Here’s what I’m thinking about Covid this fall

Variants, boosters, antivirals, and a few tricks you might not have heard

As I type this, I am on a massive plane, basically an intercontinental missile with wings, cruising at about 35,000 feet above the Earth’s surface.  We’re rocketing through the atmosphere at about 550 mph.  You might think such a situation would make one feel nervous but I’m not.  Commercial airlines are safer than driving, and I’m feeling cozy wearing my N95. I used to get sick on almost all my vacations, but since the pandemic, I’ve flown up and down 9 times. Viruses are 0 for 9 in that timeframe. And speaking of viruses, I’m writing about my Covid thoughts for this fall and winter. The in-flight movies were ho-hum. I’d rather hook you up.

As I travel again, I am thrilled it’s 2023 and not 2020.  I feel euphoric at times seeing the big world, or even just hanging out with old friends and family.  In general I’m taking many more chances, but chances are I’m still being more careful than most. As I look around this airplane, I get it.  People have made their peace with getting sick again.  A lot of them look sick right now, actually.  Coughing, sneezing, noses full of mucus being blown into cheap tissues that fall apart as they are being folded.  Viruses are back in business again, and we have opened the doors, because it’s just too awful to do otherwise anymore.

But if you’re still interested in Covid prevention and treatment, then read on.  This guide is predicated upon the following assumptions:

You agree that trying to reduce the number of times we contract Covid is still a good idea. How far we go to cut that risk is a variable proposition that’s up to the individual.

You understand that every Covid illness is a roll of the dice in terms of disease severity and chance of developing long Covid, which can be debilitating.

You balance the joy of social connections and living a fulfilling life with a realistic awareness that the pandemic has tweaked the game. There can be a new normal.

And finally you acknowledge that doctors still have a responsibility to keep reminding us of ways to improve and protect our health, and that many are failing to speak up against the false narrative that Covid is just a cold now. 

There are new variants

No surprise here.  SARS CoV-2 has kept mutating, albeit at a pace and direction that are difficult to predict. 

BA.2.86 is the most concerning variant on the radar right now because of 30+ mutations in its spike protein, not to mention changes in other parts of the viral particle as well.  Our existing antibodies will not recognize it very well.  The new booster due out in September will be less effective against it.   But most experts believe that our second line of defense including veteran T-cells should protect most people against severe disease and death quite well.  It remains to be seen whether this variant will take off in the U.S.  Testing and surveillance are a fraction of what they used to be - so we are not flying the plane blindly, but rather with cloudy windows and an old fashioned compass.

There are also EG.5 and FL.1.5.1 variants.  These seem less capable of escape from antibodies generated from recent infection or that new booster due out soon.

*Update #1 added on 9/6/2023 : good stuff from

Katelyn Jetelina

this week regarding evolving knowledge about BA.2.86. Not true clinical experience yet, but not terrifying new science either!

*Update #2 added on 9/7/2023 - this quote from a USA Today article is also very encouraging:

But three new studies out this week suggest BA.2.86 is not as infectious as earlier variants or likely to undermine vaccines and established immunity. The first, posted online and not yet peer-reviewed, showed that the variant does not penetrate cells very well, suggesting it will not cause a tremendous number of infections.

A second study, also in preprint, shows that the variant does not evade the immune system as much as had been feared. People in Sweden who had been exposed to XBB.1.5 seemed to have good protection against BA.2.86.

A third, again not yet peer-reviewed, showed that despite all its mutations, BA.2.86 does not seem to be good at avoiding immune protections. The Moderna data, though lacking the context of how the ninefold increase in antibodies compares with other variants, also indicates the vaccine will remain effective.

The new booster

For those who like to collect boosters like stamps on a passport, the new booster sounds good.  It’s based on the spike protein of an Omicron family variant called XBB.1.5.  I’ve been hearing mid-September availability.  As of this writing, the CDC has not made official recommendations about whom should or could get it. This will happen during the 2nd week of September.

Like other boosts it will pump up antibodies as a first line of defense, providing enhanced protection against infection for 2-3 months, with diminishing returns after that.  For higher risk individuals it will likely reduce the risk of severe disease, and build upon that semi-durable protection already gained from previous shots and infections.  And if a variant like BA.2.86 mentioned above does end up taking off, my guess is that an imperfectly matched boost will still be better than nothing.

Update #3 - my guess seems pretty good for now. From

Ground Truths

on 9/8/2023: “…human data for new XBB.1.5 booster vs the BA.2.86 variant: the neutralization antibody response looks very good, along with response to current main US circulating variants of EG.5.1 and FL.1.5.1 medrxiv.org/content/10.1101/2023.08.22.… This adds to the 4 lab studies and is quite reassuring.”

Which arm?

Studies have shown that getting your boosts in the same arm produces higher antibody levels and therefore potentially better results.  The local immune and lymphatic systems have already been primed, and factories are ready.

Combining shots versus spacing them out

Some people will be getting a flu shot, Covid booster, and RSV shot this fall.  While it might make logistical sense for some to get a combination of these at the same time, others might choose to space them out a bit.  You can actually get all 3 at once. However, a study last year showed a 10% increased rate of reported side effects for those people getting a flu shot + Covid booster at the same time.  In a clinical trial, getting the RSV vaccine + flu shot produced lower antibody levels in response. No studies have actually tried all 3 together.

Personally, I’m keeping an eye on the BA.2.86 variant, hospitalization rates, and even sewage analysis as a proxy for infection rates.  I’m staying aware of the CDC current flu activity map.  As a pretty healthy middle aged male, I’ll probably get my flu shot in October.  If I’m eligible I plan to get the new Covid booster a week before Thanksgiving, unless I come down with Covid illness between now and then, or Covid cases turn into a wave beyond the current swell. Everyone has individual factors to consider including age, health risks, travel, big social events, etc.

Another consideration is that the flu and RSV seasons in the northern hemisphere came early last year (in November and December).  2023 saw a similar early pattern in the southern hemisphere during our spring and summer, so some experts predict we’re in for an earlier start up here, too.

We already know what works to help prevent Covid

Nothing has changed much.  You’ve heard these one liners before, but sometimes it’s good to hear them again:

Ventilation is good.

Duration of exposure matters.

Well-fitting N95s and KN95s absolutely work.  That Cochrane meta-analysis suggesting they don’t - well, it sucked. This well written opinion for The New York Times explains how its conclusions were misunderstood.

Washing hands is good.

Assume you’re contagious when sick, and protect others.

Assume your symptoms might be Covid, even with a negative test.

And if you’re going to get Covid, which we all will, I suggest making the exposing event worth the risk at least. Breathing in aerosolized virus from a flushed toilet in a smelly, poorly ventilated, public bathroom is an example of a transmission event I personally find unacceptable.

Take an antiviral

When we do get Covid, antivirals like Paxlovid can reduce the viral load in our bodies by up to 90%.  They reduce our risk of severe disease and long Covid.  They become even more important with new variants.  Paxlovid must be started within 5 days of symptom onset, and the earlier the better.  Unless you’re really low risk, waiting to see how bad it gets is not the right call.  It often doesn’t get bad until day 7-10 after a brief and temporary improvement in symptoms. 

Long Covid occurs in young healthy people, and some studies have shown peak rates can be found in people in their late 30’s -50’s. Some would argue that taking antivirals to reduce long Covid risk is more important than reducing severe disease risks in younger, healthier individuals.

Other options still include remdesivir which currently must be given IV and is therefore increasingly hard to find as an outpatient.  Remdesivir has been shown to be effective in a pill formulation, but has yet to make it through the final stages of approval. Molnupiravir can also provide some incremental benefit.  It does not have as many medication interactions, but is less effective than the first two options.  Because it can theoretically interact with our DNA synthesis and repair I’m not a big fan except in special cases. Monoclonal antibodies might make another appearance, but existing options are mostly ineffective and not available.

Consider metformin?

At least one large trial found that the generic medicine metformin reduced the chances of developing long Covid by up to 40%.  The absolute risk reduction was from about 10% to 6%.  Additional studies need to confirm this finding before it becomes a mainstream option.  I have offered it to some highly motivated patients with Covid, but so far have had no takers.  Upsides include that metformin is cheap, safe, and now has a couple plausible mechanisms for why it might help including protecting our mitochondria. Downsides include possible gastrointestinal side effects, especially when Covid can cause distressing GI symptoms already.  It’s certainly not mainstream, but maybe it should be.

Rapid antigen testing at home, doctor’s office, or urgent care

When we have symptoms that might seem mild, like a cold, bad allergies, or the flu, we should test.  This helps stop chains of transmission and gives us the chance to take an antiviral early.  Unfortunately rapid tests aren’t as accurate as they used to be.  Often tests are staying negative until day 2 or 3 of illness.  I’ve also read estimates that tests come back positive in perhaps just 70-80% of cases now.  To increase sensitivity, consider swabbing the back of the throat in addition to the nostrils.  I’ve even read some sources recommend coughing on the swab, too.  Why not?

Have tests ready

Keep a small stash.  Some insurances will help with the cost.  When there is another wave, tests can be harder to find.

Consider taking Paxlovid on your trip outside the country if you’re higher risk

I wrote about this previously.  I don’t think it’s unethical like giving everyone antibiotics.  Prescribing Paxlovid safely takes some careful review of your current medications and kidney function.  Higher risk patients, and those looking to maximize their prevention of post Covid conditions, might have a difficult time executing this in a foreign country.

Be kind to your respiratory tract epithelium

Cold dry air and prolonged exposure to cold reduce the integrity and effectiveness of the respiratory epithelium and immune system, and make us more susceptible to infections. The old adage of catching a cold from being in the cold was disproven by the discovery of germs - but it turns out there was an intuitive truth to it   Prolonged and intense cold exposure weakens our defenses.

Takeaway

I’m going to take a nap now. I hope your travels and life in 2023 provide ample opportunities to be grateful and joyful, even as life will always present challenges and hardships. Covid is still here, and it will be here. Lulls, swells, and waves are to be expected all year round. Some new variants loom as the fall is almost here, schools open, and the holidays approach. They could be nasty, or more of the same. Our previous shots, boosters, and illnesses will help, but not as much as we would hope. The new XBB booster should be available mid to late September, with CDC guidance due in a couple weeks. Antivirals like Paxlovid should be used more often, and maybe someday metformin will gain traction in the fight against long Covid. Well-fitting masks like N95s work despite how some misinterpret the studies, and should be deployed situationally if and when we want some added protection. Vaccines present more benefit than risk, and I’ll be getting mine.

Take care, and I wish you good health, and more inspiring times soon!