.S., is preparing to offer booster shots.

DPHSS said Guam residents fully vaccinated with Moderna or Pfizer vaccines, and not just those with weakened immune systems, will be given the option to receive booster shots.

Nguyen said the message “needs to get out now,” educating the people “why it’s beneficial to get the third shot.”

The physician added that DPHSS, the Guam National Guard and private clinics have to work together to administer the shots and to come up with a system to make sure those who got the shots in December and January get their third shot first, followed by those who got their second shot in February, March and so on.

“So we have to start education now and start planning because we cannot wait with the Delta here,” he said.