Hello everyone,
Summer is coming to an end, and we are headed into Fall. This update is to plan ahead for fall cold season and to go over any recent covid updates.
This update will cover omicron and its little evil spawn subvariants, vaccines, boosters, case reports and what’s happening locally.
Local cases:
These numbers are still tracked by each hospital, clinic and lab and reported to the state health department and the federal reporting system. However, these numbers are generally quite underestimated now that we have had access to low cost home testing. Not everyone comes to a clinic for a positive test, so these reports are lower than the actual population prevalence.
Lake county, IL: Testing positivity: 13% (excludes those testing at home)
Percent of population fully vaccinated > age 5: 80%
Percent of population with first booster dose > age 5: 54%
Percent hospital beds used for covid positive: 5%
ICU bed use: 5%
Kenosha country, WI:
Testing positivity: 13% (excludes those testing at home)
Percent of population fully vaccinated > age 5: 61%
Percent of population with first booster dose > age 5: 51%
Percent hospital beds used for covid positive: 5%
ICU bed use: 10%
Racine county, WI: Testing positivity: 15% (excludes those testing at home)
Percent of population fully vaccinated > age 5: 62%
Percent of population with first booster dose > age 5: 55%
Percent hospital beds used for covid positive: 5%
ICU bed use: 10%
The Omicron variant continues to be a more mild disease. It tends to be less respiratory concentrated and more like a total systemic virus like the flu. While some people do have cough and chest congestion, many do not. If you have cold symptoms but no cough, you should still do a home test for covid because the presentation has changed since the original covid strain as the virus has changed. Typical symptoms are headache, fatigue, body aches, stomachache and sore throat. I also see a lot of nausea or vomiting without any upper respiratory symptoms.
Most people I am seeing in the last 2 months do not have cough, but they have other nonspecific symptoms of a viral illness which is helping covid to spread more easily because people think they can’t have covid unless they have a cough and then don’t test, writing off their symptoms as some other cold. I have seen a lot of sore throats with this newer strain of omicron (BA.4 and BA.5) The majority of omicron cases (>75%) don’t have cough. The exception to this is covid naïve patients. I see patients with more traditional covid symptoms of cough, chest congestion and shortness of breath in people presenting that have never had covid, especially if unvaccinated. Those that have not yet had a first case of covid but have been vaccinated are presenting more like the flu like symptoms of fever, headache, body aches and fatigue.
I am seeing almost no serious disease that requires hospitalizations, so the numbers above include those hospitalized for reasons other than covid (heart attack, stroke, surgery, other illness) but happen to be covid positive. The hospital beds used for covid do not indicate people hospitalized for covid illness specifically any longer. Death from covid is thankfully nearly nonexistent. I have seen one death since February which is a stark contrast to the last two surges, which were utterly miserable and plagued with multiple deaths per day.
The biggest risk factors for severe disease and death continue to be underlying disease and immunosuppression (diabetes, COPD, obesity) and vaccination status. Vaccination with an mRNA or Novavax vaccine is still the best way to protect against severe disease and death (other than prevention like masking or limiting time out in public). Vaccines for children and infants also have consistently shown through high quality validated peer reviewed research that vaccination protects from MIS-C, long covid and other serious but rare complications like myocarditis.
Vaccination does not considerably prevent infection as omicron has mutated too much from the original strain of covid. They do have good evidence for preventing serious disease, death and post-covid complications like long covid. The current recommendations are still for 2 mRNA and 1-2 boosters or Novavax 3 series vaccines depending on your age, co-morbidities and occupational exposure.
Testing/quarantine guidelines:
CDC official recommendations still say isolate for 5 days (with day zero being either the day you test positive or day you developed noticeable symptoms). This is followed by an additional 5 days of masking. If you can not or choose not to wear a mask, then the recommendation is isolation for the full 10 days (again starting with day zero). Here are two important takeaways- the data shows that 31% of people are still infectious after 5 days, which is why the masking for days 6-10 are very important. Testing at the end of the 5-day period is optional but if you do test and it is positive, you should continue to isolate until day 10. If it is negative, you can end isolation and proceed to the 5 days of masking around others. I feel like this is poorly thought out because if you don’t test at all at day 5, you proceed to the 5 days of masking but if you do test and test positive, it is an additional 5 days of isolation.
If you have symptoms and test negative on a rapid test, the current recommendation is NOT to repeat the test in 2-3 days and assume you are negative. This is again poorly thought out since we know that some people will test positive within a few days of symptoms so re-testing in 2-3 days makes good clinical sense and would more accurately catch positive cases.
The 5 days rule comes from data that a person is most infectious in the first 5 days and then this drops off significantly on days 6-10, but it is a spectrum, and you don’t magically turn into a covid negative pumpkin on midnight of the 5th day. Omicron infection lasts 8-10 days and peaks around days 4-5. If you are still testing positive, you are still theoretically infectious though we can not quantify how much. We do know this risk can be mitigated with masking and good hand hygiene, not sharing food, etc.
Omicron, while more mild, still is 3-4x more infectious than delta and spreads easily and with less contact and exposure. The CDC balanced this data with social and well-being needs, return to work and “maintenance of critical infrastructure” needs. They stress that 5 days of masking and layered prevention strategies such as vaccination, hand washing and less participation in public and group events are key to preventing transmission after 5 days.
Vaccination updates:
4th booster dose- Admittedly the calculus of when to get a booster dose and how many doses to get was ridiculously complicated and was not based on strong data. There was no good data that a 4th dose prevented transmission or prevented infection. The benefits to the 4th dose were a decrease in breakthrough infection rates by about 2x in high-risk groups (i.e., healthcare workers, teachers) and the real benefit of the 4th dose was in keeping the healthcare system supplied with workers during the pandemic. The other known benefit was a lower incidence of long covid cases, which is not insignificant given how little we know about the long-term effects of covid infection, especially for those who early on had loss or taste or smell, nightmares and brain fog (evidence that the covid virus had infected the brain). Getting a 4th dose is a personal decision based on risk tolerance and future expectations.
Omicron booster-
This is expected in Fall 2022. The reformulated booster with be bivalent (meaning it will still contain the original covid vaccine which was recommended as a 3-4 shot series), but it will also contain a strain for omicron as well. Many vaccines have several strains in one vaccine. For example, HPV vaccine now has 9 strains, annual influenza vaccine has 4 strains and meningitis vaccines has 4 strains. This new covid vaccine would have the 2 strains (original/alpha and omicron).
The Novavax vaccine has pretty decent coverage of the omicron lineage based on recent studies as well. If you are still unvaccinated and are looking for omicron coverage, I would consider the 3 shot series of Novavax. This was just approved.
New omicron subvariants:
This summer has been mostly dominated by the highly contagious BA.4 and BA.5 subvariants of omicron. The mutation is not enough to name these as a separate variant like we did with delta and omicron, so it is all still collectively omicron. Micro mutations have changed the omicron variant though as we see it is even more transmissible than original omicron BA.1 and symptoms are different- more cold/flu like as noted above (sore throat is very common as is headache and fatigue). This is what has been circulating for about 2 months. Who knows what exciting surprise the next mutation will bring?
Paxlovid:
This medication is now more widely available and should be used by high-risk patients (elderly or those who self-identify as elderly, immunosuppressed, those with lung disease like COPD, asthma, those who are obese). It does not need to be used by everyone and should not be used by everyone. It is not a magic pill. It does inhibit viral replication when taken at an optimal time. Taking it too early, it is likely ineffective, and we think this is why we see a rebound phenomenon with some people. More on that below. Taking it too late, it is just wholly ineffective. Optimal timing is likely around days 2-4 after diagnosis. We are still studying this.
Some people do get a rebound phenomenon and have symptoms that clear up almost instantly, only to rebound and have the same or more severe covid symptoms 8-10 days after paxlovid. I will report on this more when we have more data. You should also prepare for a fairly bitter metallic taste that does go away. Not everyone gets this, but everyone that gets it, hates it. Paxlovid also interacts with many medications so please talk to the pharmacist about any supplements and other prescription medications you are taking if you did not go through your medication/supplement list with your physician. It is much more widely available now, but it is not needed by everyone.
Monkeypox:
I know this is a covid update and we are all over viruses ruining our lives, but monkeypox is a new hot topic. I personally have not seen one case of monkey pox in any of my ERs, but it is active in certain geographic areas. So similar to covid, it’s really important to look at your local area to determine risk. Our risk right now is very low. Monkey pox is not as easy as covid to get but does have multi-modal transmission. The R0 (how many people get infected from one person) is 2 (meaning 1 person usually spreads it to 2 people). Compare that to the R0 of BA.5 of 19 (meaning 1 person usually spreads it to 19 people).
Unlike covid, which is droplet transmission, you need actual contact to contract monkeypox and that contact needs to be close and prolonged. This is why some are saying it is sexually transmitted, because of the need for close and prolonged skin contact (well, let’s be honest, not every sexual encounter counts as prolonged). The other population that meets these criteria for close prolonged skin contact is parent/child. So, we do see transmission that is typical contact as parents spend a lot of time in close contact with their children (especially infants and toddlers). There is also fomite transmission (transmission from touching object that have live replicating virus on them). This is tougher to get as the virus dies quickly with UV sunlight and just soap and water. But there have been cases of transmission after touching heavily contaminated objects. Right now, the risk is low to non-existent in our area. High risk groups would be those with prolonged skin to skin contact- multiple partner sexual encounters, wrestlers, infant/parent.
If you get exposed to a confirmed or suspected case, you do qualify for vaccination and it’s a doozy. I am not old enough to remember the smallpox vaccine. Thanks, world, for eradicating that before I was born. If you thought the covid vaccine was crazy, you’ll love the monkey pox vaccine. It is based on the old smallpox vaccine or rather it is the old smallpox vaccine, with the multiple skin pricks to inoculate and start replication in the skin, causing local reaction and a blister that then scabs up and falls off, leaving a small scar. Yikes. There are all the typical vaccine side effects like sore arm, fever, headache, rash, fatigue and yes, even myocarditis (which was never specific to just covid vaccine but was exploited for certain narratives). The incidence of myocarditis from smallpox vaccine is actually quite a bit higher than from covid vaccine (1/180 for smallpox and 1/4000 for covid). This is also a live virus vaccine so there is a small chance that you can get the disease from the vaccine.
There is also a new vaccine which is attenuated (alive but weakened and can not replicate) which is in production from Denmark. This is available in the US but is in short supply right now. More is coming. Vaccination works best if you are vaccinating before exposure, so if you are eligible for the newer Danish monkey pox vaccine, consider getting it. Monkey pox symptoms are fever/chills, headache, swollen lymph nodes, muscle aches, backache, upper respiratory infection symptoms and blisters or sores that are painful or itchy. There is no treatment other than supportive care.
Hopefully that answers some questions.
Dr. Jill Green
MedLogic Primary Care
www.MedLogicMD.com
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