We are living with Covid-19 (currently Omicron and its subvariants), likely for the rest of our lives. Infections in Massachusetts are disturbingly high, though getting through a Covid-19 illness does provide a season’s worth of enhanced immunity. Vaccinations remain highly effective in preventing severe outcomes, but have not been able to prevent the initiation of infections with the Omicron variant. Fortunately, really effective antiviral drug and antibody treatments are readily available through your doctors. We hope for more effective vaccines this winter. In the meantime, protect yourself against unnecessary exposures (use masks in stores) but outdoors is fine and, for anyone recently infected, dining and indoor social events should be safe for you for the summer months.
1. We are living with Covid. What does that mean?
a. Covid is here to stay. It is exceedingly unlikely to disappear.
b. The virus is unlike any infection anyone alive has experienced.
- It is aggressively infectious such that current vaccines cannot prevent initial infection or reinfection, but can prevent progression to more serious illness, need for hospitalization, and death.
- It remains important to get your initial shots and recommended boosters. Second boosters have been available for anyone over 50 for several months now.
c. The virus is highly contagious and is capable of reinfecting people within some months (perhaps 3-6) of a prior infection, even if immunized.
- This is especially true of the most recent subvariants of Omicron.
- Currently there is a massive surge in infections in Massachusetts. State numbers are around 3,000 daily, but likely many times higher since most cases are confirmed with home tests that are not reported. This is vastly higher prevalence than in the first major wave.
- In our practice we see the surge, with several infections a day in our membership, vastly more than last year with Delta variant.
- Breakthrough infections in immunized people are usually mild to moderate, but can be quite severe, persist for several weeks, and require active treatment.
- Unimmunized people (especially older people) remain at highest risk of severe illness and death, even with current treatments. Covid infection itself, without follow-up immunization, does not produce lasting immunity from recurrent infection with possible severe disease outcome.
d. Covid-19 mutations will continue, and worse mutations could arise from other parts of the world with even lower vaccination rates than we have.
- We don’t know now whether the future holds more of the same or whether a variant with even more serious medical consequences could show up.
2. What about immunizations?
a. Right now we are still working on second boosters of the same Moderna or Pfizer vaccines. We are offering a Moderna booster clinic next Monday, June 13.
b. Work is underway for improved vaccines for the fall, but details and deadlines are not yet available
- An intranasal vaccine is under discussion, since that route can enhance antibodies in the nasopharynx, the major portal of entry for Covid-19, and perhaps do a better job than the current intramuscular mRNA vaccines from Moderna and Pfizer.
- Another possibility is vaccines that target more of the virus than the spike protein and might not be adversely affected by mutations of the spike protein.
- We’ll all get more information on this later in the summer.
3. What about treatments?
The currently available outpatient treatments for Covid-19 are game changers, because we can do something to mitigate a breakthrough case or a new case in an unvaccinated person. Fortunately, most infections in immunized and boosted people are mild, but many such infections can be quite unpleasant and persistent and require treatment. Do not think of these Covid infections as only a minor cold.
a. Paxlovid is an oral antiviral combination of medicines that attacks viral replication. It is readily available and we prescribe to most people over 50 and anyone at risk of adverse outcome. It is given for five days within five days of infection. It is safe and effective. People report feeling better within 26-48 hours. However, there can be recrudescence of symptoms after completion of the 5 -day course in perhaps 10-15% of people. It may be that the duration of therapy should be 7-10 days, but the FDA has not announced any such changes. We can prescribe Paxlovid for you through local pharmacies, most of which now have the drug.
b. Bebtelovimab from Eli Lilly is the antibody infusion that works against the Omicron variant. It is readily available in Massachusetts through the Gothams program or at major hospitals. We can authorize that for you. This is especially useful for anyone who is somehow unimmunized or immunosuppressed and inadequately protected despite vaccines.
c. Evusheld is an injection of antibodies effective against Covid-19 that is indicated for anyone immunosuppressed who doesn’t respond to the vaccines or who has allergic responses to the vaccines. We can authorize this, again, through the Gothams program or at major hospitals. We have done so for a number of our patients at risk. The antibody protection is equivalent to being vaccinated, and the antibodies last at least six months.
4. What should I do to be prudent yet not overly isolate myself?
We strongly suggest that you continue reasonable self-protection to minimize the risk of recurrent infections. With the pervasiveness of community infections at this time, we suggest, for example:
a. When you go indoors to stores (supermarkets, Home Depot, etc.) wear a good mask (KN95 or N95). A dozen people you pass in those stores will be unknowingly infectious.
b. Enjoy yourselves outdoors for the next four or five months. It is really hard to get infected outdoors.
c. Be very careful about indoor dining. Restaurants with large spaces and high air volume and separated tables can be safe. The small crowded restaurant is not. We have multiple recent infections in our membership from the small restaurant experience.
d. Attendance at theaters and movies can be safe, given the large air volumes, if you wear your KN95 or N95 mask. Certainly that is true of the downtown theaters that require proof of vaccination for entry.
d. Talk to your family when non-immediate members are coming to visit. Double-check their exposures and behaviors. Are they masking in stores, for example? The other biggest source of recent cases is visiting family who were not doing reasonable protections.
5. Does Covid-19 infection give me immunity? For how long?
Despite all the self-protection modes mentioned above, and the vaccinations and boosters, extraordinary numbers of people have gotten Covid-19 infections in the past two months. Is there any upside to this? The short answer is yes.
a. After infection in an immunized and boosted person, it is likely that your immune response will protect you from subsequent infection for at least 3 months and possibly up to 6 months. There are not truly hard data on this, but that interval seems realistic. The omicron variant is more highly contagious than prior variants, and CDC data are not yet updated. The enhanced immune state may be shorter.
- Hence after infection, indoor dining for 3-4 and perhaps 6 months would be reasonable and should not be risky, as one example.
b. If you were unvaccinated and got Covid-19, useful immunity likely only lasts 2-3 months. Early on there were case reports of repeat infections by 3 months in unvaccinated persons. Again, CDC does not have thorough data as yet on this point dealing with Omicron infections. I’ll try to get further data on the post-infection enhanced immunity in the next several months.
There undoubtedly are many fine points unanswered, and some unanswerable at this time. Feel free to leave comments and questions. That “we are all in this together” has never been more true.