Covid rebound, the persistent pandemic, pediatric vaccinations and Monkeypox.

I have recently been reminded (not that I need to be because of what I do) that the Covid pandemic is still alive and well, not only in other parts of the world, but here at home also. Looking around at people’s behavior, you wouldn’t think that we are still in the midst of a pandemic, but we are. And its impact continues to be far reaching. I recently had a significant exposure, and it was not at work. I was a little worried about myself since I have a few medical issues which put me at risk, but moreso, I was worried about my family, my partners, who would need to cover for me if I did get sick, as well as the approximately 100 patients I would need to reschedule since my ability to do remote work is extremely limited. That’s 100 people who made plans and arrangements to see me or to have surgery. Patients with head and neck infections of all kinds, cancer… That is a lot of disrupted lives, all because of one exposure.

Once again, your behavior and concern about your own personal potential risks is not a decision that only impacts you. You are making a decision for all those around you, and subsequently, all those around them. 

The Omicron 5 variant is spreading like wildfire and along with it, more patients suffering short, and long-term symptoms, simply because of the sheer large number of people getting infected. Most are still getting through OK, but many aren’t. Vaccination and boosting is still important because it helps to minimize the degree of illness, and does reduce infection rate, particularly the boosters. Vaccine protection against Omicron 5 is admittedly much less than with previous versions, but any reduction is important with such an infectious virus. And if your last shot or booster was more than 6 months ago, you need an update.

Death rates have remained stable in the US for the last few weeks, at ~ 450/day. But projected over a year, that would make Covid-19 the 4th leading cause of death in the US after heart disease, cancer and accidents. At its peak, it was second. Once again, we have become numb to this disease, which continues to spread and re-spread in our population. This virus continues to evolve so the notion of a “steady state” is very short sighted.

COVID REBOUND.

Recently, this issue has been given a lot of attention because of our President’s infection, and re-appearance after 3 days of negative testing. This happened to Dr. Fauci as well. Our knowledge of this phenomenon is evolving. Although some immediately blame Paxlovid, the antiviral given to both men very early in their infection, rebound is also occurring in people who never got the drug. In fact, a large study done by the drug company which makes Paxlovid (I agree that we can’t trust drug companies but this is all we have now) indicated that the rate of rebound was ~ 2% in those taking Paxlovid, but that the rate was the same in those taking the placebo as well. Newer numbers suggest that the rate of rebound is nearer to 5%.

Paxlovid is actually a combination of two drugs and essentially works by preventing the virus from replicating. It is an important tool in treating Covid infections, but it needs to be used judiciously in people with significant symptoms or significant risk factors.

The argument that Paxlovid is triggering “resistant” mutations has not been supported since genetic testing shows that the rebound virus is exactly the same as the original infecting virus.

Longer courses of Paxlovid are now being prescribed by some doctors (the present course is 5 days) but this is not supported by any studies. The thought is that the 5 day course knocks the virus back a lot, but not all the way, suppressing but not killing all the virus, which then re-emerges once the drug is gone. Not a proven theory.

The reality in my opinion is that we have once again tried to get away with whatever we can. The recommendation that you can stop isolating after 5 days has caused more damage than good. There is no study showing that the duration of contagiousness has changed at all despite all the mutations and variants which this virus has produced. At least 50% of people remain contagious at 9 days. That’s it. The only reason this recommendation was even suggested had to do with the fear of losing too many critical workers. And even with them, you had to continue wearing an N95 for an additional 5 days and be fever free for at least 48 hours. Not even a surgical mask would cut it. But, as is human nature, we took these recommendations, loosened them and now it is accepted as the norm.

You can’t cheat this virus!

PEDIATRIC VACCINATIONS. Approval for Covid-19 vaccination for kids under 5 (down to 6 months) has been approved for months now, but despite that, fewer than 3% of kids in that age bracket have been vaccinated. Although kids are a little better protected against contracting Covid, primarily because of a more robust innate immune system, they are not completely immune. In fact, the numbers of new cases and hospitalization in this age bracket has been larger during the Omicron surge, than in all other surges combined since the start of the pandemic. We have no idea how this virus will affect the developing brains of these young children. Of course we do not know how the vaccine will affect kids long-term either, but we do know how some of these kids end up. Really sick, with complications or sadly, dead. PLEASE get yourselves and your children vaccinated. 

MONKEYPOX. This is an RNA virus, similar to smallpox and was first discovered in the 1950s in African monkeys. Many other animal hosts have been identified. The most recent outbreak has been blamed on deforestation and more human-wild animal interactions leading to infections. Hunting bushmeat (monkeys) is also implicated. 

Although the numbers of cases of this viral infection aren’t even remotely close to those of Covid-19, this is still a very significant issue to be concerned about. The most recent outbreak originated in Africa and although only 2 months ago, cases were limited to that continent, it has now spread to over 90 countries and almost a quarter of the cases are in the US. 

It is a respiratory virus in that if an infected person with lung symptoms coughs directly in your face, you could become infected, but it is not spread by simple breathing, as SARS-Cov-2 can. It is spread by any body fluids and this is primarily spread through sexual contact. But touching open sores or blood can also lead to transmission.

Numbers are not tremendously high, with just over 27,000 cases being reported worldwide, but again, with only 4% of the world’s population, the US has over 6000 cases, 22%. Worldwide deaths are only just over 10 so far.

Anyone born in North America after 1972 is out of luck when it comes to any form of natural immune protection since it was at that time that smallpox vaccination was discontinued in the US as the disease was considered eradicated. Those who received this vaccine have some overlap protection. There is only 1 company which makes the very fragile Monkeypox vaccine and there is a massive shortage as countries are starting to panic. I mentioned in a previous post that our public health messaging has been pathertic, focusing on safe sex practices, rather than abstinence in any situation where there is concern of infection.

It’s a crazy world out there and we need to be careful and thoughtful about others.

Continue to mask where there are large groups of people indoors. 

Use an effective mask, preferably N95.

Distance in those environments the best you can as well.

Get vaccinated or boosted.

Get healthy! It’s your best defense.

Have a great weekend.

Stay safe and be well.

AC

All over the world, including here in N. America, the Omicron BA 5 variant is causing another Covid wave. In Europe, infection case numbers have tripled in the last 2 weeks and hospital admission rates have more than doubled. ICU hospitalizations have also risen, but not proportionately. Death rates are also starting to rise, but similarly to ICU admission rates, not to the same degree that previous variants have resulted in. Another very clear pattern is also emerging. Vaccinated people may not be as protected against getting infected but they are much better protected against severity of disease.

Here in the US, BA5 accounts for 78% of reported new Covid cases, which have significantly increased in the last 2 weeks. We have over 100,000 new cases a day in the US but given the number of unreported cases, there are estimates as high as 1 million new infections every day. Many of these are reinfections.

Our hospitalization rates are similarly on the rise as is the death rate, albeit significantly lower than in the past. This week, we have just over 400 deaths a day.

But illness is still illness, and deaths are still deaths and we have no idea of the long-term impact these infections will have on people suffering long-haul complications. Long haul symptoms appear to be more frequent with repeat infections.

This virus is VERY infectious. Much more so than any other previous variant. On a positive note, it continues to appear to result in less severe disease. But ultimately, it’s all about the numbers. As I have stated numerous times, a small percentage of a large number is still a large number.

An even newer subvariant is now out, BA 2.75. Data is still very limited and we really don’t know much about it yet. It has been isolated in many countries, but has not yet been significantly implicated in the most recent outbreaks. BA5 still dominates.

HOW LONG TO ISOLATE. 

The fact is that this newest variant hangs around and can be transmitted for the same amount of time as any previous version. The whole “5 day” reduction from the initial 10-14 days originated at a time when our healthcare system was extremely taxed at the height of the pandemic and there were very serious concerns about running out of healthcare workers to care for all of the sick people. It was suggested that 5 days after symptom onset or positive asymptomatic test, FOLLOWED by 5 days of proper (N95) masking at work was adequate and a good tradeoff for not having any healthcare coverage at all. ASSUMING symptoms were much improved. As is human nature, the public and some companies and even official bodies distorted this into only a 5 day isolation period with loose masking recommendations afterwards.

The fact is this. Studies show that 50% of people infected can continue to shed live virus at day 5 and 25% at day 10 after symptom onset or positive test. And with a significantly more infectious variant, that is still very concerning. To me, 5 days is NOT enough. And wearing a cloth or even surgical mask after that timeframe is completely inadequate.

SHOULD I TEST AFTER INFECTION. 

Absolutely not. It is irrelevant. First of all, there are plenty of false negatives. Secondly, there are plenty of false positives, even with the home antigen test, for weeks and even months. A negative test on day 6 should give you NO reassurance you are no longer sick or can not transmit the virus! On the flipside, a positive test on day 10 does NOT mean you are still infectious, unless you have been not behaving responsibly and have become reinfected again (which can absolutely happen, especially with BA5). By day 10, 99% of people are no longer infectious.

Please continue to be careful out there and remember that there is still a very infectious, malicious virus out there which can, and will continue to cause problems for us for a long time.

Have a great weekend and please try to be safe (and cool).

AC