Dr. Ryan, wonderful newsletter, very informative, thank you! Couple questions and observations. 1-Fitness Centers at 28.8% YIKES! What would you guess risk is if wearing an N95 well fit respirator? Does respirator eliminate inhalation risks and then reduce risks to (?what?) for infection via eyes? 2-What is the efficacy of saline nasal spray compared to Xylear saline with xylitol? 3-Home PCR tests, great to know! 4-Website for waste water rates great to know! 5-A person already taking LDN, any benefits in terms of avoiding infection or avoiding long covid? 6-Wonderful 'election-phone call' offer BRAVO, very kind of you! Incredible that anyone could be undecided! THANKS!
Hi Panthers - I actually have not had Covid yet that I know of, so I can attest to the reliability of the 3M Aura type N95 masks in clinical situations with patients, and while stuck on airport tarmacs in commerical planes with terrible ventilation... but nothing is 100% of course. This is very airborne so I don't worry too much about eye protection, but we do wear eye protection when seeing patients with Covid in the office. No head to head saline vs xylitol studies that I know of! I don't think that LDN will show any benefit in terms of reducing transmission or severity of Covid, but just my guess. Metformin surprised us in this regard with diabetics already taking it, but there are plausible mechanisms underpinning that. Thanks for stopping by!
Here’s a bit of anecdotal data. A friend and I came down with COVID in early August. She is 76, I am 92. We probably got it at the same crowded community gathering. I got Paxlovid immediately, she didn’t get it at all. We were both quite sick for a few days and then recovered fully. Two weeks ago she had a stroke.
Hi Anne - first, very sorry to hear of your friend suffering a stroke. Second, you don't look 92 at all! Third, thanks for sharing this anecdote. Hard to draw any conclusions from it, but the anecdotes add up and compel further study... in this case you know of the increased stroke risk after Covid already, and antivirals do seem to reduce this from all the stuff I've been following (won't cite the sources except that they are strewn throughout previous Covidlandia posts).
Thank you for providing such great information— here’s a recent study showing that the Shionogi antiviral protects against household infections, so maybe the FDA will actually approve it finally— cheaper and less drug interactions than Paxlovid:https://www.shionogi.com/global/en/news/2024/10/20241029.html
I don’t need a call today but you are flat out amazing.
I been following this since I mentioned this in February this year. I did say that "Ensitrelvir is an investigational drug outside of Japan, and has not been approved
outside of Japan. This also has been fast tracked with the FDA? The original submittal did not sway the FDA committee and some are saying the FDA is slow walking this. Currently an
expanded trial is being conducted. We should have this option by fall, otherwise going to
be very annoyed"
I believe there is a meeting in next couple of weeks. I also found a few other investigation antiviral drugs that I should follow up. The only possible drawback is the study is this is an Asian population.
It was fast tracked for about 2 years now. They backed off when it didn't meet statistical significance for reducing symptoms, although it DID for reducing viral loads-?!
We need an alternative/addition to what we have and Paxlovid doesn't reduce symptoms or is effective in reducing household spread.
I'd love to have a drug that is well tolerated and less drug interactions and potentially less expensive.
In my somewhat naive grey matter, I think the endpoint of symptom resolution in clinical trials should be reevaluated. If hospitalization, ICU and mortality is reduced, as we have seen in Paxlovid, that should be the endpoint.
Yes! Very excited to see the actual data on this study, RR and AR reductions etc. Was thinking of putting this in there but want more details. If you see the actual study published and remember to circle back here, please do so!!
Thank you Doctor Ryan for all you do. How do you find the time? In six days I will be having a heart ablation (catheter/RF) for AFib which developed after I was diagnosed with Covid in 2020. First person in my family on either side to have heart problems so I kind of blame Covid although I know correlation doesn't imply causation. I'm required to have a Covid test two days before the procedure. After reading your comment, I hope it is a PCR.
Hi Michael - sincere wishes for a successful procedure and outcome for you! I'm guessing the test will be a rapid antigen test, but not sure. In terms of finding the time, it's been kind of challenging lately... I write these in small moments and then sit down with a deadline mentality as the ~1 week clock ticks!
Jan said it, I second it. “you are flat out amazing.”
I got a good, if sort of mordant, chuckle, out of this: “And another great summary article on long Covid from Ziyad Al-Aly, especially if you are trying to avoid reading about the election all day.” Usually, my habit is to scan the news first. Today, no way—instead I leapt eagerly on your article, which is superb. (I voted early and, in doing so, followed your excellent prescription.)
Some specifics:
On masks: Thanks for keeping on pounding the drum about the effectiveness of masks. The bans are completely wrong-headed, as your KevinMD article makes eloquently clear.
On rapid-tests: You confirm what I have sensed, which is that rapid tests are no longer useful when asymptomatic. It does seem, though, that they are reasonably effective for testing when symptomatic, per the below:
“In contrast, antigen rapid tests provide a quick, widely available, and inexpensive testing method of acceptable performance for detecting SARS-CoV-2 infection in individuals with respiratory symptoms, regardless of VOC and vaccination status, even if the RT-qPCR remains the gold standard for SARS-CoV-2 diagnostics.”
Just as a point of interest, does the article state % effectiveness in that case? (I wasn’t able to decipher the charts on that point.)
On indoor settings: those statistics are alarming, though not at all surprising. As the review states: “The risk of SARS-CoV-2 transmission was highest in indoor settings where singing and exercising occurred. Effective mitigation measures such as assessing and improving ventilation should be considered to reduce the risk of transmission in high-risk settings.”
It is endlessly frustrating that we are not, as a society, going full bore on indoor ventilation in public settings. Every time I went to PT, I worried about this. For the most part, no one wears a mask (except me). Imagine if there were a mask ban in place!
Well, I have already gone on too long, so will just close by adding my thanks and praise to other commenters here for all you do and all you are.
Thank you Susan! This is really not fun reading to distract oneself from the election, so I apologize for not writing about travel or food this week instead, ha! Your commentary above is great. I have to run right now, but to answer your question, I crunched the study with Claude and got this result below. I will need to circle back later and double check the accuracy for sure:
"The study found that rapid antigen tests performed significantly better in symptomatic individuals compared to asymptomatic ones. While the exact sensitivity percentage for symptomatic cases isn't directly stated in a single number, we can see from Figure 4a in the study that:
For patients with typical COVID-19 symptoms: The sensitivity appears to be approximately 55-60% (based on the graph)
For patients with atypical symptoms: The sensitivity appears to be approximately 45-50% (based on the graph)
This is in contrast to asymptomatic individuals, where the sensitivity was much lower (appears to be around 20% from the graph).
The study found that symptoms were one of only two factors (along with viral load) that directly and significantly influenced rapid test performance. The presence of typical COVID-19 symptoms increased the odds of having a positive rapid test result in cases of confirmed SARS-CoV-2 infection.
This higher detection rate in symptomatic individuals remained true regardless of vaccination status or virus variant, though the overall prevalence of symptomatic infections decreased over time due to vaccination and the Omicron variant."
OMG, you know what? You are BEYOND flat out amazing! Here you are, saying you have to run, yet you somehow managing to pass on really interesting, useful information. (I know, you used Claude—which I had to look up😎—& further verification is needed, but that you took the time to do that and then write a note is, yes, beyond flat out amazing.)
As some tiny bit of thanks to you, in return: to help us cope with this election, we decamped ourselves to Williamstown, MA, for a few days. Today, a gorgeous day here, we went to The Clark art museum. We were amply and repeatedly reminded, walking through rooms full of artistic treasures, of the unbounded magnificence of human creativity. A bequest to the museum of British art included Joseph Mallord William Turner’s “Rockets and Blue Lights (Close at Hand) to Warn Steamboats of Shoal Water, 1840” which stopped us in our tracks. https://www.clarkart.edu/ArtPiece/Detail/Rockets-and-Blue-Lights-(Close-at-Hand)-to-War-(1)
OK, yet once again, I have gone on way too long, so I will close, with grateful thanks for your compassion and generosity. May all be well . . .
Hey R - My letter was read on TWIV recently ! Had a case of Covid in a 67yo patient on Ustekinumab ( IL12/23 inhib) that began only 3-4 wks after a prior case of Covid . Was dealing with the dilemma of POS rapid Ag lingering vs new infection …. Turned out the POS Rapid was a lingering finding as PCR was NEG . Interesting and challenging case.
That's really cool to get a mention on TWiV! And the case is quite instructive, too. I'll have to submit a reader question one of these days. I can't recall if I heard this particular episode... how did you get the PCR test, through urgent care or pharmacy, or do you send out from the office?
I send from my office to Quest . Because it took 48 hrs he ended up taking the full Paxlo course anyhow . I have thought about adding a PCR capable machine to our office but so far have decided against that .
Thanks again for another great article glad you help keep us all informed.
All good, thanks for reading... I figured I wasn't going to be sleeping that well 11/4/2024 anyway, so I banged it out ;)
Dr. Ryan, wonderful newsletter, very informative, thank you! Couple questions and observations. 1-Fitness Centers at 28.8% YIKES! What would you guess risk is if wearing an N95 well fit respirator? Does respirator eliminate inhalation risks and then reduce risks to (?what?) for infection via eyes? 2-What is the efficacy of saline nasal spray compared to Xylear saline with xylitol? 3-Home PCR tests, great to know! 4-Website for waste water rates great to know! 5-A person already taking LDN, any benefits in terms of avoiding infection or avoiding long covid? 6-Wonderful 'election-phone call' offer BRAVO, very kind of you! Incredible that anyone could be undecided! THANKS!
Hi Panthers - I actually have not had Covid yet that I know of, so I can attest to the reliability of the 3M Aura type N95 masks in clinical situations with patients, and while stuck on airport tarmacs in commerical planes with terrible ventilation... but nothing is 100% of course. This is very airborne so I don't worry too much about eye protection, but we do wear eye protection when seeing patients with Covid in the office. No head to head saline vs xylitol studies that I know of! I don't think that LDN will show any benefit in terms of reducing transmission or severity of Covid, but just my guess. Metformin surprised us in this regard with diabetics already taking it, but there are plausible mechanisms underpinning that. Thanks for stopping by!
Here’s a bit of anecdotal data. A friend and I came down with COVID in early August. She is 76, I am 92. We probably got it at the same crowded community gathering. I got Paxlovid immediately, she didn’t get it at all. We were both quite sick for a few days and then recovered fully. Two weeks ago she had a stroke.
WOW…that’s terrible. Thank you for sharing. I hope she’ll be okay.
Hi Anne - first, very sorry to hear of your friend suffering a stroke. Second, you don't look 92 at all! Third, thanks for sharing this anecdote. Hard to draw any conclusions from it, but the anecdotes add up and compel further study... in this case you know of the increased stroke risk after Covid already, and antivirals do seem to reduce this from all the stuff I've been following (won't cite the sources except that they are strewn throughout previous Covidlandia posts).
Here's hoping for your friend's recovery.
Thank you for providing such great information— here’s a recent study showing that the Shionogi antiviral protects against household infections, so maybe the FDA will actually approve it finally— cheaper and less drug interactions than Paxlovid:https://www.shionogi.com/global/en/news/2024/10/20241029.html
I don’t need a call today but you are flat out amazing.
I been following this since I mentioned this in February this year. I did say that "Ensitrelvir is an investigational drug outside of Japan, and has not been approved
outside of Japan. This also has been fast tracked with the FDA? The original submittal did not sway the FDA committee and some are saying the FDA is slow walking this. Currently an
expanded trial is being conducted. We should have this option by fall, otherwise going to
be very annoyed"
I believe there is a meeting in next couple of weeks. I also found a few other investigation antiviral drugs that I should follow up. The only possible drawback is the study is this is an Asian population.
It was fast tracked for about 2 years now. They backed off when it didn't meet statistical significance for reducing symptoms, although it DID for reducing viral loads-?!
We need an alternative/addition to what we have and Paxlovid doesn't reduce symptoms or is effective in reducing household spread.
I'd love to have a drug that is well tolerated and less drug interactions and potentially less expensive.
In my somewhat naive grey matter, I think the endpoint of symptom resolution in clinical trials should be reevaluated. If hospitalization, ICU and mortality is reduced, as we have seen in Paxlovid, that should be the endpoint.
Yes! Very excited to see the actual data on this study, RR and AR reductions etc. Was thinking of putting this in there but want more details. If you see the actual study published and remember to circle back here, please do so!!
Thank you Doctor Ryan for all you do. How do you find the time? In six days I will be having a heart ablation (catheter/RF) for AFib which developed after I was diagnosed with Covid in 2020. First person in my family on either side to have heart problems so I kind of blame Covid although I know correlation doesn't imply causation. I'm required to have a Covid test two days before the procedure. After reading your comment, I hope it is a PCR.
Good luck! I think the evidence supports your supposition.
Hi Michael - sincere wishes for a successful procedure and outcome for you! I'm guessing the test will be a rapid antigen test, but not sure. In terms of finding the time, it's been kind of challenging lately... I write these in small moments and then sit down with a deadline mentality as the ~1 week clock ticks!
Jan said it, I second it. “you are flat out amazing.”
I got a good, if sort of mordant, chuckle, out of this: “And another great summary article on long Covid from Ziyad Al-Aly, especially if you are trying to avoid reading about the election all day.” Usually, my habit is to scan the news first. Today, no way—instead I leapt eagerly on your article, which is superb. (I voted early and, in doing so, followed your excellent prescription.)
Some specifics:
On masks: Thanks for keeping on pounding the drum about the effectiveness of masks. The bans are completely wrong-headed, as your KevinMD article makes eloquently clear.
On rapid-tests: You confirm what I have sensed, which is that rapid tests are no longer useful when asymptomatic. It does seem, though, that they are reasonably effective for testing when symptomatic, per the below:
“In contrast, antigen rapid tests provide a quick, widely available, and inexpensive testing method of acceptable performance for detecting SARS-CoV-2 infection in individuals with respiratory symptoms, regardless of VOC and vaccination status, even if the RT-qPCR remains the gold standard for SARS-CoV-2 diagnostics.”
Just as a point of interest, does the article state % effectiveness in that case? (I wasn’t able to decipher the charts on that point.)
On indoor settings: those statistics are alarming, though not at all surprising. As the review states: “The risk of SARS-CoV-2 transmission was highest in indoor settings where singing and exercising occurred. Effective mitigation measures such as assessing and improving ventilation should be considered to reduce the risk of transmission in high-risk settings.”
It is endlessly frustrating that we are not, as a society, going full bore on indoor ventilation in public settings. Every time I went to PT, I worried about this. For the most part, no one wears a mask (except me). Imagine if there were a mask ban in place!
Well, I have already gone on too long, so will just close by adding my thanks and praise to other commenters here for all you do and all you are.
Thank you Susan! This is really not fun reading to distract oneself from the election, so I apologize for not writing about travel or food this week instead, ha! Your commentary above is great. I have to run right now, but to answer your question, I crunched the study with Claude and got this result below. I will need to circle back later and double check the accuracy for sure:
"The study found that rapid antigen tests performed significantly better in symptomatic individuals compared to asymptomatic ones. While the exact sensitivity percentage for symptomatic cases isn't directly stated in a single number, we can see from Figure 4a in the study that:
For patients with typical COVID-19 symptoms: The sensitivity appears to be approximately 55-60% (based on the graph)
For patients with atypical symptoms: The sensitivity appears to be approximately 45-50% (based on the graph)
This is in contrast to asymptomatic individuals, where the sensitivity was much lower (appears to be around 20% from the graph).
The study found that symptoms were one of only two factors (along with viral load) that directly and significantly influenced rapid test performance. The presence of typical COVID-19 symptoms increased the odds of having a positive rapid test result in cases of confirmed SARS-CoV-2 infection.
This higher detection rate in symptomatic individuals remained true regardless of vaccination status or virus variant, though the overall prevalence of symptomatic infections decreased over time due to vaccination and the Omicron variant."
OMG, you know what? You are BEYOND flat out amazing! Here you are, saying you have to run, yet you somehow managing to pass on really interesting, useful information. (I know, you used Claude—which I had to look up😎—& further verification is needed, but that you took the time to do that and then write a note is, yes, beyond flat out amazing.)
As some tiny bit of thanks to you, in return: to help us cope with this election, we decamped ourselves to Williamstown, MA, for a few days. Today, a gorgeous day here, we went to The Clark art museum. We were amply and repeatedly reminded, walking through rooms full of artistic treasures, of the unbounded magnificence of human creativity. A bequest to the museum of British art included Joseph Mallord William Turner’s “Rockets and Blue Lights (Close at Hand) to Warn Steamboats of Shoal Water, 1840” which stopped us in our tracks. https://www.clarkart.edu/ArtPiece/Detail/Rockets-and-Blue-Lights-(Close-at-Hand)-to-War-(1)
OK, yet once again, I have gone on way too long, so I will close, with grateful thanks for your compassion and generosity. May all be well . . .
Great work again, Ryan.
Great summary and information as usual.
Thank you for another thorough edition of Covidlandia, doc.
Thanks, as always, Dr. Ryan, for your info about Covid.
Here's to our democracy and the people in it who have coalesced into a huge community of its defenders. We've got this!
Hey R - My letter was read on TWIV recently ! Had a case of Covid in a 67yo patient on Ustekinumab ( IL12/23 inhib) that began only 3-4 wks after a prior case of Covid . Was dealing with the dilemma of POS rapid Ag lingering vs new infection …. Turned out the POS Rapid was a lingering finding as PCR was NEG . Interesting and challenging case.
That's really cool to get a mention on TWiV! And the case is quite instructive, too. I'll have to submit a reader question one of these days. I can't recall if I heard this particular episode... how did you get the PCR test, through urgent care or pharmacy, or do you send out from the office?
I send from my office to Quest . Because it took 48 hrs he ended up taking the full Paxlo course anyhow . I have thought about adding a PCR capable machine to our office but so far have decided against that .