A Message from Dr. Miller

Stresses to our office and other medical facilities

Before we discuss some of the issues with the Delta Variant – I would like to share information with regards to difficulties that we and you are experiencing.   We are seeing the highest number of patient needs than ever before.   We communicate with independent pediatric practices around the country.  We are all experiencing similar and significant difficulties.  This is a result of a many factors including:

• A return of common illnesses not seen during the pandemic.  This includes sore throats, RSV, Coxsackie virus and other illnesses and fevers from many other unnamed viruses.
• Seeing many more ill patients than we otherwise would not see.  In the past, many of these illnesses were  cared for at home with occasional calls when parents were concerned.  During the pandemic, we see many of these on day 1 of illness.  With more traditional viruses occurring in the past few months, the amount of phone calls, and visits have exploded. 
• More anxiety and depression affecting the functioning of those patients who are already vulnerable – many of these visits are high intensity and take longer to sort out.
• Delayed well visits for those who have been nervous to come into the office for a period of time – many issues were put off and are leading to more visits with multiple concerns.    
• Sports – a return in school sports requiring clearance
• Delta Variant at a time when many want to get in leisure time and relaxation, but instead are anxious about going away with an illness.
• A national shortage of staff who want to continue working in healthcare.   While we have added two new doctors to our practice, we have been recruiting nurses almost continuously for about a year.  Since June we have hired 3 nurses – 2 of which start in September.  We ensure that training has been performed before staff are working independently
• Closure of Hudson Mohawk Pediatrics with a proportion of those who transferred to our practice.  This requires intensive review of transfer documentation, registration, reviewing previous records etc. 

Four Seasons Pediatrics is the top performing Pediatric Practice for the Capital Area for our largest insurer (we were just notified about this year) for 2 years in a row.  This is based on satisfaction, quality and meeting the Medical Home Model.  All that being said, we are struggling, and have not had success keeping up with the demands the pandemic has sprung on us.   We appreciate the wonderful complements that many of you have given us.  We really need that during these times.  We also know there are too many days where we run out of appointments within 30” of opening up.   We have always been able to predict needs and follow our policy that a sick child will be seen on the day you call – with the exception of calls late in the day.  At the present time, we are unable to meet those demands every day.  We are also concerned about school opening and what illness that will bring.  We are doing all we can to service all patients.  We do need to decline seeing patients when the volume cannot be safely handled.    In a perfect world we would see all patients at all times when requested.  In a pandemic world, we are unable to do so.   That means you may hear “We are unable to offer you an appointment today”.   We apologize when we need to do that.  I emphasize the word “need”.  It is to keep you and our staff safe.  We would always rather see you than send you elsewhere.  We are working to adapt to an environment that keeps changing and stressing us in different ways.  We thank you for your patience and understanding.   We are confident that we will get to a period of stabilization.

Enter the Delta Variant

As we enter the new school year, we have had an opportunity to experience both the low and high COVID rates.  This allowed us to recharge our batteries over the summer, while we weather the concerns over the Delta Variant.  

Why is this happening?

The more the SARS-CoV2 virus multiples, the more it makes mistakes in its copies.  Mistakes lead to a different look to the virus (meaning our bodies recognition of the virus).  The bigger the change, the less it looks the same to our immune system.  This is true, whether you have that immunity from getting the infection or from getting a vaccine.  The longer the time from your infection or the shot, the higher the chance of getting COVID.  This is called a breakthrough infection.   Studies are beginning to show less immunity to the mutated Delta strain somewhere around 6-9 months from your last vaccination.  For those who had the infection this is the same issue.  Breakthrough infections are 50% lower for those vaccinated (0.08%) than those who had the infection.  The good news is that infection severity has not changed for breakthrough infections.  That is why, you are hearing about booster shots 8 months after your last COVID vaccine.   

Previous to the Delta Variant, we did see breakthrough infections.  With the Delta Variant you are more likely to spread the infection, as the amount of virus in the body appears to be much higher – something called Viral Load.  At the moment, the number of infections in New York State seems to have stabilized and may trickle down some before school starts.  We have to wonder how much it will increase with the start of school.  Even if there is small increase, we have other variants right behind it (Epsilon and Lambda).  Mutations are to be expected, but these changes in the “look” of the virus render our protection less over time.  

Vaccination and mutations

The SARS-CoV2 virus will continue to mutate the more it multiplies.  Vaccinations are less available in other countries where the virus is infecting millions of people.   Vaccines are the most effective weapon for these mutations.  If you are vaccinated, we recommend booster doses when recommended, especially if you are high risk or around anyone who is high risk.  For those not vaccinated, we recommend that you get them as soon as possible.  While we cannot stop the mutations, the more people vaccinated, slows the mutations.  If our community is highly vaccinated, it will affect us less, no matter where the mutation comes from. 

If I am low risk, why should I get vaccinated?

As a whole, the more people infected without immunity, the more the virus mutates.  The more significant the mutation, the higher the risk to those who have had infection or have had shots.  The more contagious the virus (Delta variant) the more those without risk factors (like the flu) that can be severely affected.  Without immunity, your infection may be passed on to a loved one, a teacher, a co-worker or friend.   The doctors of Four Seasons Pediatrics strongly recommend that you and your children (down to age 12) get the vaccine as quickly as possible.  It appears the FDA will give full approval to the vaccine early this week.  We hope this will influence those who have waited and can now feel more comfortable getting the vaccine.

What is the update for vaccine for younger children?

It appears that Pfizer will be submitting for an Emergency Use Authorization (EUA) for younger children down to age 5 by the end of September and down to 6 months of age shortly after.  The studies on children down to age 5 appear to show that they need 1/3 of the dose of a 12 year old to get the same amount of antibodies.  Based on previous submissions, the EUA will take anywhere from weeks to months to get the EUA.  This is important because children under 12 represent 15% of the population of the US.  One estimate of the percent immunity needed (from infection and immunization) for herd immunity is 90% to prevent significant spread of the Delta Variant.  If that estimate is close to being accurate – even if 100% of those 12 and up get the vaccine, we cannot achieve that goal without including children.

Masks and School

Shenendehowa has posted its proposal for mitigation strategies for the School District.  This includes a step wise approach to masking based on community rates of infection.  I think it is a very fair strategy and takes an adaptive approach based on risk and rates of infection.  Let me say that we need more studies on masks.  We need to have hard data on whether they work, when they work, whether age makes a difference and at what community rates they are important for.  High vaccination rates will more than likely eliminate the need for masks.  In the meantime, circulation of a variant with high infectivity would lead to an appropriate recommendation to wear masks (as Shen has done.  The Shen approach makes sense at this time.  It is well thought out, structured and has taken input from the County Health Department.  Shen did an outstanding job during the 2020 to 2021 school year.   Other school districts may choose a different approach as they struggle with what is best for both students, parents and staff.   Despite the challenges and changes, we look forward to a successful and better school year.

A word about studies

Many parents see all the studies that are landing in the news.  They want to do what is best for their family.  Many of these studies are in the news before we have had a chance to review them.  When we do review them, we look at the strength of studies based on our training and experience.  The following is detailed, but we wanted you to be aware of the many factors we review (as does the FDA, and the AAP) including:

Disease: risk and its burden

Treatment: risk and benefit

Quality of evidence

Relative importance of the outcomes (benefits of therapy, harm of treatment, burdens of therapy, cost)

Baseline risks of outcomes (benefits of therapy, harm of treatments, burdens of therapy)

Magnitude of relative risk (called RR) including benefits (reduction in RR), harms (increase in RR) and burden (increase in RR)

Absolute magnitude of the effect (benefits, harms and burden)

Precision of the estimates of the effects (benefits of therapy, harms of treatments and burdens of therapy)

We also want to make sure that there are not serious methodologic limitations including:

• was there a high loss to follow-up, or was it stopped early?
• did the study apply to the group it is being used for?
• are the results consistent and reproducible?
• are estimates precise?
• has the study uncovered any bias not seen?

We want you to know that we will use any and all of these factors to review studies that give us information to make good evidence based recommendations.   This is true whether we talk about vaccines, masks, medications or any other treatment decisions.