Seemed the appropriate time of year for this - but a thousand thanks for your newsletter over the pandemic. It's been a shining beacon of data and rationality over a crazy few years.
Great post (as usual). I join the chorus of the people here who are deeply appreciative of what you do (like taking the time out during this busy stressful week to give us this post). The CDC is very lucky to have you.
Another friendly reminder: "No is a complete sentence." It's OK to punt holiday gatherings completely if, like Bartleby, you'd prefer not to. It doesn't make you Scrooge or the Grinch or Mr. Potter. I might see my parents on Thursday, I might not. I might cancel at the last minute, if I choose to. I may prefer to save my rapid tests for something I'd rather do. Or insist that my super uses one when he comes to fix my washing machine. Or save them for the next time my girlfriend and I want to hang out. You get the idea.
After all this time, all the vaccines and being super careful (always a KN95 mask, and all but necessary indoor activities with groups of people avoided,) I have come down with Covid. I am SO ANNOYED. That is probably the worst symptom I am having. I'm guessing that I must have forgotten to clean my hands before removing my mask. I'll be fine. Most people are not masking anymore here in NOVA. I really appreciate your work! Happy Thanksgiving!
Most likely, you were exposed to someone with a high viral load who was spreading, and your KN95 seal wasn't as good as you thought. I triage when I mask, and which mask I use (note the caveat, at the end). I often don't mask going into a large and well-ventilated store, e.g., "big-box" such as Walmart or Home Depot, but I don't intentionally get close to people. I have KN95s for those few occasions when I'm going into an environment with relatively few people but poorer ventilation: smaller stores with smaller footprints and lower ceilings). I have N95s (and I seal-test every time I put one on) for those cases when I harbor any concerns of real infection potential. And most of the time, I if I feel any need to mask, I grab an N95, seal-test, and just go with that regardless.
I see few masks these days, but so far, no one who is masking has been treated with any disrespect that I'm aware of. I see more masks in grocery stores and among older Veterans at the several military bases near me, but overall, the age distribution is probably equal for ages 25 and above.
As for getting the virus... I suspect you've got one of the immune-escape variants; vaccination and boosters have helped keep your disease process mild, which with the evolution of this base virus for improved fitness, is about all we can hope for, at least currently. And it's unlikely you had a dirty-hand transmission process. Not impossible, unlikely. Most of the fomite spread requires significant amount of virus capable of reproducing, which is hard to achieve on most surfaces. Knowing how to mask and unmask is valuable, especially if you work in health care, though.
You are a good egg. Thank you for this! All signs in my community this past weekend pointed to layering up with more Swiss cheese slices of mitigation between us and...well, everything else. I appreciate all of your work.
Aaand, I visited family for 5 days during Thanksgiving and tested positive for Covid today (for the first time ever). Some family members were "just getting over being sick" and one "got sick" while we were there. Had I known that, I wouldn't have gone, because I know that at least some family members are pretty casual about being careful. I'm immuno-compromised, so I am not happy that I was around sick people that were not being at all cautious. To them, they "just had a cold", and some didn't even cover their mouth and nose when they coughed or sneezed. . Sigh! I shouldn't have believed them, and should have worn my mask the entire time, rather than just part of the time. 3 other family members, thus far, have also tested positive for Covid. Live (I hope) and learn!
Monitor your symptoms. And for good measure, notify your primary care doc to let them know you've tested positive. If your symptoms get worse, get in to see the PCP quickly.
We're seeing increases in cases overall, and remember, since we do not adequately test, an increase in cases is both real, and fails to represent the actual number of cases out there. Numerical models see a sharp increase in cases but are all over the place with regard to hospital admissions and severe illness. There are plenty of new variants to keep things interesting.
Thanks. Already contacted my PCP, and we are discussing Paxlovid. I am immuno-compromised, so this is a scary situation for me. Avoided Covid up until now, and have gotten the original vaccines, as well as all of the boosters. I'm hoping the most recent booster for Omicron will help keep me out of the hospital.
Unless you're on one of the several meds that are absolute contraindications to Paxlovid, the discussion should have been very short. With indications that it can reduce or in some cases eliminate Long COVID, the reason to consider "waiting" or "withholding" is becoming less obvious.
Spoke with my PCP and oncologist yesterday, and I did decide to go with Paxlovid. First dose last night. The only "side effect" thus far is a kind of metallic taste in my mouth. I'll take that.
The metallic taste is common, but a small price to pay to prevent primary infection, and Long COVID (if it really does, as preliminary work suggests). I've become very concerned about the impacts of Long COVID as the reports progress.
Can you address facts/fiction regarding the safety of mRNA vaccines. Local medical professional is saying it's not a natural substance to put in the body--not the dead virus but man-made. Also saying local doctors (in Colorado) are blaming mRNA vaccines for life-threatening respiratory illness with kidney destruction for young men who get the vaccines. I only see the rare risk of heart damage. Any truth in the data that you're seeing?
I would be VERY interested in knowing where in Colorado (where I'm living now) you're hearing about the proposed link to mRNA vaccines and respiratory illness plus-or-minus renal damage. I'm pretty sure CU Anschutz would love to dispel their concerns. Of course, we do have medical professionals who don't believe in the pandemic, the severity of COVID disease, or the vaccines, which is unfortunate.
Larimer County/Loveland (Medical Center of the Rockies). Would appreciate any further studies or connections to Anschutz members who work in these areas. I view our COVID response as a dry run for future pandemics or, God forbid, bio-terror. We need to get it right while we can! Then again, maybe something's going on along the northern Front Range that others need to know about...
My leading contact in Loveland is deployed right now but I'll see what I can find from Anschutz. I know there are teams working on Long COVID, and Jon Samet, current Dean of the School of Public Health, would cringe at this. Let me see what I can find.
This is a good summary of the pertinent articles. @AR Morris, if you (not @KB; I know that answer) need help with interpretation of these articles, let me know.
There have been a few cases of post-vaccine acute myocarditis or pericarditis that were significant/severe, but it remains unclear to me, reading case reports on those, if they might not have had underlying issues, perhaps including a predisposition to myocarditis, with or without an occult COVID infection; this is PURE conjecture on my part.
I'll have to listen to this one, but I've found MedCram, while overall good, sometimes gets a bit over its skis with COVID. I reserve comment/judgement on this one 'til later.
I'd love your take on how risky it is to get together with unvaccinated people. For some of us it is an easier decision than others to exclude them from holiday get togethers year after year. I've generally been of the feeling that lack of vaccination obviously poses a risk to *themselves* but doesn't necessarily pose any significantly increased risk to *others*, especially now that it's clear that fully vaccinated people can and do spread Covid. I know there's the separate issue of the exposure-risk-due-to-behavior difference between someone who's vaccinated and generally Covid conscientious and someone who is vehemently anti-vax or anti-mask and doesn't take Covid seriously at all.
But my question is *all other things being equal*, is there really a greater chance that a completely asymptomatic unvaccinated person is infectious where a completely asymptomatic vaccinated person wouldn't be? And if so, enough of a chance to avoid seeing them?
You got a thorough response below. Here's a general tip on how to apply healthy skepticism to medical claims. If someone says x is "not natural," be very suspicious. "Natural" does not equal good or safe. "Artificial" does not equate with bad. Arsenic, tuberculosis, and smallpox are all natural but not exactly healthy. The development of meds in labs and subsequent double-blind testing assure that what you put into your body is precisely and only what you need to be well. By contrast, unregulated natural remedies include all kinds of unlisted substances that may cause harm. See, for example, https://www.washingtonpost.com/news/to-your-health/wp/2015/10/14/more-than-23000-people-wind-up-in-the-er-each-year-due-to-dietary-supplements/
I am puzzled by one thing. The word began to spread, maybe a year ago, that N95s and KN95s were far preferable to cloth masks, and we should toss the cloth. Yet there are companies like Enro (I do not have any association with the company), whose masks I learned about through Wirecutter, that seem to have been thoroughly tested and that have come through with flying colors. Is the N95 guidance a too-blunt instrument or is it truly the only safe path to follow?
Yes, but... evidence from years of masking with a variety of masks, in hospitals and in other countries, demonstrates adequately that any form of mask barrier, if worn properly, reduces transmission.
I've gone, first to KN95s and now almost exclusively to N95s personally. I spent years and years wearing masks for hours on end daily, and had to learn how to fit- and seal-test masks working with patients in one form of isolation or another, so wearing them, for me, is a non-issue, but for so many in the US, a mask is a nuisance and as a result they're worn poorly, or not at all.
Once again your treatment algorithm is very helpful...thank you. Something more concerning is your suggestion about antivirals. I’ve read and heard recently that flu antivirals are in short supply and per your latest post “ Who is Dying from Covid” noted that coronavirus antiviral for > 65 and at risk are being underutilized. Seems as though the ball has been dropped and no one is addressing it. As someone that is in the over 65 crowd, healthy and have been vaccinated to the max and never had Covid-19, this is concerning and feels like ageism to me and should be addressed.
FNP here. Thank you for this very useful info. So COVID+ pt need to keep testing until antigen negative? I've had a couple pts who were on day 11 or after, mild cough, but feeling well and still testing positive. Does that mean they are still contagious?
If they have tested positive, then, based on CDC guidance and some extrapolation, I'd wait 5 days before the next test. IF that test is negative, test again in 24 hours (note my discussion of how to test above) to confirm negativity. If they test positive, wait until day 8 of either first positive test or symptoms, and retest, looking for 2 or 3 consecutive negative tests, depending on your index of suspicion.
Home tests using rapid antigen processes tend to test positive when someone still has an intact viral load, thus are likely contagious. PCR testing can detect viral fragments, thus the recommendation to not retest with PCR until some 90 days post-infection.
Long time lurker, but I am going to ask this to see if you can chime in on something that is bothering me. I have noticed a lack of mentioning PCR testing for civilians. I am curious as to why. I understand the advantages and convenience of using antigen tests. I also understand the drawbacks of PCR tests as well. But you've not mentioned PCR testing for quite a few posts now. I am curious as to why this is. Was it an unconscious action or do the drawbacks of PCRs make you not really want to recommend them?
From my perspective(not a doctor just a radiology tech who has been glued to this since the first notification from the WHO), the largest drawback to PCRs in the States is the fact you can pop positive on them for up to 3 months after infection. There are obviously waiting period for results with a PCR as well. But the latter is not as much a concern as it used to be as many results can be returned in less than 24 hours. Most can still receive a PCR test for a grand total of $0. The discussion around testing these days seems to exclude PCR options which is making it an underutilized tool(from my perspective).
Obviously PCRs are not as convenient as a test you can administer at home and have results in 20 minutes. But there is no reason for us to not use PCRs for follow-up testing in high risk situations, no? Even the CDC recommends testing 6 days after being exposed to covid regardless of vaccination status. Surely a PCR would be a better tool to pick up cases under these guidelines? I think if the medical field encouraged folks to regularly test a week after any very high risk event(family gathering, funeral, concert, travel etc.) it would genuinely help us move forward. I get that almost every activity can transmit omicron, but at some point our foot has to go down on emphasizing that people need to check themselves. Since society doesn't want mass-masking, emphasis needs to be put somewhere. Post-exposure testing is so under mentioned after family gatherings from most I know. I understand pandemic fatigue is real, but I don't see why messaging on testing after holidays being extremely important would be a bad thing.
I hope I don't sound arrogant or condescending. I have loved your posts and this is genuine curiosity. The CDC guidelines seem almost a minimum to break transmission and with PCRs being absent in your posts, I really am curious why this is in your literature. I was swabbed yesterday at a drive through and my PCR ran for influenza and covid. I got my results back in 22 hours. Not bad turnaround time for a weekend and all for $0!
Depending on the degree of cyclic amplification, rt-PCR tests can continue to demonstrate positive results based on viral fragments for, as you note, several months. We've known of this issue; there was, earlier in the pandemic and still in the phase where we were seeing the ancestral strains, advice to not retest with PCR for at least 90 days; we also were not seeing reinfections or breakthroughs at the rate and degree we see them in the omicron era.
In general, if you tested positive on a lateral-flow test, and subsequently test negative (a minimum of 5 days after the positive test), you likely are no longer contagious. That is the best reason to consider use of the rapid-antigen test vs the molecular (PCR) test. There is, as well, little control as to how many cycles may be used to attempt to detect the RNA fragments with rt-PCR, despite a fairly well accepted value of 38 for a cycle threshold.
PCR testing still requires (with a few home-approved exceptions) trained lab technicians and specialized hardware, as well as several hours, to accomplish. When the public health emergency expires, costs on testing are likely to go up, and insurers are likely to impose restrictions on obtaining molecular tests. Lateral flow tests are likely to fill the bill.
A significant issue in combating the COVID-19 pandemic has been a failure to communicate, something Katelyn has not been guilty of (although I have personally had my own problems communicating with non-professionals). If we could reduce the degree of misinformation and reestablish a reliable communications conduit with authoritative and trusted information, we could renew our efforts to improve vaccination rates, discuss masks and other non-pharmaceutical interventions, and take a proactive approach to combat this disease process. As it is, this virus has been mutating so rapidly that, without a coherent plan and policy, and consistent funding (blame Congress for inconsistent funding; they're so done with this virus), we're looking at a pandemic phase persisting for years.
Lateral-flow tests are a very useful adjunct to our other testing options. Their biggest downfall is the lack of a central, trusted reporting site for ALL testing (PCR and Lateral-Flow).
I did not say Dr.Katelyn has been guilty of failure to communicate so I am not sure if that was directed at me or just a general comment. She's done a phenomenal job at translating scientific data to the general public. I never thought I would pay to subscribe to anything like her updates but her posts have been invaluable.
My question simplified remains the same: is her omission of mentioning PCRs as testing options accidental or intentional? All the pros and cons you mentioned I am already very well familiar with as I mentioned in my post. The biggest downside I see personally is how long someone can test positive after being infected. I am curious as to her thoughts on using PCRs moving forward.
Consider the following: Antigen tests for low-income, uninsured, individuals are not free. Using them for larger families in this demographic for meetups is prohibitively expensive. PCRs can still be acquired with no charge in certain cases(although I get most funding has been reduced for the uninsured). But, on the other hand, if these resources are not used, these services will be cut. I tried looking for the testing site that used to be right down my street in a transit hub in Houston. Closed down along with literally countless others(Curative). At the end of December Curative will be closing their doors for all PCR testing. The PCR testing options are shockingly reduced now. Like it or not, we live in a capitalist medical system of supply and demand. With the push to antigens, these sites were going to close down. I don't think they should be closed down and I do think PCRs for the public are something we should absolutely have as an option. After all, they do detect better than antigen tests at the end of the day! But without encouragement, or even mention, from others I fear we will lose these options completely. Again though I am just a average guy so I know nothing but I want to know someone else's thoughts on the matter.
I would agree the lack of centralized reporting is an appalling failure of our system. You can't even count home tests in many jurisdictions, that is just a GIANT amount of valuable data that will never be collected. But blaming Congress is too simple. The problem is much deeper than that. Our education system is a failure if people keep electing individuals who may accurately represent them back home. Meaning, Congress is a reflection of the people back in their home districts and the display of lack of critical thinking skills is overt. I get that is an oversimplification to an extent. But when my very own friends ask me, consistently why I would get tested if I don't feel sick, it demonstrates the same problem. We have done a poor job educating people. Sure some of it selfishness of course. But even basic mathematics would tell someone to test before/after the holidays during a pandemic. The fact many people still don't genuinely understand this says alot.
Edit: An aside, I would loveeeee ideas on reducing misinformation. I forgot how bad it was until I saw how Twitter has unfolded since it's takeover/removal of moderation. Truthfully I have no good ideas in that area that don't involve some sort of heavy regulatory rules that would be deeply unpopular in the USA. Your point on this particular issue is so spot on though. I forget just how big a problem it is because I'm truthfully not on social media anymore.
The comment on communication failure was more general, but Katelyn's done an incredible job of righting that error. She's been clear and concise. Her work's made mine easier as I can use snippets of what she's said (yes, with attribution) to support my routine updates to a large volunteer organization. I don't have to translate what my research says... unless, in the rare instance, I disagree with her findings.
As for testing, I'm appalled that we've lost funding because of a Congress who, like a lot of the population, are so over COVID they're ignoring the issues. Funding has not been continued for testing, and at the expiration of the Public Health Emergency, patients will suddenly become fully responsible for testing, and perhaps treatment. That said, we're still seeing high levels of test positivity, increasing hospitalizations, and deaths are generally up around 400/day, well past a "normal flu season", AND so far, COVID's defined season is 12 months long. Cyclic waves seen reflect infection, recovery and (transient?) immunity with some degree of breakthrough infection still occurring.
What I want to see is ready availability of rt-PCR testing, with faster turn-arounds, which, as you note, are positive, AND a central data collection site for at-home tests. The at-home testing would not be as good as the mandatory reporting of certified lab tests but if handled properly would provide more data on community status. Also, CDC and FDA need to evolve their ivory tower preference for ONLY CMS/CLIA certified lab based reports for results. Flooding the community, weekly, with testing would provide much more granular information on where we are with this virus, and might allow us to interpret how it's evolving and how we're coping better.
I also hope to see more, and better antibody testing to determine what percentage of the population has been infected, and to what degree their immunity remains intact. With recent reports of B- and T-cell damage from COVID infection, this becomes a more urgent question than we'd imagined 6 months ago.
I've not lived in Houston for years. Wasn't aware of the widespread community testing, but during the early pandemic years, living in Oklahoma, we went from frank governmental denial (and the governor meddling in how public health reports were written) to widespread testing supported by hospitals, and even a company doing immunologic assay research, all at no cost to the public. Responsible adults in Oklahoma encouraged vaccinations, although the governor did so grudgingly.
If you'd like to engage on sensitivity and specificity of the rt-PCR tests vs lateral-flow antigen tests, I can probably help you understand better how both can be used in the ecosystem. They shouldn't be viewed as mutually exclusive; you have to know the strengths and weaknesses of both approaches, and use them appropriately.
All good advice, and I hope all had a good Thanksgiving.
I'd take a bit of exception to home testing (lateral flow rapid antigen tests) advice for the future. The biggest drawback to those tests compared to a properly performed PCR test is, rapid antigen tests have no mechanism to amplify the viral load; what you've got in the area sampled, usually the nasopharynx or anterior nares, is what the test has to work with. If concentrations are below the sensitivity of the test, or borderline, you might get a false negative test. Cadence testing is good to help with finding and clarifying a false negative test, and I've used it successfully for that purpose.
Symptoms are important, at least in the less sensitive lateral flow tests. If you're not symptomatic, you probably won't have sufficient viral load in the nose to test positive... but if you KNOW you were exposed, and 4-5 days have passed, it's OK to test; you could have an asymptomatic infection. Also, how you get ready before the test is important. I've seen package recommendations, and have discussed with colleagues, that blowing your nose before the test is a good practice and also helps standardize the testing procedure. Also, if administering the test, make sure to follow the package instructions as to where to sample, or if they're not clear, sample about as far back as you can see in the nose. The deep "brain biopsy" sampling done early in the pandemic has its place but there are possibilities for problems. The swab should be rotated, and the same swab used for both nares (sides of the nose). Follow the instructions for the medium used for the lateral flow test (it varies from manufacturer to manufacturer; I'm now good with at least 4 different tests and their only common point is 15 minutes of toe-tapping while you wait for a result.
In general terms, I've always treated a positive test as, well, a positive test. A negative is a "presumptive negative" but must be confirmed by retesting. Said retesting should be planned. I like to test 24 and 48 hours after the first negative test, and if symptoms subsequently develop, test again. If all are negative, you should be good.
I also like the idea of testing just before the event. One last check, to make sure everything is OK.
As an anecdote, I recently had an influenza-like illness. I'm fully vaccinated, and up to date including the bivalent booster (all Moderna). I've also had my annual flu shot. I was symptomatic and miserable, but 4 successive lateral flow tests were negative. My own primary care doc accepted this as "you've probably got a version of the flu we didn't cover in the vaccine", a position I agreed with. Unlike previous bouts of COVID, documented by positive PCR or home rapid antigen testing, I had none of the other ugly symptoms like loss of smell or taste. I just felt miserable for 7 days.
As always, I'm grateful for your advice. After dodging the coronavirus for three years, I finally came down with Covid. It's a disappointment, as I was cautious, but not really a shock. The coronavirus is ubiquitous. What really surprises me is how severe my case is. I'm a 66-year-old male in generally good health. I got my 4th Pfizer vaccination on Oct. 2. In principle, I should have peak immune response about now. Within 16 hours of my first symptom, I got started on Paxlovid. But my symptoms worsened by Day 3. To be clear, I'm not so sick as to need hospital care, but this is like a serious and enduring flu. I have a wicked sore throat, lung and sinus congestion, cough, chills, weeping eyes, aches, lethargy, and weakness. No fun at all! Any insights? Or is this just Covid roulette?
Seemed the appropriate time of year for this - but a thousand thanks for your newsletter over the pandemic. It's been a shining beacon of data and rationality over a crazy few years.
Great post (as usual). I join the chorus of the people here who are deeply appreciative of what you do (like taking the time out during this busy stressful week to give us this post). The CDC is very lucky to have you.
Another friendly reminder: "No is a complete sentence." It's OK to punt holiday gatherings completely if, like Bartleby, you'd prefer not to. It doesn't make you Scrooge or the Grinch or Mr. Potter. I might see my parents on Thursday, I might not. I might cancel at the last minute, if I choose to. I may prefer to save my rapid tests for something I'd rather do. Or insist that my super uses one when he comes to fix my washing machine. Or save them for the next time my girlfriend and I want to hang out. You get the idea.
Words to live by. It’s so easy to be intimidated by others.
Stand your ground
After all this time, all the vaccines and being super careful (always a KN95 mask, and all but necessary indoor activities with groups of people avoided,) I have come down with Covid. I am SO ANNOYED. That is probably the worst symptom I am having. I'm guessing that I must have forgotten to clean my hands before removing my mask. I'll be fine. Most people are not masking anymore here in NOVA. I really appreciate your work! Happy Thanksgiving!
Most likely, you were exposed to someone with a high viral load who was spreading, and your KN95 seal wasn't as good as you thought. I triage when I mask, and which mask I use (note the caveat, at the end). I often don't mask going into a large and well-ventilated store, e.g., "big-box" such as Walmart or Home Depot, but I don't intentionally get close to people. I have KN95s for those few occasions when I'm going into an environment with relatively few people but poorer ventilation: smaller stores with smaller footprints and lower ceilings). I have N95s (and I seal-test every time I put one on) for those cases when I harbor any concerns of real infection potential. And most of the time, I if I feel any need to mask, I grab an N95, seal-test, and just go with that regardless.
I see few masks these days, but so far, no one who is masking has been treated with any disrespect that I'm aware of. I see more masks in grocery stores and among older Veterans at the several military bases near me, but overall, the age distribution is probably equal for ages 25 and above.
As for getting the virus... I suspect you've got one of the immune-escape variants; vaccination and boosters have helped keep your disease process mild, which with the evolution of this base virus for improved fitness, is about all we can hope for, at least currently. And it's unlikely you had a dirty-hand transmission process. Not impossible, unlikely. Most of the fomite spread requires significant amount of virus capable of reproducing, which is hard to achieve on most surfaces. Knowing how to mask and unmask is valuable, especially if you work in health care, though.
Thanks!
I understand “your worst symptom.” Almost no masks in our area either.
You are a good egg. Thank you for this! All signs in my community this past weekend pointed to layering up with more Swiss cheese slices of mitigation between us and...well, everything else. I appreciate all of your work.
Aaand, I visited family for 5 days during Thanksgiving and tested positive for Covid today (for the first time ever). Some family members were "just getting over being sick" and one "got sick" while we were there. Had I known that, I wouldn't have gone, because I know that at least some family members are pretty casual about being careful. I'm immuno-compromised, so I am not happy that I was around sick people that were not being at all cautious. To them, they "just had a cold", and some didn't even cover their mouth and nose when they coughed or sneezed. . Sigh! I shouldn't have believed them, and should have worn my mask the entire time, rather than just part of the time. 3 other family members, thus far, have also tested positive for Covid. Live (I hope) and learn!
Monitor your symptoms. And for good measure, notify your primary care doc to let them know you've tested positive. If your symptoms get worse, get in to see the PCP quickly.
We're seeing increases in cases overall, and remember, since we do not adequately test, an increase in cases is both real, and fails to represent the actual number of cases out there. Numerical models see a sharp increase in cases but are all over the place with regard to hospital admissions and severe illness. There are plenty of new variants to keep things interesting.
Thanks. Already contacted my PCP, and we are discussing Paxlovid. I am immuno-compromised, so this is a scary situation for me. Avoided Covid up until now, and have gotten the original vaccines, as well as all of the boosters. I'm hoping the most recent booster for Omicron will help keep me out of the hospital.
Unless you're on one of the several meds that are absolute contraindications to Paxlovid, the discussion should have been very short. With indications that it can reduce or in some cases eliminate Long COVID, the reason to consider "waiting" or "withholding" is becoming less obvious.
Spoke with my PCP and oncologist yesterday, and I did decide to go with Paxlovid. First dose last night. The only "side effect" thus far is a kind of metallic taste in my mouth. I'll take that.
The metallic taste is common, but a small price to pay to prevent primary infection, and Long COVID (if it really does, as preliminary work suggests). I've become very concerned about the impacts of Long COVID as the reports progress.
Can you address facts/fiction regarding the safety of mRNA vaccines. Local medical professional is saying it's not a natural substance to put in the body--not the dead virus but man-made. Also saying local doctors (in Colorado) are blaming mRNA vaccines for life-threatening respiratory illness with kidney destruction for young men who get the vaccines. I only see the rare risk of heart damage. Any truth in the data that you're seeing?
I would be VERY interested in knowing where in Colorado (where I'm living now) you're hearing about the proposed link to mRNA vaccines and respiratory illness plus-or-minus renal damage. I'm pretty sure CU Anschutz would love to dispel their concerns. Of course, we do have medical professionals who don't believe in the pandemic, the severity of COVID disease, or the vaccines, which is unfortunate.
Larimer County/Loveland (Medical Center of the Rockies). Would appreciate any further studies or connections to Anschutz members who work in these areas. I view our COVID response as a dry run for future pandemics or, God forbid, bio-terror. We need to get it right while we can! Then again, maybe something's going on along the northern Front Range that others need to know about...
My leading contact in Loveland is deployed right now but I'll see what I can find from Anschutz. I know there are teams working on Long COVID, and Jon Samet, current Dean of the School of Public Health, would cringe at this. Let me see what I can find.
This is a good summary of the pertinent articles. @AR Morris, if you (not @KB; I know that answer) need help with interpretation of these articles, let me know.
There have been a few cases of post-vaccine acute myocarditis or pericarditis that were significant/severe, but it remains unclear to me, reading case reports on those, if they might not have had underlying issues, perhaps including a predisposition to myocarditis, with or without an occult COVID infection; this is PURE conjecture on my part.
I'll have to listen to this one, but I've found MedCram, while overall good, sometimes gets a bit over its skis with COVID. I reserve comment/judgement on this one 'til later.
Thank you for this and all of the other links you provided. I'm working my way through them!!
I'd love your take on how risky it is to get together with unvaccinated people. For some of us it is an easier decision than others to exclude them from holiday get togethers year after year. I've generally been of the feeling that lack of vaccination obviously poses a risk to *themselves* but doesn't necessarily pose any significantly increased risk to *others*, especially now that it's clear that fully vaccinated people can and do spread Covid. I know there's the separate issue of the exposure-risk-due-to-behavior difference between someone who's vaccinated and generally Covid conscientious and someone who is vehemently anti-vax or anti-mask and doesn't take Covid seriously at all.
But my question is *all other things being equal*, is there really a greater chance that a completely asymptomatic unvaccinated person is infectious where a completely asymptomatic vaccinated person wouldn't be? And if so, enough of a chance to avoid seeing them?
You got a thorough response below. Here's a general tip on how to apply healthy skepticism to medical claims. If someone says x is "not natural," be very suspicious. "Natural" does not equal good or safe. "Artificial" does not equate with bad. Arsenic, tuberculosis, and smallpox are all natural but not exactly healthy. The development of meds in labs and subsequent double-blind testing assure that what you put into your body is precisely and only what you need to be well. By contrast, unregulated natural remedies include all kinds of unlisted substances that may cause harm. See, for example, https://www.washingtonpost.com/news/to-your-health/wp/2015/10/14/more-than-23000-people-wind-up-in-the-er-each-year-due-to-dietary-supplements/
Thanksgiving blessings to you and your family. Thank you so much for all you do every day.
Thank you as usual for the excellent advice.
I am puzzled by one thing. The word began to spread, maybe a year ago, that N95s and KN95s were far preferable to cloth masks, and we should toss the cloth. Yet there are companies like Enro (I do not have any association with the company), whose masks I learned about through Wirecutter, that seem to have been thoroughly tested and that have come through with flying colors. Is the N95 guidance a too-blunt instrument or is it truly the only safe path to follow?
Cloth masks don't work well and they break down over time. Enro's "data" comes from their own marketing materials. Aaron Collins is an aerosol engineer who tests masks, you can see from his dataset how Enro stacks up. (filtration efficiency in the mid 60s% even new and lower after washing.) https://docs.google.com/spreadsheets/d/1M0mdNLpTWEGcluK6hh5LjjcFixwmOG853Ff45d3O-L0/edit?usp=sharing
Yes, but... evidence from years of masking with a variety of masks, in hospitals and in other countries, demonstrates adequately that any form of mask barrier, if worn properly, reduces transmission.
I've gone, first to KN95s and now almost exclusively to N95s personally. I spent years and years wearing masks for hours on end daily, and had to learn how to fit- and seal-test masks working with patients in one form of isolation or another, so wearing them, for me, is a non-issue, but for so many in the US, a mask is a nuisance and as a result they're worn poorly, or not at all.
Thank you--much appreciated.
If you don't mind a follow-up question, which upstream concentration and in-mask concentration numbers indicate reasonably effective masks?
Once again your treatment algorithm is very helpful...thank you. Something more concerning is your suggestion about antivirals. I’ve read and heard recently that flu antivirals are in short supply and per your latest post “ Who is Dying from Covid” noted that coronavirus antiviral for > 65 and at risk are being underutilized. Seems as though the ball has been dropped and no one is addressing it. As someone that is in the over 65 crowd, healthy and have been vaccinated to the max and never had Covid-19, this is concerning and feels like ageism to me and should be addressed.
FNP here. Thank you for this very useful info. So COVID+ pt need to keep testing until antigen negative? I've had a couple pts who were on day 11 or after, mild cough, but feeling well and still testing positive. Does that mean they are still contagious?
If they have tested positive, then, based on CDC guidance and some extrapolation, I'd wait 5 days before the next test. IF that test is negative, test again in 24 hours (note my discussion of how to test above) to confirm negativity. If they test positive, wait until day 8 of either first positive test or symptoms, and retest, looking for 2 or 3 consecutive negative tests, depending on your index of suspicion.
Home tests using rapid antigen processes tend to test positive when someone still has an intact viral load, thus are likely contagious. PCR testing can detect viral fragments, thus the recommendation to not retest with PCR until some 90 days post-infection.
Thanks much. You are great. Happy Thanksgiving to you and your family.
Hi Dr.Katelyn!
Long time lurker, but I am going to ask this to see if you can chime in on something that is bothering me. I have noticed a lack of mentioning PCR testing for civilians. I am curious as to why. I understand the advantages and convenience of using antigen tests. I also understand the drawbacks of PCR tests as well. But you've not mentioned PCR testing for quite a few posts now. I am curious as to why this is. Was it an unconscious action or do the drawbacks of PCRs make you not really want to recommend them?
From my perspective(not a doctor just a radiology tech who has been glued to this since the first notification from the WHO), the largest drawback to PCRs in the States is the fact you can pop positive on them for up to 3 months after infection. There are obviously waiting period for results with a PCR as well. But the latter is not as much a concern as it used to be as many results can be returned in less than 24 hours. Most can still receive a PCR test for a grand total of $0. The discussion around testing these days seems to exclude PCR options which is making it an underutilized tool(from my perspective).
Obviously PCRs are not as convenient as a test you can administer at home and have results in 20 minutes. But there is no reason for us to not use PCRs for follow-up testing in high risk situations, no? Even the CDC recommends testing 6 days after being exposed to covid regardless of vaccination status. Surely a PCR would be a better tool to pick up cases under these guidelines? I think if the medical field encouraged folks to regularly test a week after any very high risk event(family gathering, funeral, concert, travel etc.) it would genuinely help us move forward. I get that almost every activity can transmit omicron, but at some point our foot has to go down on emphasizing that people need to check themselves. Since society doesn't want mass-masking, emphasis needs to be put somewhere. Post-exposure testing is so under mentioned after family gatherings from most I know. I understand pandemic fatigue is real, but I don't see why messaging on testing after holidays being extremely important would be a bad thing.
I hope I don't sound arrogant or condescending. I have loved your posts and this is genuine curiosity. The CDC guidelines seem almost a minimum to break transmission and with PCRs being absent in your posts, I really am curious why this is in your literature. I was swabbed yesterday at a drive through and my PCR ran for influenza and covid. I got my results back in 22 hours. Not bad turnaround time for a weekend and all for $0!
Depending on the degree of cyclic amplification, rt-PCR tests can continue to demonstrate positive results based on viral fragments for, as you note, several months. We've known of this issue; there was, earlier in the pandemic and still in the phase where we were seeing the ancestral strains, advice to not retest with PCR for at least 90 days; we also were not seeing reinfections or breakthroughs at the rate and degree we see them in the omicron era.
In general, if you tested positive on a lateral-flow test, and subsequently test negative (a minimum of 5 days after the positive test), you likely are no longer contagious. That is the best reason to consider use of the rapid-antigen test vs the molecular (PCR) test. There is, as well, little control as to how many cycles may be used to attempt to detect the RNA fragments with rt-PCR, despite a fairly well accepted value of 38 for a cycle threshold.
PCR testing still requires (with a few home-approved exceptions) trained lab technicians and specialized hardware, as well as several hours, to accomplish. When the public health emergency expires, costs on testing are likely to go up, and insurers are likely to impose restrictions on obtaining molecular tests. Lateral flow tests are likely to fill the bill.
A significant issue in combating the COVID-19 pandemic has been a failure to communicate, something Katelyn has not been guilty of (although I have personally had my own problems communicating with non-professionals). If we could reduce the degree of misinformation and reestablish a reliable communications conduit with authoritative and trusted information, we could renew our efforts to improve vaccination rates, discuss masks and other non-pharmaceutical interventions, and take a proactive approach to combat this disease process. As it is, this virus has been mutating so rapidly that, without a coherent plan and policy, and consistent funding (blame Congress for inconsistent funding; they're so done with this virus), we're looking at a pandemic phase persisting for years.
Lateral-flow tests are a very useful adjunct to our other testing options. Their biggest downfall is the lack of a central, trusted reporting site for ALL testing (PCR and Lateral-Flow).
I did not say Dr.Katelyn has been guilty of failure to communicate so I am not sure if that was directed at me or just a general comment. She's done a phenomenal job at translating scientific data to the general public. I never thought I would pay to subscribe to anything like her updates but her posts have been invaluable.
My question simplified remains the same: is her omission of mentioning PCRs as testing options accidental or intentional? All the pros and cons you mentioned I am already very well familiar with as I mentioned in my post. The biggest downside I see personally is how long someone can test positive after being infected. I am curious as to her thoughts on using PCRs moving forward.
Consider the following: Antigen tests for low-income, uninsured, individuals are not free. Using them for larger families in this demographic for meetups is prohibitively expensive. PCRs can still be acquired with no charge in certain cases(although I get most funding has been reduced for the uninsured). But, on the other hand, if these resources are not used, these services will be cut. I tried looking for the testing site that used to be right down my street in a transit hub in Houston. Closed down along with literally countless others(Curative). At the end of December Curative will be closing their doors for all PCR testing. The PCR testing options are shockingly reduced now. Like it or not, we live in a capitalist medical system of supply and demand. With the push to antigens, these sites were going to close down. I don't think they should be closed down and I do think PCRs for the public are something we should absolutely have as an option. After all, they do detect better than antigen tests at the end of the day! But without encouragement, or even mention, from others I fear we will lose these options completely. Again though I am just a average guy so I know nothing but I want to know someone else's thoughts on the matter.
I would agree the lack of centralized reporting is an appalling failure of our system. You can't even count home tests in many jurisdictions, that is just a GIANT amount of valuable data that will never be collected. But blaming Congress is too simple. The problem is much deeper than that. Our education system is a failure if people keep electing individuals who may accurately represent them back home. Meaning, Congress is a reflection of the people back in their home districts and the display of lack of critical thinking skills is overt. I get that is an oversimplification to an extent. But when my very own friends ask me, consistently why I would get tested if I don't feel sick, it demonstrates the same problem. We have done a poor job educating people. Sure some of it selfishness of course. But even basic mathematics would tell someone to test before/after the holidays during a pandemic. The fact many people still don't genuinely understand this says alot.
Edit: An aside, I would loveeeee ideas on reducing misinformation. I forgot how bad it was until I saw how Twitter has unfolded since it's takeover/removal of moderation. Truthfully I have no good ideas in that area that don't involve some sort of heavy regulatory rules that would be deeply unpopular in the USA. Your point on this particular issue is so spot on though. I forget just how big a problem it is because I'm truthfully not on social media anymore.
The comment on communication failure was more general, but Katelyn's done an incredible job of righting that error. She's been clear and concise. Her work's made mine easier as I can use snippets of what she's said (yes, with attribution) to support my routine updates to a large volunteer organization. I don't have to translate what my research says... unless, in the rare instance, I disagree with her findings.
As for testing, I'm appalled that we've lost funding because of a Congress who, like a lot of the population, are so over COVID they're ignoring the issues. Funding has not been continued for testing, and at the expiration of the Public Health Emergency, patients will suddenly become fully responsible for testing, and perhaps treatment. That said, we're still seeing high levels of test positivity, increasing hospitalizations, and deaths are generally up around 400/day, well past a "normal flu season", AND so far, COVID's defined season is 12 months long. Cyclic waves seen reflect infection, recovery and (transient?) immunity with some degree of breakthrough infection still occurring.
What I want to see is ready availability of rt-PCR testing, with faster turn-arounds, which, as you note, are positive, AND a central data collection site for at-home tests. The at-home testing would not be as good as the mandatory reporting of certified lab tests but if handled properly would provide more data on community status. Also, CDC and FDA need to evolve their ivory tower preference for ONLY CMS/CLIA certified lab based reports for results. Flooding the community, weekly, with testing would provide much more granular information on where we are with this virus, and might allow us to interpret how it's evolving and how we're coping better.
I also hope to see more, and better antibody testing to determine what percentage of the population has been infected, and to what degree their immunity remains intact. With recent reports of B- and T-cell damage from COVID infection, this becomes a more urgent question than we'd imagined 6 months ago.
I've not lived in Houston for years. Wasn't aware of the widespread community testing, but during the early pandemic years, living in Oklahoma, we went from frank governmental denial (and the governor meddling in how public health reports were written) to widespread testing supported by hospitals, and even a company doing immunologic assay research, all at no cost to the public. Responsible adults in Oklahoma encouraged vaccinations, although the governor did so grudgingly.
If you'd like to engage on sensitivity and specificity of the rt-PCR tests vs lateral-flow antigen tests, I can probably help you understand better how both can be used in the ecosystem. They shouldn't be viewed as mutually exclusive; you have to know the strengths and weaknesses of both approaches, and use them appropriately.
All good advice, and I hope all had a good Thanksgiving.
I'd take a bit of exception to home testing (lateral flow rapid antigen tests) advice for the future. The biggest drawback to those tests compared to a properly performed PCR test is, rapid antigen tests have no mechanism to amplify the viral load; what you've got in the area sampled, usually the nasopharynx or anterior nares, is what the test has to work with. If concentrations are below the sensitivity of the test, or borderline, you might get a false negative test. Cadence testing is good to help with finding and clarifying a false negative test, and I've used it successfully for that purpose.
Symptoms are important, at least in the less sensitive lateral flow tests. If you're not symptomatic, you probably won't have sufficient viral load in the nose to test positive... but if you KNOW you were exposed, and 4-5 days have passed, it's OK to test; you could have an asymptomatic infection. Also, how you get ready before the test is important. I've seen package recommendations, and have discussed with colleagues, that blowing your nose before the test is a good practice and also helps standardize the testing procedure. Also, if administering the test, make sure to follow the package instructions as to where to sample, or if they're not clear, sample about as far back as you can see in the nose. The deep "brain biopsy" sampling done early in the pandemic has its place but there are possibilities for problems. The swab should be rotated, and the same swab used for both nares (sides of the nose). Follow the instructions for the medium used for the lateral flow test (it varies from manufacturer to manufacturer; I'm now good with at least 4 different tests and their only common point is 15 minutes of toe-tapping while you wait for a result.
In general terms, I've always treated a positive test as, well, a positive test. A negative is a "presumptive negative" but must be confirmed by retesting. Said retesting should be planned. I like to test 24 and 48 hours after the first negative test, and if symptoms subsequently develop, test again. If all are negative, you should be good.
I also like the idea of testing just before the event. One last check, to make sure everything is OK.
As an anecdote, I recently had an influenza-like illness. I'm fully vaccinated, and up to date including the bivalent booster (all Moderna). I've also had my annual flu shot. I was symptomatic and miserable, but 4 successive lateral flow tests were negative. My own primary care doc accepted this as "you've probably got a version of the flu we didn't cover in the vaccine", a position I agreed with. Unlike previous bouts of COVID, documented by positive PCR or home rapid antigen testing, I had none of the other ugly symptoms like loss of smell or taste. I just felt miserable for 7 days.
As always, I'm grateful for your advice. After dodging the coronavirus for three years, I finally came down with Covid. It's a disappointment, as I was cautious, but not really a shock. The coronavirus is ubiquitous. What really surprises me is how severe my case is. I'm a 66-year-old male in generally good health. I got my 4th Pfizer vaccination on Oct. 2. In principle, I should have peak immune response about now. Within 16 hours of my first symptom, I got started on Paxlovid. But my symptoms worsened by Day 3. To be clear, I'm not so sick as to need hospital care, but this is like a serious and enduring flu. I have a wicked sore throat, lung and sinus congestion, cough, chills, weeping eyes, aches, lethargy, and weakness. No fun at all! Any insights? Or is this just Covid roulette?