A COVID Roundup: Where to Go Now?

You can also check out this episode on Spotify! Three years after the World Health Organization declared the COVID-19 pandemic, we have widespread population immunity against the virus. But no one is immune to accumulated fear and uncertainty. On this episode, Dr. McBride talks about where we are now and what to expect with COVID. She discusses various topics including * the transition from pandemic to endemic * rapid antigen versus PCR testing * treatments, including Paxlovid * the recent Cochrane review on masks and mask mandates * vaccines and immunity * what to expect in fall 2023 * addressing our pandemic story Finally, Dr. McBride argues that recovering from the distress of last three years requires understanding our unique risks and risk tolerance—and appropriately reckoning with vulnerability. Join Dr. McBride every Monday for a new episode of Beyond the Prescription. You can subscribe on Apple Podcasts, Spotify, or at lucymcbride.com/podcast. Get full access to her free weekly Are You Okay? newsletter at https://lucymcbride.substack.com/welcome Please be sure to like, rate, review — and enjoy — the show! The full transcript of the show is here! Hello, and welcome to my home office. I'm Dr. Lucy McBride, and this is "Beyond the Prescription." Today, it's just you and me. Every other week this season, I'll talk to you like I do my patients, pulling the curtain back on what it means to be healthy, peeling back the layers of everyday medical problems I see. In clinical practice for over 20 years, I've found that patients generally want the same things, a framework to evaluate their risks, [00:00:30] access to the truth and the courage to face it, and tools and actionable information to be healthy, mentally and physically. So, whether it's managing weight, cholesterol, cancer, or mental health issues, we all want to feel more in control of our health. Here, I'll talk to you about how to be a little more okay tomorrow than you are today, and how to be healthy from the inside out. Let's go. Today is a little ditty about COVID-19, my friend and foe for the past three years. Something you have probably thought quite a lot about, that has probably occupied a fair amount of real estate in your brain and in your everyday life for the past three years. Let's talk today about where we are now, where we have been, and where we're going with this virus. It's the three-year anniversary of the World Health Organization's declaration of the pandemic. That was on March 11th, 2020, and over the last three years, we have learned so much. We have [00:01:30] learned about the virus, about immunity; we've learned about how to protect the most vulnerable among us. We've also learned about ourselves. We've all had to reckon with grief, loss, uncertainty, and significant vulnerability. So, let's take a minute to talk about COVID itself. We'll talk about symptoms, testing, isolation, the vaccines, boosters, and where we might go from here. Okay. So, first of all, [00:02:00] let's acknowledge, COVID is here in perpetuity. It has now been woven into the fabric of our everyday lives, whether we like it or not. It is endemic. Endemic means hospitals are no longer overwhelmed from COVID-19. It means that the vast majority of people in this country and around the world have some sort of immunity to the virus, either from the vaccine or from past infection, and that we have widely-available vaccines and therapeutics. Endemic does not mean that we are done with COVID-19. [00:02:30] No, no. COVID and COVID risk are something we will have to reckon with here on out. What's happening with the virus right now? Well, the virus is here. In D.C., I'm seeing a couple patients a week with COVID-19. They mostly have typical cold or flu symptoms and are doing generally very well with at-home remedies like Tylenol, Advil, hydration, and rest. Now, some of my patients have been sicker, like patients who are older, who have underlying health conditions, like lung disease, for example. But it's important to note [00:03:00] that they're as sick as they probably would have been with another respiratory virus—one that we have known about since pre-pandemic times. For example, flu, RSV, metapneumovirus, parainfluenza virus. In other words, we have seen these kinds of respiratory viruses since the beginning of time, and COVID, in the vaccine era, has been added to the list of viruses that we will now be susceptible to, and for whom it is particularly potentially dangerous for people who are at higher risk in general. What about Paxlovid? [00:03:30] So, Paxlovid is the oral antiviral medication that is FDA-approved, and appropriate for patients who are at particularly high risk for serious COVID outcomes. Who do I prescribe it to in the spring of 2023? The truth is, not many people, because at this point in the pandemic, most people have had COVID-19. Most patients, at least my patients, have had the vaccine, and that protection, that hybrid immunity, the combination of vaccine-induced and infection-acquired immunity, is marvelously protective against serious COVID outcomes, such that Paxlovid is not really necessary. Paxlovid has some downsides as well. So, when the upsides are minimal, and the downsides are not zero, it's worth a conversation to explain, not to hang our hat on Paxlovid as a panacea, and more importantly, to have confidence in our own immune system, and the marvelously effective vaccines, to protect us when we need it. Do I still prescribe Paxlovid? Absolutely. It's just a nuanced discussion, and one that the headlines really can't capture. So, what about booster shots? Are we going to need a booster [00:04:30] shot every fall, like we need the flu shot? Well, the short answer is we don't know. Right now, public health agencies are predicting that they'll roll out an annual COVID shot like we do the flu shot. And this fall, when we're indoors, in crowded, poorly-ventilated spaces, we might need a booster shot. But that's not based on any particular science. It's based on the emerging evidence that there's a seasonal component to COVID, like there is for so many respiratory viruses. What that projection is not based on is the clear evidence that everyone will absolutely need a booster in the fall. That would not be accurate to project. In fact, right now, in 2023, immunity from the vaccine and from past infection continue to do a marvelous job at protecting us where it counts, preventing severe disease, and mitigating but not blocking transmission. Remember that the vaccine can no longer protect against infection. The current variants, which are Omicron sub-sub-variants, are so highly contagious [00:05:30] that they outskirt the antibodies made by vaccination and from past infection. What that means is that you can get 3, 4, 5, 10 vaccine doses with the current vaccine formulation and still get COVID-19. You're just very unlikely to land in the hospital, and your symptoms will be mitigated if you've had a recent vaccine or recent bout of COVID itself. So, when people talk about waning immunity, that refers only to the antibody levels that inevitably and normally fall over time, three to four months after a shot or after an infection. If our antibody levels did not wane after exposure to a vaccine dose or a virus, our blood would be a thick milkshake full of antibodies. So indeed, those antibody levels go down with time, but our immunity against serious outcomes is lasting. How long will it last? We don't know. But at least for right now, people who have had vaccine doses for their age and underlying health conditions, [00:06:30] and/or who've had COVID itself, are not landing in the hospital from COVID-19 more than they would have from other viruses at this moment. Are people still being hospitalized for COVID and people dying from COVID-19? They are. And these are people who are our most high-risk patients. They are also patients in the hospital who have so many underlying health condition… This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit lucymcbride.substack.com/subscribe